The Big Picture:Adapting PhotoVoice to enhance psychological, social & cultural insights into & prevention & treatment of youth substance use in India

Lead Research Organisation: University of Leeds
Department Name: School of Psychology

Abstract

This project focuses on understanding the lived experience of young Indian people around risk, recovery and resilience in relation to substance use disorder (SUD). The goal is to increase knowledge, enhance the voice of young people, and inform practice through impacting policy and promoting public awareness. Our visual participatory method - PhotoVoice (PV) - centralises the lived experience of young people in efforts to understand, prevent and intervene - at both a service and policy level - in substance-use-related mental health difficulties in India. The research will be conducted in Assam and we will explore transferability to other Indian States.

Global mental health strategies prioritise adolescents given their potential trajectory towards lifelong disadvantage. Poor mental health in young people is also a risk factor for SUD, and the Childline Foundation reports that 13% of people using substances in India are children. In the National Mental Health Survey of India 2015-16, Assam has the lowest prevalence of mental disorders so offering an opportunity to understand psychological, social and cultural resilience. Even so, in Assam stigma around mental health problems is high, the treatment gap immense, and The Assam Report of The India Survey classifies adolescent SUD as an urgent problem.

Our aims are to:
-enhance psychological, social and cultural insights into the experience of risk, resilience and recovery with regard to youth substance use in Assam
-promote young Assamese people's voice with respect to substance use in order to reduce stigma, raise public awareness and inform mental- and public-health policy and practice
-learn if and how PV can be adapted in culturally-sensitive ways to enhance local mental health services seeking to prevent and treat youth substance use in Assam.

We will conduct photo-led interviews with: (i) ~fifteen 15-18 year olds successfully refraining from substance use despite being at increased risk; and (ii) ~fifteen 19-24 year olds in successful recovery from SUD. These will be analysed using Thematic Analysis to explore protective and enabling factors around risk and recovery and will shed light on complex psychological, familial, social and cultural pathways to, and away from, SUD. Our innovation of PV is to extend it to participatory film-making. Hence, participants will be invited to make a poster of their photos to inspire ~6 short, resilience-focused films on the issues at stake and the changes they feel could best address them.

We will also explore how evidence informs mental health policy and practice in Assam. We will review key policy documents and conduct ~15 interviews with purposefully-sampled stakeholders. Material will be analysed using Framework Analysis. We will hold 3 stakeholder workshops to credibility check our assessment of conceptualisations, practices and research-policy pathways, and to help plan public awareness and policy-directed activities.

In relation to potential applications and benefits we will:
-launch a social media mental health photographic campaign to raise awareness and understanding of how young people manage risks around substance use in order to stay well;
-strengthen research capacity through training staff in our Partner Organisations in the design, delivery and analysis of PV and support them drive implementation where it will improve services;
-promote PV as a low-cost, easy-to-implement tool initially targeting prevention and treatment of SUD;
-develop an ESRC-compliant, open-access, educational, and resource e-mental health website including easy-to-use, culturally sensitive guidance on how to deliver, analyse and evaluate PV mental health projects, through to flexible ways that outputs can inform service development;
-engage with key decision-makers pan-India who are able to facilitate wider service and/or policy level implications of outputs and contribute to the development of an Assam State mental health policy.

Planned Impact

We anticipate the following people and organisations will benefit from this research in the following ways.

Young Indian people at risk of, and suffering, substance use disorder (SUD)
We will communicate our research so as to raise awareness of substance use and mental health from a young person's perspective and prompt new conversations about risk, recovery and resilience. First, we will organise a public and policy awareness exhibition in central Guwahati. (Potential) service users, Partner Organisations and other stakeholders and policy-makers will be invited to a public discussion of project implications. Second, the exhibition and related workshop will be taken to a large health policy event in Karnataka. Third, the exhibition will form the cornerstone of a knowledge and cultural exchange event hosted by Leeds Cultural Institute at which our Consultant from MIND India (Goswami) will be key speaker. Fourth, we will launch a social media mental health photographic campaign to raise awareness and understanding of how young people manage risks around substance use in order to stay well.

