Thinking, Feeling, Choosing: How Affect Is Reflected in Prostate Cancer Treatment Decision Making-A Qualitative Study.

Poor mental health is recognized as a major global health issue and remains among the ten leading causes of disease burden worldwide. Meeting the rising need for mental health support and treatment remains a major challenge, particularly in low- and middle-income countries (LMICs). At the same time, scholars within the field of global mental health have questioned the applicability of universal, biomedical, and predominantly Western approaches to addressing these needs. These critiques extend to dominant conceptualizations of mental health, including the WHO definition, which has been challenged for its Western-centric orientation, cultural inappropriateness in some contexts, and tendency to medicalize and individualize experiences of distress. We echo these considerations and use the term ‘mental health’ more in line with the definition of Galderisi et al. 2015 (p.231 f.) as “a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society”. Communities that are particularly vulnerable to mental distress are often the most underserved. This imbalance is accelerated by climate change and changes in the social and natural environment with direct and indirect effects on mental health, such as depression, increased suicide rates, or withdrawal. In Bangladesh, mental health services and research following the tenets of the WHO definition are limited, with formal – as in institutionalized – mental health services existing only in major cities and being almost non-existent in rural, poor communities and stigma towards mental illness being pervasive. 18,7% (about 31 million people of a population of nearly 170 million) of Bangladeshis are considered to have a ‘psychiatric disorder’ such as depression or anxiety. However there are only 260 registered psychiatrists, and less than 0.5% of national health expenditure is allocated to mental health. Local mental health concepts in Bangladesh are scarcely researched or described, but the limited evidence there is reflects fundamentally different frameworks from Western psychiatric models across explanatory systems, intervention approaches, and epistemological foundations. Supernatural and spiritual explanations and deprivation in different areas of life are considered to be the root causes of mental ill health, and community-based, collective help-seeking are modes of healing. Additionally, concepts and terms used show incompatibilities with Western approaches. Community-based mental health services in underserved areas can be an essential support for common mental disorders and community-based support delivered by community health workers (CHWs) has been shown to be an effective way to deliver health services. Community services promise to be most relevant for and adapted to the local context and culture, thereby being needs-driven and sensitive to local beliefs and understandings. Community tailored services increase acceptance among communities and leads to more effective and efficient service delivery. In addition, increased feasibility and cost-effectiveness of community services are important considerations when designing health care interventions. Such services often use effective talk-based therapies but are resource-poor, delegated to lay-counselling approaches, and provided by health workers without a clinical degree. This common and often a-priori model of ‘task-shifting’ means that service provision can be altered from the initial conception or model of care envisioned by clinical practitioners, as community services operate and are delivered in ways that are fundamentally redefined by the context, available resources, and training. Through shared roles and responsibilities, lay mental health services shape understandings and definitions of mental health beyond biomedical frameworks and can be especially relevant in places where concepts of mental distress, its acceptability, diagnosis and treatment are defined differently or less recognized as support-needing and coincide with additional environmental stressors as a result of climate change. In Bangladesh, community health services play an important role in the pluralistic health system and often act as the first touchpoint for people in need in underserved areas. However, as in many LMICs, Bangladeshi community health services have mainly focused on the acute physical health needs of the community, leaving a dearth of research regarding the type, availability, acceptability, conceptualization, and access to mental health services.