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Adolescent mental health, magico-religious beliefs, stigma, discrimination, help-seeking behavior
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Prabhu V, Chandra Sekaran V, Ashok L et al. Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India [version 1; peer review: 1 not approved]. F1000Research 2023, 12:362 (https://doi.org/10.12688/f1000research.130101.1)
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Research Article
Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India
[version 1; peer review: 1 not approved]
PUBLISHED 03 Apr 2023
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Abstract
Corresponding author:
Varalakshmi Chandra Sekaran
Competing interests:
No competing interests were disclosed.
Grant information:
This study was funded by the Indian Council of Medical Research (ICMR) (No. Adhoc/2015/85/HSR). The grant was secured by Varalakshmi Chandra Sekaran.
Copyright:
© 2023 Prabhu V et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Prabhu V, Chandra Sekaran V, Ashok L et al. Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India [version 1; peer review: 1 not approved]. F1000Research 2023, 12:362 (https://doi.org/10.12688/f1000research.130101.1)
First published: 03 Apr 2023, 12:362 (https://doi.org/10.12688/f1000research.130101.1)
Latest published: 03 Apr 2023, 12:362 (https://doi.org/10.12688/f1000research.130101.1)
Introduction
Common mental disorders such as depression affects an estimated 264 million individuals worldwide (WHO, 2019b). Over 197.3 million in India suffer from mental health conditions, with 457 million suffering from depression and 449 million suffering from anxiety respectively (Sharan & Sagar, 2008). Despite the high prevalence of mental disorders, a considerable majority of the population in poor and middle income communities do not seek treatment for mental health conditions (Rathod et al., 2017). Among adolescents, mental health disorders account for 16% of the worldwide burden of the disease. Half of all mental health disorders begin before the age of 14, however, the majority of instances go unnoticed and untreated (Patel et al., 2008; WHO, 2019a). Depression is one of the most common causes of illness in adolescents around the world with suicide recorded as the fourth highest cause of mortality among teenagers aged 15–19 years. According to the National Mental Health Survey 2015, 83% of people with mental illnesses in India do not seek treatment, resulting in a treatment gap that is larger than in any other health sector (Gururaj et al., 2016). This could have major ramifications for the person, their family, and their community. Religious beliefs and willingness to seek help are two elements that determine help-seeking behavior (Choudhry et al., 2016; Tesfaye et al., 2020). Religion and religious activities are major aspects of life in India, and individuals routinely seek help from faith healers for mental health conditions. Treatment seeking may depend on perceptions of family members, peer groups, relatives, and community members who may be involved in treatment decisions involving mental health help-seeking behavior. Help-seeking traditionally may impinge on a variety of reasons, including the decision-maker's belief that religious practices cure mental illnesses, ease of access, the stigma associated with psychiatric consultations, strong belief in the supernatural origins of mental illnesses, insufficient knowledge about mental illnesses, and relatively scarce mental health services(Padmavati et al., 2005; Sagar et al., 2020). According to the bio-psychosocial spiritual model, individuals have spiritual needs in addition to biological, psychological, and social requirements. These needs are enhanced during times of sickness (Koenig, 2012). Accessing religious and spiritual resources may also aid the individual and family to cope with mental illnesses.
Societal beliefs and attitudes that drive help-seeking for adolescent mental health conditions are not adequately explored in our setting and rarely include multiple stakeholders including adolescents. To bridge this gap, our study aimed at exploring diverse stakeholder perspectives on mental health risks among adolescents, prevalent magico-religious beliefs, and mental health help-seeking using qualitative methodology.
Methods
Ethical considerations
Ethical clearance was obtained from Kasturba Medical College and Kasturba Hospital Institutional Ethics committee with IEC no:230/2015. The study areas included Udupi and Brahamavara educational blocks of Udupi taluk. Prior to data collection, approval was obtained from the Deputy Director of Public Instruction, Karnataka, and concerned school authorities. Written informed consent from parents of adolescents for their participation in the study and assent from the adolescents for audio recording was obtained prior to data collection. Participant information sheets (PIS) were provided as part of the informed consent process to the participants which clearly indicated that anonymized data from the study will be used for publication purposes.
