Depression in women; perceptions do matter in the development of a community-based intervention

Depression is two times more prevalent among women; however women’s access to mental health care is poor and many do not seek care even when they are referred to a mental health professional.  We conducted a qualitative study to understand the perception of key stakeholders about the burden of depression in women, its risk factors and barriers to seek care, with a view to develop a community based intervention to manage depression among women.  We interviewed women with depression, their family members, community volunteers, multipurpose health workers, primary care physicians (PCPs), psychiatrists, psychologists, social scientists, public health experts, gender experts, administrators and policy makers. The 49 audio-recorded in-depth interviews and one focus group discussion were transcribed, free-listed, coded and content analysis was performed. Stakeholders perceived that burden of depression was substantial; but mostly unidentified because complaints were somatic or anxiety-related and in many situations symptoms of depression remained unvoiced. The suggestions from stakeholders were consolidated as follows; community and family level interventions should address gender issues, autonomy of women, alcohol use among partner, marital conflicts, domestic violence, financial problems, and unemployment. Partners and other family members need to share the routine household responsibilities. Primary care is an ideal setting to implement a sustainable intervention for depression management, with re-orientation and training of existing health care providers. However there were explicit differences in the perceptions of women with depression and many other stakeholders regarding who should be involved to provide psycho social interventions. Many health workers, local leaders and community volunteers suggested involving local volunteers for social support; however, women and their family members preferred the multipurpose health workers.  Multipurpose health workers, who carry out home visits, as part of their routine work, were the most acceptable to women with depression. Multipurpose workers can screen for depression at the field level, refer the screened positive women to primary care physicians for diagnosis and treatment and provide psychosocial support. Primary care physicians can provide the drug treatment and supervise psychosocial intervention provided by multipurpose workers or junior public health nurses. We propose a model for community based intervention, which is more relevant for settings with limited resources in mental health care.