The key findings of this qualitative study among women from rural Maharashtra participating in a well-established PHC project are summarised as follows: The women viewed the determinants of mental health and illness as predominantly cultural and socio-economic; mental health was commonly conceptualised as an absence of stress and the most commonly identified stressors were conflict with husbands and mother-in-laws, domestic violence and poverty; women's mental health and women's empowerment were inextricably linked for these participants; and the CRHP's activities were perceived to be effectively addressing the determinants of mental health, but a range of mental health problems were also highlighted.
India is characterised by a range of diverse cultural and philosophical systems, mixed in recent years with Western modes of thinking, making it difficult to identify a uniform Indian paradigm of mind and mental health [21
]. Furthermore, acceptance of allopathic forms of treatment does not necessarily equate with acceptance of the bio-medical perspectives that underpin such treatments, and many explanations for mental illness can be found [22
]. Depressive illness is understood by some using a Western bio-medical framework, and by others using more traditional concepts such as Aryuveda that attribute illness, including mental illness, to an imbalance of humours and/or heat and cold. Supernatural, astrological and religious explanations are also common including karma, evil-eye and spirit possession [13
The women in our study had a concept of mental health and depressive illness that is characterised by the presence or absence of 'pressure', 'worries' or 'tension', which roughly equates to the Western concept of stress. They understood mental health and depressive illness to be the product of relational and economic factors that contribute directly to the presence or absence of stress in women's lives, and consequently their mental health and well-being. Although our findings are similar to those of other authors who investigated explanatory models for depressive illness among Indian women [4
], it is interesting that no participant in this study mentioned religious, super-natural, karmic or astrological factors. The absence of these explanatory models may have been due to participants' unwillingness to disclose them as the CRHP's health education program discourages such beliefs. On the other hand, no participant suggested that an imbalance of humours, heat and cold, or chemicals within the brain or body are the cause of mental illness, even though explanatory models such as these are compatible with traditional and allopathic systems of healing supported by the Project.
The women in this study attributed the development of mental illness exclusively to strained relationships and deprivation. Follow-up research is indicated to explore how they might explain the advent of mental illness in a woman who is living in comfort and has a good relationship with her husband and in-laws. Additionally, it is not clear that their explanations for more serious mental illnesses such as schizophrenia would be the same as those outlined above. Supernatural explanations may be more relevant in such cases.
The relational and economic factors identified as determinants of mental health for women were primarily external to the women themselves, and often beyond their control. Essentially, if a woman is lucky enough to be married to a man who does not drink or gamble, remains faithful and earns some money, and the mother-in-law does not harass her, and she has sons, then she will have good mental health. As Indian village women are usually unable to earn their own money, cannot influence the sex of their child, and are rarely able to choose their husbands and mothers-in-law, the perceived determinants of their mental health and well-being are located largely outside their control. A constellation of reasons including socio-cultural expectations, their own sense of duty and obligation, and financial dependence on others make it difficult for women in conflicted family situations to escape. For many this has a negative impact on their mental health.
The women identified a range of ways in which the CRHP assisted them to gain a measure of control over their own lives. They frequently acknowledged that the opportunity to independently earn money resulted in a range of positive changes at both the individual and family levels. In turn, this was seen to have a direct and desirable impact on mental health. Increased freedom of movement and greater participation in decision-making were linked to economic participation, and these were also seen as important for women's sense of competence and control, and consequently for their mental health.
Descriptions of suicide were commonplace in this study and a range of reasons for suicide were provided including family conflict, financial difficulties, alcoholism, violence and failure to produce a son. The pattern of suicide in developing countries such as India is different from that observed in developed countries. For example, the male to female ratio for successful suicide in developed countries averages 3:1 whereas in India it is 1.4:1 [25
]. The most common means of suicide in India are pesticide poisoning, hanging, self-immolation and drowning, and this was reflected in the findings of this study. The descriptions of attempted and completed suicide in most of the interviews highlight the seriousness of this problem in rural Indian communities, which is well-recognised elsewhere in the country [26
]. There is a significant problem of young married women committing suicide, often in relation to dowry demands and conflict with the husband and parents-in-law [28
]. In south India suicides accounted for 8–12% of total deaths, and women aged 15–24 years were more likely to commit suicide than males of the same age (164/100,000 vs
A strategy for effectively integrating mental health into PHC includes promoting mental health by addressing the key determinants of social inclusion, freedom from discrimination and violence, and economic participation. From the perspective of the study participants, CRHP interventions are successfully addressing the determinants of mental health and have positively changed the lives of many people, especially women. However, suicide, violence, alcohol abuse and other mental health problems remain major concerns for women, their families and communities. Extending the reach of the Project so that it more actively addresses the inter-linked problems of violence and alcohol abuse would likely benefit both men and women.
When interpreting these findings a number of limitations should be kept in mind, some of which are inherent to research conducted in a resource-poor setting. A number of biases are possible as the sample was self-selecting: women whose lives had been affected in some way by a mental health problem or women who felt particularly indebted to the CRHP may have been more likely to participate. The possibility of social acceptability bias influencing some responses also needs to be considered as the interviewers were not independent of the Project. The sample size is not large, but a larger sample size is unlikely to affect the findings as data saturation was rapidly reached.
It is difficult to assess to what extent the perceived changes in attitudes and behaviours reported by these women are attributable to the influence of the CRHP and how much is due to wider social changes in India itself. However, the reported benefits of CRHP on the well-being of women specifically and the community generally [17
] suggest that the women connected to this Project may be in a unique situation. Views of women from other areas of rural Maharashtra could well be different. The findings reported here reflect participants' perceptions, which may or may not accord with reality. Further systematic investigation is needed to quantify the prevalence of and risk factors for mental illness, suicide and violence in the Jamkhed community.