Settings, study design and population
The study employed a phenomenological approach to study the lived experiences of the participants. The study area included two educational blocks of Brahmavara and Udupi under Udupi taluk situated in coastal Karnataka, south India. Our study adopted a qualitative design with focus group discussions (FGDs) and in-depth interviews (IDIs) and was conducted over a span of one year and three months between October 2018 and December 2019 among 70 participants using purposive sampling. Participants included parents of adolescents, high school teachers, adolescents aged 14–16 years and mental health professionals (MHP) and a pediatrician. Parents of adolescents were identified at the community level through healthcare workers. Apart from contacting them for the study, the researchers had no prior relationships established with the participants. They were contacted face-to-face and an interview/FGD was arranged at a time convenient to them in a private space. Prior to conducting the interview or FGDs, the participants were provided details of the study and the reasons for conducting the study. The FGDs for parents were carried out at an anganwadi’s after school hours Anganwadis are part of the Integrated Child Development Scheme which is a government initiative at the community level. The Indian school system consists of government, private and aided schools. An attempt was made to include participants (adolescents and teachers) from all three types of schools. Data collection with adolescents and teachers happened at the school in a private room. All interviews were conducted face-to-face. Two adolescents refused participation as their parents had not provided consent. Apart from the participants and the primary researcher, there was a note-taker from the research team present during the FGDs and IDIs. The primary researcher and note taker were trained in qualitative methods. The interviewer facilitated the interview to achieve the study objectives and did not impose on how the interview proceeded.
Data collection instruments
The qualitative approach was adopted, and data collection spanned between 2018 and 2019. Interview guides for parents, teachers, adolescents and MHP and other health professionals were developed following literature review and quantitative data analysis of our larger study involving multiple phases. These were validated by a team of health professionals including clinical psychologists, a psychiatrist and social workers. FGD and IDI guides are publicly available (Chandra Sekaran, 2023b).
Data collection procedure
In all, three focus group discussions (FGDs) and six in-depth interviews (IDIs) each were conducted among parents and teachers; one FGD and six IDIs among adolescents and six IDIs were conducted among mental health and other professionals (Pham et al., 2021). The interviews were conducted by the primary researcher. Note-taking during the interviews was also performed. Each FGD lasted for about an hour to an hour and a half while interviews lasted about 45 minutes to one hour. Written informed consent was obtained for the audio recording of the interviews. Parents of adolescents were approached with the help of community health workers while teachers and adolescents were recruited through the schools. The interviews were conducted in a private room to maintain confidentiality. There were no repeat interviews conducted. Data was collected until saturation. Transcripts were discussed by the research team only and participants were not involved beyond data collection.
Statistical analysis
Per participants' preference, the interviews were conducted either in the local language (Kannada) or in English. The Kannada transcripts were first transcribed verbatim and translated into English prior to analysis by native Kannada speakers well versed in English who were part of the research team. Thematic analysis was performed using Atlas.ti (version 8) to identify codes and code families following which themes were identified and are presented in Table 1. Open access qualitative data analysis software are available online such as QDA Miner for similar analysis. Several other software provide open access with restrictions for limited periods of time including Atlas.ti and MAXQDA. Thematic analysis involves reading each of the transcripts derived from both the interviews and FGDs are read through and coded. This enables identifying various meanings that may emerge across the data and how they may answer the objectives of the study. Coding was performed by three research team members with two repeated rounds of discussion to decide on the themes. Thematic analysis was both deductive and inductive. No feedback was sought from the participants.
Results
In all, 70 participants were included in this qualitative study including 12 adolescents aged between 14–16 years and 58 adults. Among the 12 adolescents, eight lived in nuclear families while four lived in joint families. All adolescent participants except for one had at least one sibling. Two male adolescents and four female adolescents participated in the IDIs with five of them residing in nuclear families and one in a joint family. Only one of them was a single child. The number of family members ranged from two to nine in numbers. The parents of the adolescent participants were employed largely as unskilled workers (n=20 out of 24 parents of adolescent participants).
Of the six IDIs among parents, three were conducted among fathers and three among mothers. Two FGDs were conducted among 15 mothers and one FGD among five fathers. A total of 26 teachers with teaching experience ranging from five to 22 years were recruited. Among the three FGDs with teachers, two were conducted in aided schools and one at a private school. The IDIs were conducted among three head teachers and three high school teachers and included one male and five female teachers from three private, two government and one aided school. Among MHP and other health professionals, the IDIs included two female and four male participants with a psychiatrist, a school counselor, a clinical psychologist, a pediatrician and two psychiatric social workers, all of whom were practicing at the time of the study. The major themes and sub themes that emerged from the study are listed in Table 1 and transcripts are publicly available (Chandra Sekaran, 2023a).