Partner Organisations
We will strengthen research capacity through training staff in each PO in the design, delivery and analysis of PhotoVoice (PV) and will support them drive implementation where it will improve services. We will invite trained staff to join Emerging Voices for Global Health of which Prashanth of our Advisory Group is Chair.

Mental health service delivery organisations pan-India and, potentially, globally
We will promote PV as a low-cost, easy-to-implement tool initially targeting prevention and treatment of SUD. Through planned workshops and Steering Group meetings, we will explore the response of our POs to experience-based knowledge, collaborate to utilise knowledge gleaned for organisational development and be advised by them - and by our Advisory Group - on facilitators and barriers to the uptake of PV by other mental health services and users in India. We will communicate our project widely to stimulate interest from mental health organisations beyond Assam, beginning with our launch at MIND India's International Conference on Positive Psychology where we will hold a workshop with key stakeholders to discuss project aims and situate it in local context. We will continue to establish new connections via MIND India and our Advisory Group, appointed to represent North, South, Southwest, and Northeast India. We will select 3 prominent Indian mental health organisations seeking service development to whom we will showcase the potential of PV inviting knowledge exchange on transferability. We will develop an open-access, educational, and resource e-mental health website.This will include easy-to-use, culturally sensitive guidance and information on how to deliver, analyse and evaluate PV mental health projects, through to flexible ways that outputs can inform service development. UK-hosted, the website will be a forum for an international community of researchers and practitioners working to increase user experience and voice in mental health services.

Government of Assam
We will engage key decision-makers in Assam and pan-India who are able to facilitate wider service and/or policy level implications of outputs. Via planned knowledge exchange workshops, we will learn how to capitalise on existing pathways for impact and to 'package' outcomes to ensure maximum acceptability, relevance and usability. Embededness of the project within the routine practices of mental health facilities and continuous engagement with key decision-makers will ultimately ensure the longer-term sustainability of changes in mental health policies and practices. Securing as Adviser Chowdhury of the Assam Regional Institute of Mental Health will enable us to contribute to the development of an Assam State mental health policy as recommended by the Institute in its State report to the National Mental Health Survey of India, 2015-16.

Publications

10 25 50
 
Title Film - Introduction to The Big Picture 
Description 5th UK Community Psychology Festival, 13th -14th September 2019, Grand Parade Building, University of Brighton, Brighton, UK https://blogs.brighton.ac.uk/cpfestival19/ Film - Introduction to The Big Picture 
Type Of Art Film/Video/Animation 
Year Produced 2019 
Impact In Feb 2020, 87 views on YouTube and shown at two conferences, including the one report here. 
URL https://www.youtube.com/watch?v=nwPnZPLHx7g
 
Title Film presentation - Young People the Arts and Mental Health: A Cultural Institute Conference. 
Description Introductory film describing the project - Published on 17 Jun 2019 Global Challenges Research Funded international team led by the University of Leeds, UK to learn how at-risk young people remain resilient to mental health conditions. This short film introduces The Big Picture project in which we are working with young people in Assam, India to understand how they stay away from harmful use of substances or engage successfully with rehabilitation. 
Type Of Art Film/Video/Animation 
Year Produced 2019 
Impact In Feb 2020, 87 views on YouTube and shown at two conferences, including the one report here. 
URL https://www.youtube.com/watch?v=nwPnZPLHx7g
 
