Contribution
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Udaan- Soar

“Let your story take flight.”

Udaan will empower marginalized youth with mental illnesses in Uttar Pradesh, India by facilitating the publication of a collection of their personal stories, poetry, and art. Trained peer support workers will deliver therapeutic interventions and encourage the creation of marketable artwork and stories of youth struggling with mental illness to allow others to understand mental illnesses.

Adolescents progress through an important developmental stage between the ages of 10-19. During this phase of psychosocial development, adolescents explore the world to form a basic self-identity, setting the basis for many social and health behaviours for years to come. Unfortunately, in a country where one-fourth of its population is comprised of adolescents, Indian youth also exhibit some of the highest rates of psychiatric morbidity (depression, conduct disorder, social anxiety, panic disorder). Data from community based studies shows that, in a country of 225,062,738 adolescents (World Bank Group, 2016), the general prevalence of psychiatric morbidity is 23.33% amongst students (Malhotra & Patra, 2014).

Despite the high prevalence of mental illness in India, there is a significant treatment gap; only 4000 psychiatrists serve a population of over 1 billion (Mohandas, 2009). Both under-equipped government psychiatric services, and economic barriers result in a significant population left to combat their illness on their own. This not only hinders economic growth and productivity, but also puts a greater strain on the healthcare system as mentally ill patients often present comorbidities such as cardiovascular disease and diabetes (Thirunavukarasu, 2010).

According to the World Health Report, those with lower income are more likely to suffer from mental and behavioral disorders and more likely to suffer poor outcomes as a result of their illness. Uttar Pradesh, India’s most populous state, has a population of 200 million, with 60 million living under the poverty line (World Bank Group, 2016). As students in Uttar Pradesh are met with challenges of socialization, academic stress, income status, and limited mental health services, the state is an ideal target demographic to introduce a mental health intervention.  

Alongside the challenge of meeting daily expectations, students also face significant societal stigmas and a lack of awareness amongst family members of mental illness. Analysis of community mental health highlights the potential of community based interventions; however, without family and community involvement, these interventions are often unsustainable (Thara, Padmavati, Aynkran, & John, 2008). As patient care continues to evolve, narrative medicine is being incorporated into traditional health care to allow patients to share their story and offer personal insights into their situation. Narrative medicine allows healthcare providers to bear witness to the patient’s’ suffering and offer optimal personalized care.

Cognizant of the current conditions and challenges faced by Indian youth, especially those of low-income status, Udaan proposes an evidence-based innovation that will empower adolescents to take ownership of their stories and validate mental illness. The solution is two fold: first, Udaan will work with students to publish an anthology that will comprise of patient narratives in the form of short stories, poems, and other means of artistic explorations. By encouraging students to share their stories, Udaan hopes that individuals will have the chance to think deeply about the various parts of their journey, the intersectionality of their identities, and how they have given rise to a unique story. Through this means of self-exploration and finding their voice, we hope to support students in sharing their story as a means of building their own resilience and allowing their journey to help others as well.

The production of the anthology depends on student involvement and resource allocation. In order to support students while they write and produce their stories, peer support workers will be instrumental in leading therapy sessions and connecting students to appropriate healthcare resources. At these therapy sessions, participants will be encouraged to express their experiences with mental health in whichever medium they find meaningful, discussing root causes of their illness, challenges they’ve faced, perceptions of available resources, and how they are hoping to recover. It is our hope that through these artistic expressions will help community members, parents, and other students understand the nature of mental illnesses experienced by youth in their community. By raising awareness of mental illnesses and their legitimacy, this will allow for a more supportive environment for patients to seek treatment.

Udaan aims to collaborate with one of India’s most influential non-governmental organizations, Sangath, to leverage existing community resources to provide appropriate psychological and social therapies for adolescent mental health. The peer support workers will primarily consist of senior students who have experienced some degree of mental illness. These peer support workers will be expertly trained under the guidelines provide by Sangath and work closely with experienced counsellors and mental health professionals to ensure the success of the initiative (“Sangath: What We Do-Workshops,Training & Conference”, 2016).  