Perceived reasons for adolescent mental health conditions
Internet and smartphone use
Perspectives of each of the stakeholder groups were gleaned on the reasons that adolescents were at risk for mental health conditions. Parents, teachers and adolescent participants largely cited the increased usage of smartphones, the use of internet, social media including accessing pornographic sites as major reasons for emotional disturbances among adolescents.
They are bombarded with so many things around them, especially today. I think it's the mobile. It is just disturbing children the utmost”. (IDI, Participant 2, Female)
One girl, she was not yet using social media. Then, her friend came to class and telling about these things. She was attracted by that and she also joined social media. Then, their academic progress came down. (FGD 5, Participant R4, Male)
Mental health professionals concurred with these life experiences and stated that reduction in communication between the parent and the child as well as developmental changes and other external factors as leading to mental health risks among adolescents.
There are the normal physiological changes, biological changes, physical changes, hormonal changes which are occurring. They don’t know what is right, what is wrong. So, there are chances that they get into the wrong hands or wrong websites or pornography and later pornography addictions. (IDI, Participant 3, Male)
Bullying
Bullying was also cited as a major problem in the school setting. The emphasis on understanding the phenomenon of bullying in addition to bully victims was evident from the data.
Bullying is a major problem, very major problem. There is something called bullying within cycle. So, today’s victims are tomorrow’s bullies. In a recent research which we did in our department, what we see is that most of the students are bully victims. Bully victims are adolescents who have been victimized and they have bullied also. (FGD 1, Participant R6, Male)
The stigma surrounding mental health also prevented students from seeking the help they could receive at the school level for fear of being bullied about it.
When we go to school for interventions, if we call out one student for counselling that student is 100% bullied for coming for counselling. They are called ‘psycho’ or some other names. They are bullied just for coming to counselling. Without addressing these issues, I don’t think anything will be helpful. (FGD 1, Participant R6, Male)
The need to destigmatize mental health promotion and counselling at the school and community level is an important step in helping adolescents seek help at the right time.
Academic pressure
Expectations from parents to perform better in academics was also cited by teachers.
Maybe, the competitive parents, they always want their child to be toppers. So, that causes anxiety for the children. When they have that stress from their home that he/she has to get to a certain level, definitely anxiety will be more, isn't it? (IDI, Participant 2, Female)
Adolescents were an important stakeholder group who raised the concern regarding inter-parental conflict or substance abuse, commonly alcoholism, by either or both parents which caused conflict. The added burden of academics, they stated, caused them to have ‘tension.’
At home, when parents fight and then there is pressure from teachers to study, students only take tension. (IDI, Participant 2)
This problem is, I think, the main thing is family issues, may be broken family, single parenting all these things. (FGD 1, Participant R2, Female)
In the Indian context, the emphasis on academics as an indicator of the child’s development was also discussed in that parents may observe poor academic performance of their child and deal with this rather than recognize possible underlying mental health conditions, hampering early identification and treatment.
Magico-religious beliefs
Magico-religious beliefs describe cultural beliefs that people hold surrounding mental health. The etiology is credited to supernatural activities. The belief that one’s past deeds, either of the individual or of the family, were thought to affect the present mental state which was evident from the interviews. Use of horoscopes or birth charts that predicted life circumstances, ‘Karma’ or the cycle of good and bad, and ‘fate’ was quoted often by community participants.
These beliefs, right from many centuries, we have been following, and it is deep-rooted in our society; we are not ready to change, particularly in poor families. (FGD 3, Participant R2, Female)
It is not our misdeeds but theirs. People who are mentally strong will have the ability to face it. But who are mentally weak will become victims easily. Sometimes it is fate. (IDI, participant 5, Female)
Interestingly, adolescents were also able to recount instances of observing practices that they termed ‘black magic.’ These narratives indicated the intergenerational transmission of such societal beliefs.
Astrologers cannot help. With sorcerers (magicians), it is possible to heal. They will do some black magic. It will cure mental illness. They will give something which they will keep in one place. If somebody crosses over that, the illnesses will pass on to that person. (IDI, Participant 3)
Among individuals with higher education and teachers, it was found that some participants questioned these beliefs.
We can see among the educated; they don’t follow such things because of media and awareness among people. (FGD 3, Participant R2, Female)
Almost all community stakeholders (98%), however, ascribed their belief in God to work things through for them.