Description Workshop - Youth Wellness Hub Festival, Young people against drugs: Capturing and promoting resilience using photo-voice
Geographic Reach Asia 
Policy Influence Type Influenced training of practitioners or researchers
Impact Duara, R. (2019, 9 & 10 Nov) LGBRIMH Youth Wellness Hub Festival:Young people against drugs: Capturing and promoting resilience using photo-voice x2 (repeated workshop). Introduction to the project, showcasing of first participant film, and small group work on participant posters. Feedback on the posters made by project interview participants from 20 attendees. Male n=10, age range 14-24, mean=18yrs Female n=7, age range 14-20, mean=18yrs Unknown n=2 Q1 - What messages about drug use do you get from these posters? • Destroying close relationships Negative effects of drugs cause the breakdown of relationships between loved ones, especially previously harmonious family units. • Drugs are never the solution It was inferred that drugs should never be sought as the primary method for resolving problems, talking to others is perceived as a better approach. • Recovery is dependent on the individual The ability for the drug user to recover was emphasised as being reliant on individual factors such as will power and personal effort alongside environmental influences. • Hardship of recovery Recovery is regarded as a painful process which spans across a long time period. • Importance of awareness It was revealed that to avoid the harmful impacts of drugs, individuals should be aware of the negative realties underpinning its use and the further consequences of addiction. Q2 - In what ways have the posters changed your understanding about young people who use drugs? • Predisposed vulnerabilities The posters inferred that drug abusers were in vulnerable mental health states, wherein they experienced tension, stress or depression. • Loss of control The choice element decreases in addicted users, whereby conscious control is diminished. • Distinction of temporal effects It was understood that short term euphoric effects mask the potential long-term negative consequences concerning drug use. • Supporting drug users The poster highlighted that instead of shaming, society should support recovery as shaming can make already guilty individuals feel worse. Therefore, the importance of educating the user was stressed in order to prevent further use and/or relapse. • Impact on others It was understood that the effects of drugs, not only negatively impacts the self but also impacts family members and the wider society. Q3 - What impact could posters like these have on young people who see peers already taking drugs? • Being informative about the consequences of drug abuse to both who are taking and not taking drugs • Helps non-drug users to build compassion towards drug addicts • Teaches negative consequences of drug misuses • Encourages non-drug users to help their peers who are taking drugs to overcome the addiction • Increases awareness on drug addiction and consequences of it • Hope to encourage those who are taking drugs to quit • Encourages non-drug users to initiate support and care towards drug users • Corrects the misunderstanding on the fantasy of drugs taking • Restricts the curiosity about taking drugs • Motivates drug users to overcome their addiction and restore healthy life • Reduces drug addict suicide rate • Teaches how difficult to get rid of addiction once it starts Q4 - What impact could posters like these have on adults who know very little about young people and drug taking? • Greater understanding of addicts states and choices • Changing views of addicts • Helping addicts rather than blaming them • More open discussion of drugs • Education for young people over drugs Q5 - Is there anything else you would like to share with us? • 'Appreciable job' - participants highlighted their belief that the work performed by the big picture was both important and helpful. • 'Forward to ... schools' - some respondents said they think the information given on the posters and in the sessions was useful for raising awareness and should be used in primary and secondary schools. • 'Adults' - some children expressed a view that adults should more directly intervene in youth drug use, this included parents keeping an eye out more closely and government action to ban drugs assign people to/build more rehabilitation centres. • Consequences of drug use - one respondent commented about cigarette packets having cancer warnings, while another stated that it is better to face reality rather than escape it. Both are examples of additional awareness of the consequences of drug use and how it would harm them in the long run. • I am re-sending the email because I mistakenly sent the first email without pasting the short list of analysis • • Informative to both who are taking and not taking drugs • • Builds understanding (empathy) towards drug addicts • • Teaches negative consequences of drug misuses • • Encourages non-drug users to help their peers who are taking drugs to overcome addiction • • Reduces the use of drugs through informing the consequences of drug addiction • • Increases awareness of drug addiction and consequences of it • • Hope to encourage those who are taking drugs to stop their practice • • Encourages non-drug users to initiate support and care towards drug users • • Corrects misunderstanding of drug taking by breaking the fantasy on drugs • • Motivates drug users to overcome their addiction and restore healthy life • • Reduces drug addict suicide rate • • Teaches how difficult to get rid of addiction once it starts
 