Along with establishing partnerships with key stakeholders, Udaan will be heavily involved in the editing and publication process of the anthologies. While the original stories and artwork will remain the property of the students themselves, Udaan will empower students to publish their works in order to reach a wider audience. By facilitating sales to non-governmental organizations, hospitals, schools, the general public, and other potential consumers, and allowing local youth to sell the anthology, our organization truly embraces a market-based philosophy.

In a country where the validity of mental health as an illness often comes under scrutiny, it is the stigma that first needs to be treated before health care services can be used effectively.

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Unanswered Questions

While our solution is cognizant of the stigma of mental illness in India and aims to reduce it in hopes of helping students come to terms with their condition and seek treatment, the treatment itself needs to be made accessible. Our proposal involves training peer support workers to interact with and assist students in dealing with mental health conditions. However, some cases may require interventions that are more involved than expressive arts therapy. Even after the the stigma of mental illness subsides, how will adequate primary and specialized care be delivered in rural settings? In order to meet this challenge, a more comprehensive, policy-based intervention is necessary to increase the training of clinicians in mental healthcare, and make existing services more accessible.

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Critical Assumptions

1. Students will be willing to share their stories despite the existing stigma in their communities
One of the greatest strengths of this product is that it uses a participatory methodology; representatives of our target group provide their input in creating a solution for the challenges they are facing. This makes the intervention not only unique to the target population, but appropriately addresses the right issues in a culturally safe manner. While initial acceptance and involvement may be a barrier that needs to be overcome, past innovations serve as models for the success of co-innovation.

2. There are students that will be willing to act as peer support workers and facilitate group therapy sessions
In light of India’s limited resources, healthcare strategies must be cost-effective and involve all stakeholders. With only 4000 mental health professionals available to serve a population upwards of 1 billion, there are significant challenges to be overcome with this treatment gap. As health systems have also evolved to address urgent, more immediate healthcare concerns, non-communicable and mental health diseases often do not receive the attention they deserve. While there is a shortage of medically trained mental health professionals, the highly populated country is a rich source of manpower. One of India’s most successful NGOs has leveraged this resource through the training community lay workers in providing mental health care. The success of community empowerment through individuals with relatable life experiences is widely established in literature through the management of other chronic diseases including diabetes (Aswathy, Unnikrishnan, Kalra, & Leelamoni, 2013).

3. Successful community partnerships and cultural acceptance will be established
It is not clear whether a lack of cultural acceptance of mental health was influenced by a lack of mental health services or if the limited resources resulted in a lack of awareness of mental illnesses. Studies monitoring the management of the chronically ill through community based mental health programmes suggest that lack of access, cost of treatment, limited knowledge, and health care provider dependance to provide solutions that presented major challenges to the success of interventions (Thara, Padmavati, Aynkran, & John, 2008). By involving students, their families, and communities throughout the production of the anthology, we intend to ensure the initiative is sustainable.

4. There is sufficient market interest in our intervention, and anthologies.
Ensuring sufficient market interest is a challenge that accompanies any new innovation. Udaan has identified potential consumers, an established marketing plan, and a critical that needs to be solved. The anthology serves as narrative based art therapy for students suffering from mental illness that can then be a means of awareness for community members and other students experiencing similar challenges. The product’s primary consumers will be schools and health care providers that can purchase the book to be shared amongst students and patients. Ultimately, the anthology will be available in bookstores for mainstream consumers to purchase for household use as informative stories for parents and children. As the innovation is created by community members, each issue of the anthology will be unique. This characteristic makes it highly adaptable to community needs, and provides scope for broadening the topics discussed in the anthology depending on the community and consumer interests.

Most Significant Challenge

Our current solution aims to reduce the stigma surrounding mental illness among adolescents. However, we also need to address the stigma against mental illness and psychological disorders amongst Indian doctors so they are better equipped to reduce the treatment gap. Research has shown that doctors are demotivated to specialize in psychiatry by the lack of patients stepping forward to seek treatment for their mental illnesses. This presents a dangerous feedback loop as it prevents the provision of care for those with mental illness even if they have acknowledged their condition.

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