title: Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration.
abstract: BACKGROUND
  There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.
  
  
  METHODS
  Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥ 5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.
  
  
  RESULTS
  We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.
  
  
  CONCLUSIONS
  Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.
authors.affiliation: University College London Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK. k.clarke.09@ucl.ac.uk.
authors.forename: Kelly
authors.initials: K
authors.lastname: Clarke
authors.forename: Naomi
authors.initials: N
authors.lastname: Saville
authors.forename: Bishnu
authors.initials: B
authors.lastname: Bhandari
authors.forename: Kalpana
authors.initials: K
authors.lastname: Giri
authors.forename: Mamita
authors.initials: M
authors.lastname: Ghising
authors.forename: Meena
authors.initials: M
authors.lastname: Jha
authors.forename: Sonali
authors.initials: S
authors.lastname: Jha
authors.forename: Jananee
authors.initials: J
authors.lastname: Magar
authors.forename: Rinku
authors.initials: R
authors.lastname: Roy
authors.forename: Bhim
authors.initials: B
authors.lastname: Shrestha
authors.forename: Bhawana
authors.initials: B
authors.lastname: Thakur
authors.forename: Rinku
authors.initials: R
authors.lastname: Tiwari
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.forename: Dharma
authors.initials: D
authors.lastname: Manandhar
authors.forename: Michael
authors.initials: M
authors.lastname: King
authors.forename: David
authors.initials: D
authors.lastname: Osrin
authors.forename: Audrey
authors.initials: A
authors.lastname: Prost
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005190:Family / Q000523:psychology; D005191:Family Characteristics; D005260:Female; D066296:Grounded Theory; D006801:Humans; D007182:Income; D008875:Middle Aged; D009035:Mothers / Q000523:psychology*; D009390:Nepal / Q000453:epidemiology; D011247:Pregnancy; D012111:Residence Characteristics; D012424:Rural Population; D013315:Stress, Psychological / Q000453:epidemiology* / Q000523:psychology*; D055815:Young Adult