1. Global Mental Health: How Do Our Metrics Fail Us? Anne E. Becker, M.D., Ph.D., Sc.M. October 8, 2009 SW 25

2. Why Fiji?

3. Why mental health in Fiji?

4. Why eating disorders?

5. Where is Fiji?

6. What can Fiji teach us about key challenges in global mental health care delivery?

7. Global mental health: Resource and allocation gap

8. Inequitable allocation of resources for mental health Burden of mental disorder* % of health budget for mental health† Low-income countries7.88% Lower-middle-income14.50% Higher-middle-income19.56% High-income21.37% All countries11.48% †Median values for proportion of total health budget allocated to mental health. Saxena S, Thornicroft G, Knapp M et al, Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; published online Sept 4. DOI:10.1016/S0140-6736(07)61239-2. 2.26% 2.62% 4.27% 6.88% 3.76%

9. GMH shortfalls are especially pronounced for children and adolescents The prevalence of mental disorders is high (20%) in children and adolescents Only 7% of countries worldwide have child and adolescent mental health policies Source: Child Mental Health Atlas, WHO, 2005

10. Strategies for global risk assessment and response Global School-based Health Survey –Includes dietary behaviors –Implemented in 89 countries –13 languages –Validity or reliability examined in: –0 populations Becker AE, Roberts AL, Perloe A, Bainivualiku A, Richards LK, Gilman SE, Striegel-Moore RH. Youth health risk behavior assessment in Fiji: The reliability of Global School-based Health Survey content adapted for ethnic Fijian adolescent girls. Under review at Ethnicity & Health;

11. Risk behaviorYRBS Mean Kappa (U.S.) GSHS Mean Kappa Tobacco use.69? Alcohol use.63? Sexual risk.63? Injuries/violence.60? Physical activity.55? Dietary behaviors.50? (Brener et al., 2001) How reliable is youth behavioral risk assessment?

12. Risk behaviorYRBS Mean Kappa (U.S.) GSHS Mean Kappa (Fiji; N=81) Tobacco use.69.62 Alcohol use.63.72 Sexual risk.63.69 Injuries/violence.60.41 Physical activity.55.43 Dietary behaviors.50.33 (Brener et al., 2001; Becker et al., under review) How reliable is youth behavioral risk assessment?

13. Complementary signals and limitations: Epidemiologic data Data from: Cornelius M, Cecourten M, Pryor J, Saketa S, Waqanivalu T, Laqeretabua A, Chung E. Fiji Non-communicable diseases (NCD) STEPS Survey 2002. Ministry of Health: Shaping Fiji's Health 2002: 1-65. Becker AE, Perloe A, Richards L, Roberts AL, Bainivualiku A, Khan AN, Navara K, Gilman SE, Aalbersberg W, Striegel-Moore RH for the HEALTHY Fiji Study Group Prevalence and Socio-demographic Correlates of Cigarette Smoking, Alcohol Use, and Unsafe Sexual Behavior among Ethnic Fijian Secondary Schoolgirls. Fiji Medical Journal; 2009, in press.

14. How do we measure impact of socio-cultural environment on mental health?

15. Ethnographic study of body, self, and society in Fiji Traditional economy based upon subsistence agriculture Ethnographic data from: Becker AE. Body, Self, and Society: The View from Fiji. Philadelphia: University of Pennsylvania Press; 1995. pp. 1-206.