Mental health help-seeking for adolescents
Perceived Stigma, fear of discrimination from the community and labeling as barriers to help-seeking
Association with terms such as ‘mental’ or ‘mad’ are deeply stigmatizing. The belief that mental health help-seeking meant taking treatment for life and its associated side effects were barriers that were identified. As stated by a participating teacher:
When we inform them (parents) to take help from the medical professionals, immediately they say that my child doesn’t have a problem. They never ever understand that, even mind will be sick. Immediate reaction is, they reject: “No, my child is healthy” (IDI, Participant 6, Female)
Once they start giving the pills and all, they will undergo depression and I don't know how much it will help them. (IDI, Participant 1, Female)
However, participants stated that perceptions towards reaching out to professionals for mental health help were changing.
But now, I feel it is not like before. Earlier, people who are taken to the mental hospital were considered as ‘mad.’ Now, people’s approach has changed. Now, people have started calling it ‘psychological problem’ instead of madness. (IDI, Participant 5, Female)
Traditional means of care
Help-seeking was found to be complex with community determinants and personal beliefs driving it. Participants from the community stated that deity belief, performing puja (religious rituals), or having their ‘horoscope’ checked would help in managing it.
We have our own deity in our house which belongs to our family and soon we are going to have puja which we perform every year. All that we have done, nothing is pending” (IDI, Participant 5, Male)
Mental health professionals stated strong beliefs surrounding supernatural entities led people to seek traditional healers, and that these magico-religious beliefs helped people cope.
Effect of evil powers, effect of the stars, birth stars and effects of people who have died in the family, those things still exist. And these sorts of some magico-religious beliefs definitely will help psychologically.” (IDI, Participant 3, Male)
Teachers and religious leaders as a bridge in the referral gap
Regarding providing referral to adolescents, most schools it was observed, did not have counselors. Among those who did have counselors, they were important in the chain of referral.
Even counselors themselves will refer. They work out from their side and refer. (FGD 5, Participant R2, Female)
In the absence of counselors, teachers largely took on the role of counselors themselves. Interviews with teachers brought about insights into their informal role as channels of liaison. As one teacher shared:
His (student’s) family members were saying that it is due to the possession of a spirit. Then, the headmaster called the parents and told them -‘I am not against your belief but he can be corrected if you take him for counselling.’ Family members agreed to take him and gradually, he improved. (FGD 3, Participant R2, Female)
Some schools took initiative and also provided mental health awareness programs.
We have so many programs in the school. We call doctors or we call other organizations during special days. By different resource persons, we try to give more awareness to the children. Because of that, such problems are less in our school. (FGD 3, Participant R2, Female)
It was of interest that religious leaders also played the role of agents of referral in the community.
I see a lot of them (mentally ill individuals) over there (at the temple). And they also have that main person (the priest). He supports professional help and in fact, he tells many people who go to the hospital. I have heard him recommending: “You go and speak to the doctor there. (IDI, Participant 2, Female)
Promotion of adolescent mental health
At the family level, parents recognized that communication between family members was key. Family support with love and supportive school environments were thought to be important in nurturing adolescents.
Affectionate talk has to be there; it should be by parents as well as family members, even teachers also should talk affectionately. They expect love and affection. (FGD2, Participant R2, Female)
The fear associated with stigma appeared to be a major barrier in seeking help. The MPH recounted that behavioral disturbances during adolescence were seldom brought to their notice. The knowledge that the first episodes of mental disorders can appear in early adolescence and were a risk for suicides was not common knowledge among parents and teachers.
What we observe is that the initial episodes during adolescence is missed sometimes. Only when they come for help as adults, they will give a history that during his high school, he had these problems. We see mental illnesses are directly leading to suicide rates too. (IDI, Participant 3, Male)
Parents and teachers thus needed to be equipped with awareness on what could be considered normal versus abnormal behaviors among adolescents.
Psycho-educate them regarding what is normal behavior and what is abnormal behavior in adolescents. (FGD 1, Participant R2, Female)
Imparting life-skills education (LSE) to adolescents through schools was seen as another important preventive measure. While some central schools did, this was not ubiquitously adopted by others.
Giving full attention to adolescent health until they are 22 years or so, we are creating very strong and physically and mentally healthy adolescents. With life skills being taught to them, it becomes an armor to prevent them from future problems. (IDI, Participant 3, Male)
These findings indicate the perceptions at the community level on adolescent mental health and the need for promoting mental health at the school and community levels as opined by mental health professionals.