Description PhD: Understanding research-to-policy pathways in the area of mental health in Assam
Amount £62,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 10/2018 
End 09/2021
 
Description Attendence at Assam Forum GB, Annual Conference, University of Leeds 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Project PhD student attended the Assam Forum GB, Annual Conference, University of Leeds. At this event she met members of the Assam Government - including the Health Minister - who agreed that she could approach him for a research interview on her fieldwork visit to Assam in 2020. She also networked with other important Indian health policy makers and influencers and discuss her research with them. This was an important event to open the door to her mental health-to-research interviews with Assam policy makers.
Year(s) Of Engagement Activity 2019
URL http://www.assamforumgb.com/index.php/announcement/75-8th-annual-conference-assam-forum-gb
 
Description Conference presentation - The European Conference on Mental Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Hugh-Jones, Duara, Madill
2-4 October 2019, International Convention Centre, Belfast
Substance use disorder in young people in Assam, India: using participatory visual methods to understand their experience of risk, resilience and recovery
Year(s) Of Engagement Activity 2019
URL https://www.ecmh.eu/
 
Description Conference presentation - University of Leeds, Postgraduate Research Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Project PhD student Chloe Brooks
17th October 2019
Understanding mental health research-to-policy pathways in Assam, India
University of Leeds, Postgraduate Research Conference
Year(s) Of Engagement Activity 2019
 
Description Invited public address (Tezpur University) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact While visiting Assam to set-up the project, the PI - Professor Anna Madill - was invited to give a public address about the project to students and staff at Tezpur University. The talk was titled: Addressing youth substance abuse in India, and was attended by Tezpur University VC and the Dean of the Faculty of Social Sciences, as well as representative Heads of Department of the LGB Regional Institute of Mental Health, and many university staff and postgraduate students. The intended purpose was to disseminate information about the study, to stimulate discussion, and to network. An impact of the presentation is greater knowledge of and interest in the study, the gathering of e-mail addresses and the linking-up on social media with staff and students who want to keep in touch with the project. A further impact is to have brought together staff at Tezpur University and at LGBRIMH who did not as a matter of course collaborate, although they are with a 30 minute drive of each other. Collaborating to host my visit, workshops and public address was the first major official contact between these two major educational institutions in Tezpur.
Year(s) Of Engagement Activity 2019
 
Description Panel discussion member 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Professor Anna Madill - Invited Panel Discussion member: Evaluation and measurement of mental health outcomes. Chaired by Professor David Cottrell. Young People the Arts and Mental Health: A Cultural Institute Conference, University of Leeds, UK. Contributed to discussion of global mental health impact and evaluation from experience of The Big Picture and leaned from other panel members and the audience.
Year(s) Of Engagement Activity 2019
 
Description Presentation - The Big Picture, University of Sussex Social & Applied Psychology Group. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Graber, R. (2020, Feb), The Big Picture, University of Sussex Social & Applied Psychology Group.
Very well received. Questions posed at the end.
Why did you choose to situate the project within a resilience framework instead of a recovery framework?
Do you intend to develop an intervention as a result of this project?
What does NA think of your findings and are they willing to change what they do as a result of their project?
How much do you think the rehab context is influencing your findings?
Do you need to explore resilience and recovery processes among people who recover without the rehab centres?
Year(s) Of Engagement Activity 2020
 
Description Presentation - The Big Picture: Using participatory visual methods to explore resilience to substance use in Assam, India. School of Applied Social Science Forum, University of Brighton 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Graber, R. (2019, Dec) The Big Picture: Using participatory visual methods to explore resilience to substance use in Assam, India. School of Applied Social Science Forum, University of Brighton,
Year(s) Of Engagement Activity 2019
 