16. Rigid social hierarchy & expectations

17. Ethnographic study of body, self, and society in Fiji Family and social life revolved Around food preparation, food exchange, and feasting

18. Ethnographic study of body, self, and society in Fiji Mealtimes in Fiji were highly structured and socialized, featuring rhetoric that encouraged people to eat abundantly

19. Ethnographic study of body, self, and society in Fiji A number of social mechanisms encouraged a hypervigilance for appetite or weight loss, including an appetite disorder, macake, and the locally identified illness, “going thin”

20. Ethnographic study of body, self, and society in Fiji Traditional aesthetic body ideals favored a robust body, which reflected a dense social network Bodies were less a site for personal identity than social identity

21. Ethnographic study of body, self, and society in Fiji Prior to 1995, eating disorders were thought to be rare in Fiji

22. Ethnographic study of body, self, and society in Fiji Until the mid 1980’s, rural areas of Fiji had no access to electricity

23. The impact of mass media and rapid social transition Television was only introduced to these areas as recently as 1995

24. Would Western-based mass media exposure undermine resilience against eating disorders? Data on the following slides from: Becker AE, Burwell RA, Gilman SE, Herzog DB, Hamburg P. Eating behaviours and attitudes following prolonged television exposure among ethnic Fijian adolescent girls. The British Journal of Psychiatry 2002; 180: 509-14. Becker AE. Television, disordered eating, and young women in Fiji: Negotiating body image and identity during rapid social change. Culture, Medicine and Psychiatry 2004; 28:533-59.

25. Two wave cohort comparison: No TV exposure vs. TV exposure 19951998 Interview confirmed purging for weight 0%11.3% p<.05

26. What mischief did mass media exposure bring?

27. Narrative data: Transformation of body ideals “... the actresses and all those girls, especially those European girls, I... just admire them and want to be like them. I want their body, I want their size. I want myself to be in the same position as they are.” S-64

28. Shortland Street

29. Narrative data: Television-based role models I like Shortland Street because of the many young adults involved with it. [...] I want to be like that, I want to imitate them—the way they live, the type of food they eat [...] and also the ideas they have

30. X-Files

31. Narrative data: Television-based role models [... X Files] gives me ideas of how to solve problems when being in this world (s-64).

32. Golden Country

33. Narrative data: Transformation of ideals: competitive social positioning Because every teenager, I think,... she has to lose weight, and she has to attain a size... to be in competitive world... because in this age, teenage girls are competing with others... (S- 62)

34. Narrative data Transformation of body ideals... most of us Fijians are... getting fat. And now, we are feeling [...] that it is bad to have this huge body. We have to have those thin, slim bodies. S-64

35. Narrative data: Emerging pathology... when I eat, I sometimes want to vomit it out. [...] so I can know for myself I am losing weight. S-62

36. Community and parents’ primary concern with social health

37. Rural-urban drift a huge strain on jobs Monika Singh Sunday, November 02, 2008 THE rural-urban movement has increased the gap between productive jobs available and increased social problems. Glue sniffing high on agenda Thursday, October 09, 2008 THE increasing number of students turning to glue sniffing and other substance abuse is a worrying trend for the country's principals. Taking risks Tuesday, October 07, 2008 THE most recent statistic on sexually transmitted infections in this country shows an alarming and staggering trend. Most of our people afflicted by sexually transmitted infections are between the ages of 20 and 29 –– the period during which we expect them to be productive and preparing to settle into family life. More worrying is the fact that despite the many workshops on STIs, the young continue to treat sex with reckless abandon and apparent disregard for others. Youths populating Pacific prisons Tuesday, October 14, 2008 Update: 6:13PM Youths are dominating the prisons population in almost all Pacific Island countries. Figures disclosed by the national reports tabled at the Prisons Conference held at the Forum Secretariat today, stated inmates ages representing the bulk of the population is between 19 to 20 years. Text excerpts from the Fiji Times Online. 2008

38. Autonomy, self-agency, & ambition: More social disruption

39. Social dislocation of the clan Multiple dimensions of social disruption Shifts in distribution

40. Stimulation of consumerism with little opportunity to generate income

41. How do we measure impact of socio-cultural environment on mental health?

42. Uniformity of social environment obscures relation between exposures and outcome

43. Methodologic advantages of heterogeneous social infrastructure

44. Heterogeneous social environment offers unique methodologic advantage Opportunity to examine effects of exposure as compared with a “counterfactual” non-exposure Heterogeneous social environment

