Kathryn Bowen

Climate change and mental health: a causal pathways framework

ObjectivesClimate change will bring more frequent, long lasting and severe adverse weather events and these changes will affect mental health. We propose an explanatory framework to enhance consideration of how these effects may operate and to encourage debate about this important aspect of the health impacts of climate change.MethodsLiterature review.ResultsClimate change may affect mental health directly by exposing people to trauma. It may also affect mental health indirectly, by affecting (1) physical health (for example, extreme heat exposure causes heat exhaustion in vulnerable people, and associated mental health consequences) and (2) community wellbeing. Within community, wellbeing is a sub-process in which climate change erodes physical environments which, in turn, damage social environments. Vulnerable people and places, especially in low-income countries, will be particularly badly affected.ConclusionsDifferent aspects of climate change may affect mental health through direct and indirect pathways, leading to serious mental health problems, possibly including increased suicide mortality. We propose that it is helpful to integrate these pathways in an explanatory framework, which may assist in developing public health policy, practice and research.

Attitudes to people with mental disorders: a mental health literacy survey in a rural area of Maharashtra, India

IntroductionPeople with mental disorders experience discrimination as a consequence of stigmatising attitudes that are largely socio-culturally constructed. Thus, there is a need to understand local contexts in order to develop effective programs to change such attitudes. We undertook a mental health literacy survey in rural Maharashtra, India, prior to developing a mental health training program for village health workers (VHWs) in a primary health care setting.MethodsA cross-sectional mental health literacy survey was undertaken in late 2007, which involved interviewer-administration of a questionnaire to 240 systematically sampled community members, and 60 purposively sampled VHWs. Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis), and were asked about attitudes towards, and desired social distance from, the people in the vignettes (the latter being a proxy measure for stigma). Linear regression modelling was undertaken to identify predictors of social distance.ResultsAlthough the community was relatively accepting of people with mental disorders, false beliefs and negative attitudes were still evident. Desired social distance was consistently greater for the person depicted in the psychosis vignette compared to the depression vignette. For both vignettes, the main predictor of greater social distance was perceiving the person as dangerous, and the predictors of reduced social distance were being a VHW, and seeing the problem as a sign of personal weakness. For depression, believing the cause to be family tensions also reduced social distance. For psychosis, labelling the disorder as a mind/brain problem, and believing the cause to be lack of control over life or genetic factors increased social distance. The vast majority did not agree that the problems experienced in the vignettes were ‘a real medical illness’.ConclusionPromoting bio-medical explanations for mental disorders in this setting may exacerbate discriminatory attitudes. Provision of contextually relevant mental health training for the VHWs so that they are able to communicate, model and shape more positive attitudes is the next step.

Climate Change, Noncommunicable Diseases, and Development: The Relationships and Common Policy Opportunities

The rapid growth in noncommunicable diseases (NCDs), including injury and poor mental health, in low- and middle-income countries and the widening social gradients in NCDs within most countries worldwide pose major challenges to health and social systems and to development more generally. As Earths surface temperature rises, a consequence of human-induced climate change, incidences of severe heat waves, droughts, storms, and floods will increase and become more severe. These changes will bring heightened risks to human survival and will likely exacerbate the incidence of some NCDs, including cardiovascular disease, some cancers, respiratory health, mental disorders, injuries, and malnutrition. These two great and urgent contemporary human challenges-to improve global health, especially the control of NCDs, and to protect people from the effects of climate change-would benefit from alignment of their policy agendas, offering synergistic opportunities to improve population and planetary health. Well-designed climate change policy can reduce the incidence of major NCDs in local populations.

Pathways to sex-work in Nagaland, India: implications for HIV prevention and community mobilisation

Abstract There are an estimated 1800–3500 sex-workers in Dimapur, the commercial capital of Nagaland, which is the second-highest HIV prevalence state in India. The HIV prevalence among these sex-workers has increased from 4.4% in 2004 to 16.4% in 2006, highlighting their vulnerability. The aim of this study was to contribute to understanding of the pathways to sex-work for women in Nagaland in order to inform the development of effective HIV prevention strategies. A convenient sample of 220 female sex-workers completed a cross-sectional survey, and 30 female sex-workers participated in semi-structured in-depth interviews during mid 2007. Participants were asked about their life situation at the time of initial engagement in sex-work and circumstances of the first occasion of sex-work. The four main pathways into sex-work were identified as: (1) to obtain money to meet basic needs for self and family (45% of survey and 43% of interview participants); (2) to obtain money to purchase drugs or alcohol (15% of survey and 27% of interview participants); (3) being coerced, tricked or forced into sex-work (13% of survey and 30% of interview participants); and (4) for pleasure (12% of survey and no interview participants). Women from each of these pathways were significantly different from each other in relation to a range of socio-cultural variables (e.g., ethnicity, marital status and education), and HIV risk factors (e.g., drug and alcohol use, age of sexual debut and HIV awareness). This diversity has implications for HIV prevention strategies, including the willingness and capacity of sex-workers to mobilise as a community and NGO capacity to ensure that the interests of all sex-workers are adequately captured and represented.