Description Public address (Royal Global Unversity, Guwahati) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Undergraduate students
Results and Impact While visiting Assam to set-up the project, the PI - Professor Anna Madill - was invited to give a public address about the project to students and staff at Royal Global University, Guwahati. The talk was titled: Young people, resilience and mental health, and was attended by under- and postgraduate students in Psychology and staff of the Psychology Department. The intended purpose was to disseminate information about the study, to stimulate discussion, and to network. An impact of the presentation is greater knowledge of and interest in the study, and the linking-up on social media with staff and students who want to keep in touch with the project.
Year(s) Of Engagement Activity 2019
 
Description Social media 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We have set-up social media accounts for the study on Instagram, facebook, and twitter. The intended purpose of this activity is to catalyse interest in the project, disseminate information about our activities and outcomes, engage policymakers and practitioners with a view to impacting policy and practice, and engage young people and the general public in Assam and wider India in discussion about youth substance abuse and how to capitalise on the resilience of young people and of Indian society to tackle this problem. We have just got our social media up and running and have 87 followers on Instagram, 44 on twitter, and 43 on facebook.

In February 2020, our project followers have increased to 141 on Instagram, 128 on twitter, and 82 on facebook.
Year(s) Of Engagement Activity 2018,2019
 
Description Workshop (LGB Regional Institute of Mental Health. Tezpur) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact The study PI - Professor Anna Madill - provided an invited workshop at LGBRIMH on her visit to Assam in January 2019. The intended purpose of the activity was to provide students at LGBRIMH a specialist workshop on using visual research methods, as used in the funded project. 27 postgraduates attended from a range of practitioner disciplines including clinical psychology and social work. Outcomes and impacts include intense engagement by the students with the experiential aspects of the workshop which catalysed many interesting questions and discussion. On a score of 1 (low)-5 (high), the workshop was rated by attendees: mean=4, mode=4. The feedback on 'What did you particularly like about the workshop?' included the following:
- New ideas, interesting, provided personal insights
- Interactive, space to express oneself and to hear about other people's experiences with their photos
- Practical demonstration of what photos can contribute
- Freedom of the method
- Preparation notified beforehand.

Attendees also very helpfully made the following recommendations in response to the question: 'Can you suggest any person or organization who might be interested in being contacted about The Big Picture?'
- Schools such as Assam Valley http://www.assamvalleyschool.com/
- Youth associations such as the YMCA
- https://en.wikipedia.org/wiki/Assam_Don_Bosco_University
- https://www.dibru.ac.in/ DIBRUGARH UNIVERSITY
- http://www.tiss.edu/ Tata Institute of Social Sciences
- Moushumi Kandali, Tezpur University http://www.tezu.ernet.in/dtcaf/moushumi_kandali.php
Year(s) Of Engagement Activity 2019
 
Description Workshop (Tezpur University) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact The study PI - Professor Anna Madill - provided an invited workshop at Tezpur university on her visit to Assam in January 2019. The intended purpose of the activity was to provide students at Tezpur University a specialist workshop on using visual research methods, as used in the funded project. !6 post- and undergraduates attended from a range of social science disciplines. Outcomes and impacts include intense engagement by the students with the experiential aspects of the workshop which catalysed many interesting questions and discussion. On a score of 1 (low)-5 (high), the workshop was rated by attendees: mean=4, mode=4/5. The feedback on 'What did you particularly like about the workshop?' included the following:
- Personal revelation through the workshop experiential activity
- The participatory nature of the workshop
- Friendly, open atmosphere
- Helpful introduction to a method that might be useful for own research

Workshop participants were also very helpful in providing possible networking contacts in response to the question 'Can you suggest any person or organization who might be interested in being contacted about The Big Picture?':
https://www.facebook.com/sikunrelief/
Professor D P Nath, Cultural Studies, Tezpur University
Dr Nandaseni? Chendhury? Tezpur University
Dr. Mousumi Mahanta, Women's Studies, Tezpur University mousumi@tezu.ernet.in
Year(s) Of Engagement Activity 2019