Supporting 'community' in an era of global mental health : a case study of an HIV-affected South African community

How may the mental health of socially deprived HIV/AIDS affected communities be supported in an era of ‘global mental health’? To date, ‘community’ efforts have been informed by a largely biomedical and epidemiological body of evidence, distracting attention from lived realities, local contexts and their abilities to frame understandings of mental distress and treatment. This thesis seeks to contribute a productive critique of the Global Mental Health field, by expanding on some of the missing dimensions in their conceptualisations of health and healing. Through a focus on social psychological processes of community, knowledge and social change, it formulates a series of suggestions for how the Movement for Global Mental Health (MGMH) and other policy actors can build on their existing efforts, through establish health enabling contexts where communities actively participate in addressing mental distress, and tackling the contexts that constitute distress in locally relevant ways. The thesis reports on a case study of KwaNagase (Manguzi), an HIV-affected rural community in KwaZulu-Natal, South Africa. It takes interest in the intersection of three respective groups, exploring how they understand, cope with, and work together in efforts to support mental well-being: 1) poor HIV/AIDS affected women experiencing mental distress; 2) community level supports (local NGOs and traditional healers); and 3) public health services (primary health sector). Data was collected over a three month period using multiple methods. In-depth individual interviews (n = 43) were triangulated by a motivated ethnography (Duveen and Lloyd, 1999) that explored local cultural, structural and symbolic contexts of community that frame understandings of mental health and delivery of care. Grounded thematic analyses identified that women’s understandings of mental distress were shaped by experiences of poverty, violence and HIV, which in turn, limited their ability to meet normative expectations linked to gender roles of ‘mother’ and ‘wife’. Indigenous psychosocial coping strategies employed by women to tackle the aforementioned drivers of distress were underpinned by the presence or absence of social psychological resources that optimise health and well-being: agency, partnerships, critical thinking and solidarity. Primary mental health care actors’ (NGOs and formal health service actors) understandings of women’s distress were informed by an awareness of the structural and symbolic issues facing women in everyday life, aligning with the women’s own understandings. Their best practices highlighted efforts to establish receptive social spaces – a critical dimension of health enabling contexts but were limited by symbolic and structural barriers such as stigma among providers, and general under-resourcing of the sector. To overcome the limits facing community mental health services in Manguzi and similar contexts, the thesis concludes by highlighting a series of suggested actions to bolster identified community mental health competencies, and provides a tool kit of recommended strategies to support existing public sector efforts to promote mentally healthy communities.