Community beliefs about causes and risks for mental disorders: A mental health literacy survey in a rural area of Maharashtra, India

Background: Explanations for mental disorders in India can be influenced by biomedicine, systems of traditional medicine and supernatural beliefs. Community beliefs about causes of mental distress influence help-seeking behaviours. This study aimed to assess local knowledge and understanding of causes and risks for mental disorders in a rural area of Maharashtra, and to assess the prevalence of possible common mental disorders. Methods: A cross-sectional mental health literacy survey was undertaken in late 2007. A questionnaire was administered to 240 systematically sampled community members and 60 village health workers (VHWs). Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis); they were asked about the causes of the problems and the vulnerabilities of community sub-groups. Additionally, the General Health Questionnaire (GHQ12) was administered to assess prevalence of possible common mental disorders. Results: The most commonly acknowledged causes of the problems were a range of socioeconomic factors. Supernatural and biological explanations were not widely endorsed. Women, the unemployed and the poor were judged as more likely to develop mental disorders, while both young and older people were perceived to be less vulnerable. Results of the GHQ12 indicated that 27% had a possible common mental disorder and that the elderly were at increased risk, contrary to community perceptions. Conclusion: Enhancing mental health literacy of both VHWs and community members using approaches that are sensitive to local conceptualizations of mental health and illness will contribute to improved treatment and care for people with mental disorders. Further investigation of mental health among the elderly in this community is indicated.

Killing Time With Enjoyment: A Qualitative Study of Initiation into Injecting Drug Use in North-East India

Manipur and Nagaland are north-east Indian states characterized by a high prevalence of injecting drug use and HIV in a context of socio-economic underdevelopment and political instability. This qualitative study aims to increase understanding of the contextual factors associated with initiation into injecting drug use in these two states. Forty semi-structured in-depth interviews were conducted among injecting drug users (10 women, 30 men) aged 18–28 years in mid-2006. The interview transcripts were thematically analyzed. All participants were initiated into injecting by another person, most commonly a friend and often in the context of well-established social networks. Most were poly-drug users and unsafe injecting practices were frequently associated with the initiation experience. The subjective reasons for deciding to inject were pleasure-seeking, influence of peers, and economic reasons. We hypothesize that initiation into injecting in this part of the world is also linked to ideas of masculinity, and that young men engage in drug use in order to fill a social vacuum created by limited opportunities to meaningfully engage in adult roles within the community. The findings from this study suggest that harm reduction programs need to target (noninjecting) drug users, and that existing social networks could be creatively used to extend the reach of these programs.

Climate change adaptation: Where does global health fit in the agenda?

Human-induced climate change will affect the lives of most populations in the next decade and beyond. It will have greatest, and generally earliest, impact on the poorest and most disadvantaged populations on the planet. Changes in climatic conditions and increases in weather variability affect human wellbeing, safety, health and survival in many ways. Some impacts are direct-acting and immediate, such as impaired food yields and storm surges. Other health effects are less immediate and typically occur via more complex causal pathways that involve a range of underlying social conditions and sectors such as water and sanitation, agriculture and urban planning. Climate change adaptation is receiving much attention given the inevitability of climate change and its effects, particularly in developing contexts, where the effects of climate change will be experienced most strongly and the response mechanisms are weakest. Financial support towards adaptation activities from various actors including the World Bank, the European Union and the United Nations is increasing substantially. With this new global impetus and funding for adaptation action come challenges such as the importance of developing adaptation activities on a sound understanding of baseline community needs and vulnerabilities, and how these may alter with changes in climate. The global health community is paying heed to the strengthening focus on adaptation, albeit in a slow and unstructured manner. The aim of this paper is to provide an overview of adaptation and its relevance to global health, and highlight the opportunities to improve health and reduce health inequities via the new and additional funding that is available for climate change adaptation activities.

Life Circumstances of Women Entering Sex Work in Nagaland, India

Background and objectives: The study objective was to enhance understanding of female sex workers’ lives in Nagaland, India (one of the country’s highest HIV prevalence states), to inform the development of interventions to reduce HIV transmission and assist women who want to leave sex work. Methods: A cross-sectional survey (n = 220) and semi-structured interviews (n = 30) were conducted with sex workers. Topics included the following: life situation currently and at time of initial engagement in sex work, circumstances of first sex work occasion, and current patterns of sex work. Results: Participants’ lives at time of entry into sex work were socio-culturally and economically vulnerable as evidenced by the early age of sexual debut, low levels of education, unemployment, absence of protective male partners, and poor relationships with families. Participants experienced high levels of mobility, insecure accommodation, the need to financially support family, and the demand to give a portion of their income to others. The use of alcohol and other drugs, including heroin, was widespread. Discussion and conclusions: For these women, sex work can be seen as a pragmatic option for earning sufficient income to live. The women’s lives would be improved by strategies to promote their health, ensure their safety, and protect their rights as long as they are engaging in sex work. This is likely to benefit not only the sex workers but also their children, their families, and the wider community. The development of alternative employment opportunities is vital to protect against entry into sex work and to support women who want to exit sex work.

Governing for a Healthy Population: Towards an Understanding of How Decision-Making Will Determine Our Global Health in a Changing Climate

Enhancing the adaptive capacity of individuals, communities, institutions and nations is pivotal to protecting and improving human health and well-being in the face of systemic social inequity plus dangerous climate change. However, research on the determinants of adaptive capacity in relation to health, particularly concerning the role of governance, is in its infancy. This paper highlights the intersections between global health, climate change and governance. It presents an overview of these key concerns, their relation to each other, and the potential that a greater understanding of governance may present opportunities to strengthen policy and action responses to the health effects of climate change. Important parallels between addressing health inequities and sustainable development practices in the face of global environmental change are also highlighted. We propose that governance can be investigated through two key lenses within the earth system governance theoretical framework; agency and architecture. These two governance concepts can be evaluated using methods of social network research and policy analysis using case studies and is the subject of further research.

The relevance of a coproductive capacity framework to climate change adaptation: investigating the health and water sectors in Cambodia

The authors wish to gratefully acknowledge that the research this paper is based upon has been made possible through an AusAID Australian Development Research Awards (ADRA) grant (ADRA0800117) for the project entitled Evaluating the Connections and Contributions of Climate Change Vulnerability Assessments to Adaptation Strategies in the Health and Water Sectors: A Three-Country Study in the Asia-Pacific Region.