Impact of Discrimination on Access to Mental Health Services

This paper investigates the impact of social discrimination in posing constraint to the access of mental healthcare. The study aims to contribute to the vast wealth of literature on mental health and social discrimination.

Running head: IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Name of the student:
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1IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Abstract
The global economic burden on mental health has plagued people from all over the world and the
rural hinterlands of India are not far behind. It has been found that the stigma and lack of
awareness about mental health illness impedes people in the rural belt of the country from
accessing healthcare service. Mental healthcare service has become low for rural India, therefore
creating a gap for people with mental health illness. In this light, my paper aims to investigate
the impact of social discrimination in posing constraint to the access of mental healthcare. I aim
to argue that social location has bearing on the access of mental healthcare service in rural India.
I aim to adopt the critical social science research and adopt the mixed method approach for the
purpose of my study. I feel the study will be helpful in contributing to the vast wealth of
literature on mental health and social discrimination.

2IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Table of Contents
1Introduction....................................................................................................................................3
Search strategy.............................................................................................................................3
Background of the study..............................................................................................................4
Statement of the problem.............................................................................................................5
Rationale of the research.............................................................................................................5
Research aims and objectives......................................................................................................6
Research questions.......................................................................................................................6
Research hypothesis.....................................................................................................................7
Literature review..............................................................................................................................7
Methodology....................................................................................................................................7
Research philosophy....................................................................................................................7
Research design...........................................................................................................................8
Sampling method and sampling size...........................................................................................8
Data analysis technique...............................................................................................................8
Research ethical consideration....................................................................................................8
Limitation of the study.................................................................................................................8
Proposed timeline of the study....................................................................................................9
Literature review............................................................................................................................10

3IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
References......................................................................................................................................14
Research proposal
“Investigating the impact of discrimination on access to mental health services in rural
communities in India”
Introduction
Search strategy
The database used for searching the relevant materials was Google Scholar, Scopus,
Proquest, PubMed, MEDLINE, Web of Science and Psychinfo. These are advanced search
engines comprise of high-quality peer-reviewed journals, and enabled me to look for the relevant
articles using the appropriate keywords.

4IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Name of databases Wave 1 Original
found
Wave 2 No. 1
(After applying
priori rules)
Wave 3
shortlisted
Wave 4 Final no.
(cited)
Google scholar 3 1 4 3
Scopus 185 56 24 2
Psycinfo 48 28 16 2
ProQuest 109 65 11 2
PubMed 56 20 16 2
MEDLINE 12 31 65 2
Web of science 5 12 4 1
Grey literature 1
total 418 173 140 15
Some of the keywords that were used to search the literature were discrimination, mental health
and rural India. I have consulted my friends who have studied on health sociology and teachers
who specialize on the area of stratification. Discrimination refers to exclusion and subjugation in
relation to access of resources, mobility and so on. Mental health refers to the condition of the
person about their emotional and psychological state. Rural India refers to village or countryside
regions of India. The timeframe of the search persisted for a period of one week as I found this
period enough to find the relevant documents for the research. The inclusion criterion for the
search was literature on mental health concerning rural India. The exclusion criterion was
keeping away articles that were not concerned with rural India or articles that did not discuss

5IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
about discrimination. I have obtained around 15 literatures for the purpose of the study that
discusses about the context of discrimination regarding mental health in rural India.
Inclusion criteria Exclusion critera
Journal (Peer-reviewed journal related to health,
psychiatry and social science)
Journals that are not related to this topic
Date ( 2012-2018) Anything before that
Keywords mental health, rural Indi and
discrimination
Urban India, mental health in the west and related
keywords
The process that I used to identify the themes emerged from the research questions and
objectives of the research. These themes are impact in accessing healthcare service, role and
degree of social location and role of government bodies in disseminating healthcare services in
India.
Background of the study
Mental health illness is a serious issue that has plagued countries across the world. India
features in the list of countries have a bad reputation of dealing with mental health disorder.
Kumar (2012) have found that the delivery of mental healthcare services in rural India is quite
poor. This is due to the lack of a robust approach by the government, civil society institutions

6IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
and the policymakers. The National Mental Health Programme had attempted to usher in
transformation in the rural areas but this without much result. There is an overall absence of
community based interventions in minimizing the effects of stress in the rural areas (Thornicroft
et al. 2016). At the village level, the non-trained service providers mostly provide mental health
services in rural India. According to Das et l. (2012), the service delivery in mental health has
become low for the rural India, thus creating a gap in access to health. Studies have demonstrated
that stigma precludes people in the hinterlands of rural India from the pursuit of healthcare
service.
Statement of the problem
Mental health illness has become an issue of great concern for the India. It has been
reported that around 14 per cent of the global burden of illness in the world is related to
neuropsychiatric disorders (Firstpost 2018). Mental health awareness have yielded positive
impact, however that is insufficient considering the persistence and stigma that continue
circumscribe around discussions on mental health services in India. This leads to the silencing of
people with mental health disorder and posits further obstacles in their access to mental health
care service in rural India. This has motivated me to intervene into the issue of discrimination
that impacts on the access to healthcare service in India.
Rationale of the research
In the context of increasing incidents of mental health disorder, there is no corresponding
initiatives to espouse and implement mental health literacy (Patel et al. 2016). The term mental
health literacy alludes to the ability of a community or an individual to understand their plight,

7IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
access healthcare service and tap the information in the promotion of good health. The WHO
have recognized that the rate of suicide in India as a consequence of severe mental health
disorder is higher than the global average (Semrau et al 2015). There is a gap in the treatment of
mental health disorder. In the light of existing research on mental health, I purport to conduct a
study to understand the impact of discrimination in accessing healthcare service in rural India.. I
feel that the large wealth of literature have not addressed the issue of social location of the
person that may exacerbate their plight in reaching out to the adequate service providers,
professionals and institutions in access to healthcare.
Research aims and objectives
The aim of this research is to study the impact of discrimination on people with mental
healthcare service in accessing healthcare. The objective of the research would be to
To examine the role and degree to which the social location of an individual or the position of a
community determines their chance in accessing healthcare in rural India.
To investigate whether there is presence of any community-based intervention to address the
issue.
To examine the role of government bodies in disseminating healthcare service in rural India and
the attitude of the service providers.
Research questions
RQ1. What is the role and degree to which the social location of an individual or the position of a
community determines their chance in accessing healthcare in rural India?

8IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
RQ2. Is there is presence of any community-based intervention to address the issue and what
have been their contributions so far?
RQ3. What is the role of government bodies in disseminating healthcare service in rural India
and the attitude of the service providers?
Research hypothesis
The research hypothesis is that there is a strong impact of discrimination in accessing
mental healthcare service in rural India.
Literature review
An elaborate discussion on literature review have been done in the second part of the
assignment.
Theme Identification
Based on the critical review of literature I found that the key themes that emerged in the
study were that there is stigmatization of mental health patients are common in the rural
hinterlands of India. Secondly, it was found that this fesr being labelled and stigmatization
pushes prevents the mental health patients in India in accessing healthcare services. Thirdly, it
was found that mental health patients are subjected to discrimination and this discrimination is
exacerbated by their gender identity. However, there is a silence on the caste identity and mental
health discrimination in context of modern India that I found quite startling considering caste
violence an important aspect of the Indian society. Fourthly, it has been found that there has been
interventions from the government at the grassroot level. However, those interventions fail to

9IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
grasp the complexity of the multiple dimensions that subject mental health patient to greater
discrimination. There has been no discussion on the training of health care service providers
operating at the grassroot level to alleviate the ordeals of the mental health patients and help
them to come out of the closet of stigma. This review of the literature enabled me to identify the
themes based on the keywords of each of the articles and also enabled me to identify the lacuna
in literature and scope of further research in this domain.
Methodology
Research philosophy
According to Neuman, (2014), research philosophy or epistemology can be defined as the
foundational premise of knowledge that would influence the methodological framework.
Keeping in consideration the temperament of the research, I feel critical social research theory
would be appropriate. The aim of critical social research is to generate knowledge that would
catalyse a social transformation through praxis. Through my research, I intend to explore the
range, ramifications and nuances of discriminatory practises that impedes patients with mental
health in accessing mental healthcare service.
Research design
Since the research aims to generate awareness and contribute to the existing wealth of
knowledge about the discrimination associated with mental health, I feel the action research
design would serve the purpose (McKenney 2014).

10IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Sampling method and sampling size
My universe of study will be two villages in India (Andhra Pradesh and Tamil Nadu). I
would employ the purpose sampling technique and approach my respondents through the
snowball sampling technique. The sample size would be 30 people in each of these villages.
Data analysis technique
I would employ mixed methods to collect data. These methods would include
ethnography, participant observation, focussed group discussion and in-depth qualitative
interviewing. I would also conduct archival research through the analysis of the government
documents to examine the timeline of initiatives of the government
Research ethical consideration
Some of the ethical considerations for the research will be marinating the confidentiality
of the patients and respect their privacy. The second ethical consideration would be not to
interfere with daily activities of the people in the village through my research. I would take
special care not to lacerate the sentiments of the people in village especially the ones suffering
from mental health disorder.
Limitation of the study
Limitations are common in any research despite the accurate planning involved in
research. One major limitation of the study would be the timeline for the study. The second
limitation of the study would be the lack of availability of resources. The third limitation of the
study may be that since it is concerned with one village each in the states of Andhra Pradesh and
Tamil Nadu it will be difficult to generalize the data for the rest part of the country.

11IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Proposed timeline of the study
Activities 1st
to 3rd
Week
4th
to 10th
week
11t
h to
13th
Week
14th
to 17th
Week
18th
to 21st
Week
22n
d to
23rd
Week
24th
Week
Selection of the topic 
Data collection from
secondary sources
 
Creating layout 
Literature review   
Analysis and
interpretation of the
collected data
  
Findings of the data  
Conclusion of the
study

Formation of draft  
Submission of final
work

Fig: Gantt Chart
(Source: As created by the author)

12IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
Literature review
Mental health is believed to be an integral part of the health system. It refers to a wide
array of activities that are associated with mental health and the welfare of an individual. It
concerns with the prevention of disorders and the treatment of people who are affected by mental
health condition (India is facing a possible mental health epidemic, says President, 2017). In the
context of India, it has been identified that there is an urgency of mobilization of endeavours to
espouse the principles of mental health.
According to a report published in the Times of India, it was found that mental health has
become an epidemic in India. The NHMS (National Health and Mental Sciences) in India, have
provided insightful data regarding the mental health disorder in the country. In ‘Evaluation of an
anti-stigma campaign related to common mental disorders in rural India: a mixed methods
approach’, Maulik et al (2016), found that stigma associated with mental health poses
impediment in seeking succour of mental health services. The method used in this study is multi-
media interventions as part of the SMART Mental Health Project in rural Andhra Pradesh. There
was the conduction of mixed-methods in two villages of Andhra Pradesh through a pre-post
design. There were pre- and post interview phases of interview. It was identified that drama and
social contract are the most beneficial interventions recognized during the qualitative interviews.
The authors argued that the campaign has been beneficial and steered to the amelioration of the

13IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
behavior and attitude of mental health. Social contract has been found to be the most effective
intervention.
In Promoting wellbeing and improving access to mental health care, Shields-Zeeman et
al, (2017), have argued that mental health is substantial in India. They reported that 70 million
people in the Indian nation have experienced some kind of mental health problem or the other.
More than 20 per cent of the population is exacerbated by common health disorders (CMDs) that
includes depression and anxiety. These kind of disorders are underreported and naturally remains
untreated due a variety of other factors. They discuss about the Atmityata programme that has
been implemented in Maharashtra from 2013 to 2015. Frequent consultations with the
psychiatrist facilitates in securing the consultations of people who have been affected by mental
health disorders. The authors have emphasized on the importance of funding in the supervision
and the mentoring mechanism for the training of new groups.
In Under the Banyan Tree-exclusion and inclusion Mathias, et al (2015), it was found
that social inclusion contributes to both the cause and consequence of mental disorders. It has
been found that people with mental health disorders are among the ones who are marginalized in
the society. This qualitative study conducted by the authors found that there is a spectrum of
exclusion that has been a pre-dominant experience for the participants that range from the
nuanced distancing, negative perceptions and isolation from the social circles. Stigma acts to
overt situations of exclusion. This exclusion is manifested in the form of ridiculing, physical
violence and disinheritance. Some of the participants of the interview found a sense of belonging
with the community, there were opportunities for participation and there were support from both

14IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
the family members. In-depth interviews were conducted with 20 PWMD and 8 caregivers.
Some of the questions that were addressed in the interview were exclusion and agency,
participation and discrimination. A qualitative content analysis was implemented to bring
attention to 12 key themes. The authors have identified that the various social and non-social
actors need to collaborate and work together in expanding the knowledge base and enhancing the
participation of the people who belong to the disadvantageous sections of the society.
Knaak, Mantler & Szeto (2017), found that mental health related stigma is quite common
the healthcare system in India. This posits a serious barrier for the providers of healthcare and
practitioners in catering to the needs of people who are suffering from mental healthcare issues.
Stigma has been understood as a complex process of labeling, devaluation, othering and
associated discrimination. It has been reported that stigmatization and discriminatory behavior is
meted out to people and is ubiquitous all across the health sector. The authors have identified
that lack of awareness and unconscious biases that acknowledges the power dimensions that
influence stigmatized behavior. Another interesting finding of the study is that healthcare
providers are quite pessimistic about the reality and likelihood of recovery.
Similar arguments have emerged from Shidaye and Kermonde (2013) (in Stigma and
discrimination as a barrier to mental health service utilization in India) who are of the view that
stigma contributes in the discrimination of people in rural India. Another argument put forth by
the authors is that this experience of stigma poses constraint in seeking mental healthcare
services and rehabilitation therefore limiting the opportunities for fuller participation. In the
context of India, it has been found that there is a general negative attitude towards people who
have mental disorder. The author exhorts for collaboration between the professional care-givers,
mental health service providers and community health workers.

15IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
According to Srivastava, Chatterjee and Bhat,(2016), mental health has been identified as
an issue that demands urgent attention. Indians are quite slow when it comes to the acceptance of
people with mental health disorder. The barriers in the dissemination of effective healthcare
system is low and middle income countries. The problems in the delivery of mental healthcare
service can be attributed to the lack of a robust approach by the government.

16IMPACT OF DISCRIMINATION ON ACCESS TO MENTAL HEALTH SERVICES
References
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India is facing a possible mental health epidemic, says President. 2018. The Hindu. Retrieved 18
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possible-mental-health-epidemic-says-president/article22335971.ece.
Knaak, S., Mantler, E. and Szeto, A. 2017, March. Mental illness-related stigma in healthcare:
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psychiatry, 59(1), 21.
Neuman, L. W. 2014. Social research methods. Pearson Education Limited.

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