Discussion
This qualitative exploration was undertaken to explore facets of adolescent mental health from the viewpoint of multiple stakeholders including middle to late adolescents, high school teachers, parents of adolescents, MHP and a pediatrician. Since the study was conducted at the community level, our findings elicited community-held beliefs and attitudes indicating pathways and barriers to seeking care. Concerning risks for adolescent mental health conditions, most stakeholders including adolescents perceived that increased device or internet use, accessing pornographic material, academic stress, as well as supernatural causes, contributed. Literature supports the findings that unhealthy internet use can lead to addictions and can negatively impact physical and mental wellbeing (Camilleri et al., 2020; Chao et al., 2020; Pal Singh Balhara et al., 2019; Yu & Chao, 2016). These findings mirror that of Choudhry et al. in their meta-synthesis (Choudhry et al., 2016). Parental expectations and academic pressures (Jayanthi et al., 2015) as well as parenting factors(Sekaran, Ashok, et al., 2020; Sekaran, Kamath, et al., 2020) have been linked to a rise in mental health conditions among adolescents. Legislative measures to limit harmful internet exposures while reinforcing awareness on potential benefits and risks for adolescents is the need of the hour.
Cultural beliefs and help-seeking behaviors were found to be highly connected. Seeking help from MHP was not the initial recourse sought toward the mental health of adolescents. Barriers to help-seeking included stigmatizing cultural perceptions to labels such as the use of the term ‘mad.’ Kar (2008) describes similar belief systems prevalent in Orissa, India. A considerable proportion of patients and families asserted beliefs in ‘Karma’ or ‘fate’ and found faith-healing reassuring and more acceptable (Kar, 2008). Participating MHP recognized that seeking help from traditional providers was an important part of psychological coping. However, resorting to help seeking from traditional healers may also delay early intervention. Sensitivity to these belief systems is important for practicing mental health professionals.
Though magico-religious beliefs appeared to be barriers in seeking early professional help, the integration of spiritual care in the context of health has been discussed in the literature (Kar, 2008; Roy et al., 2020). In the South Asian context, a study focusing on traditional healers and MHP in Nepal recommended integrating referrals and training traditional healers (Pham et al., 2021). Estrada et al. reported that integrating religious education can promote mental well-being among adolescents (Estrada et al., 2019). School counselors, teachers and even religious leaders in the community may act as effective liaisons in bridging adolescents to seek timely help from MHP as was comparable to findings in other settings (Long et al., 2017; Prabhu et al., 2021; Thomas et al., 2020). There is an urgent need to equipping the existing school system with competent counselors to aid mental health promotion among them.
Conclusion
In conclusion, our study elicited community stakeholders’ beliefs and attitudes towards the mental health of adolescents and help-seeking behavior. Increasing mental health awareness and equipping adolescents with the right coping strategies and establishing pathways to early referrals were important takeaways from this study. Targeting the community on sensitizing and destigmatizing issues surrounding mental health emerged as an important step in this direction. There is a need for further studies on interventions at the community and school levels targeting important stakeholders.
Author contributions
Vidya Prabhu
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing
Varalakshmi Chandra Sekaran
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Lena Ashok
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Brayal D’Souza
Roles: Formal Analysis, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Ravichandran Nair
Roles: Formal Analysis, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
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how to cite this article
Prabhu V, Chandra Sekaran V, Ashok L et al. Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India [version 1; peer review: 1 not approved]. F1000Research 2023, 12:362 (https://doi.org/10.12688/f1000research.130101.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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How to cite this report:
Daher-Nashif S. Reviewer Report For: Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India [version 1; peer review: 1 not approved]. F1000Research 2023, 12:362 (https://doi.org/10.5256/f1000research.142831.r207415)
The direct URL for this report is:
https://f1000research.com/articles/12-362/v1#referee-response-207415
https://f1000research.com/articles/12-362/v1#referee-response-207415
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 19 Oct 2023
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This qualitative study aimed to explore perspectives of parents, adolescents and educators on adolescents' mental health experiences, perceptions and help seeking behaviours. The authors present an important topic and interesting findings, but major methodological and ethical issues are raised in
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Daher-Nashif S. Reviewer Report For: Magico-religious beliefs, stigma and help-seeking for adolescent mental health at the community level – A multi-stakeholder qualitative exploration in southern India [version 1; peer review: 1 not approved]. F1000Research 2023, 12:362 (https://doi.org/10.5256/f1000research.142831.r207415)
The direct URL for this report is:
https://f1000research.com/articles/12-362/v1#referee-response-207415
https://f1000research.com/articles/12-362/v1#referee-response-207415
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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