45. School-based study on Social change & health risk behaviors Survey and narrative data collected at all schools within an administrative area of the Ministry of Education

46. School-based study on Social change & health risk behaviors

47. Global School-based Health Survey Proxies for social adversity and exposures developed based on ethnographic data Translation/back translation Psychometric evaluation Narrative data collected by interview

48. School-based study on Social change & health risk behaviors 523 eligible ethnic Fijian high school girls enrolled and completed 71% response rate > 300 interviews

49. (Concomitant) appetite stimulants frequently used Results: Disordered eating remains prevalent 45% of respondents reported having purged in the last month

50. Prevalent and Paradoxical Symptoms Parents appear to be managing weight to enhance their daughters’ social opportunities

51. DSM-IV Eating Disorder Categories Not Useful for Classifying Potential Cases Source and relevant discussion in: Thomas JJ, Crosby RD, Wonderlich SA, Striegel-Moore RH, Becker AE. A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: Evidence of cross-cultural variation in phenomenology. Under review at Psychological Medicine.

52. Eating Disorders: Can the DSM V have Global Clinical Utility? Clinical observational and trial data –Only 6% of papers in high impact psychiatric journals are from regions of the world that comprise > 90% of the world’s population (Patel & Sumathipala, 2001) Cultural dominance of the DSM nosology –Selective attention to universal patterns of mental illness

53. Are these behavioral symptoms locally meaningful? Indigenous nosologic correlates? Significantly correlated with distress and impairment (as measured by the CIA) Global EDE-Q also highly correlated with the CIA 1. Becker AE, Thomas JJ, Bainivualiku A, Richards L, Navara K, Roberts A, Gilman SE, Striegel-Moore R. Adaptation and Evaluation of the Clinical Impairment Assessment to Assess Disordered Eating Related Distress in an Adolescent Female Ethnic Fijian Population. International Journal of Eating Disorders 2009, in press. Becker AE, Thomas JJ, Bainivualiku A, Richards L, Navara K, Roberts A, Gilman SE, Striegel-Moore R. Validity and Reliability of a Fijian Translation and Adaptation of the Eating Disorder Examination Questionnaire. International Journal of Eating Disorders 2009, in press.

54. What was the dominant personal narrative?

55. Material and aspirational gaps Percent frequency Living without basic needs*58.7 Hunger in the last 30 days60.1 Household ownership of TV64.5 *Without at least one of these: r unning water, electricity, gas stove, refrigerator

56. Material and aspirational gaps Parental occupation Respondents’ aspirational occupation Agrarian & domestic labor62.4%1.34% Retail, service, other unskilled labor 21.3%18.4% Professional occupation16.2%79.5%

57. Personal narratives reveal ambition for new social opportunities I: And what does your family think about it? S: They think that I should lose weight, too. I: Why do they think that you should lose weight? S: Because I’m like, fat. I: But what do they think would be different if you lost weight? S: I would be, I mean, I would get lots of friends. And they won’t be treating me like this. [I-28]

58. I: What about other things outside of friends, what about jobs? Do you think that size and shape influences that? S: Yeah, sometimes. I: When? S: Like, air hostess. I: Air hostess? Do you want to be an air hostess? S: Of course, yes. They only want slim girls. I: How do you know that? S: One of my friends told me. I: So why do they want slim girls? S: I don’t know. Maybe to walk easily into the plane. [I-28]

59. Respondent who purges with mother’s help I: [... ] And do you feel different if you’re thinner or slimmer? S:Yes. I: And how, what would you feel like? S: I’d not be my own self and I would be like doing other stuff that I wasn’t doing before. Like hanging around with cool kids. I: [...] Do you think that it would influence what kind of job you would get? S: Yes. I: What do you want to do? S: I want to become an air hostess. [I-12]

60. What was the meta-narrative?