Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries.

BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care

Conditional disclosure on pathways to care: coping preferences of young people at risk of psychosis

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. “Pathways to care” was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as “conditional disclosure,” a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people’s perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms

Reported stigma and discrimination by people with a diagnosis of schizophrenia

Aims. This article examines the extent of stigma and discrimination as reported by people with a diagnosis of schizophrenia. The hypothesis is that when people express in their own words the discrimination they experience such discrimination will be found to be widespread. Methods. Seventy-five people with a diagnosis of schizophrenia from 15 different countries were interviewed with a mixed methods instrument to assess reported discrimination. The data were analysed for frequency counts and then a thematic analysis was performed. A conceptual map is provided. Results. The study was a cross-cultural one but, contrary to expectations, few transnational differences were found. The main hypothesis was supported. Conversely, we found that when participants reported ‘positive discrimination', this could as easily be conceptualised as being treated similarly to how others in society would expect to be treated. Conclusion. Negative discrimination is ubiquitous and sometimes connotatively very strong, with reports of humiliation and abuse. ‘Positive discrimination' conversely indicates that people with a mental illness diagnosis expect discrimination and are grateful when it does not occur. The literature on self-stigma is discussed and found wanting. Similarly, the theory that contact with mentally ill people reduces stigma and discrimination is not fully supported by our result

Public knowledge, attitudes, social distance and reported contact regarding people with mental illness 2009-2015

Objective To investigate whether public knowledge, attitudes, desire for social distance and reported contact in relation to people with mental health problems have improved in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009–2015. Methods Using data from an annual face-to-face survey of a nationally representative sample of adults, we analysed longitudinal trends in the outcomes with regression modelling using standardised scores of the measures overall and by age and gender subgroups. Results There were improvements in all outcomes. The improvement for knowledge was 0.17 standard deviation units in 2015 compared to 2009 (95% CI 0.10, 0.23); for attitudes 0.20 standard deviation units (95% CI 0.14, 0.27) and for social distance 0.17 standard deviation units (95% CI 0.11, 0.24). Survey year for 2015 vs. 2009 was associated with a higher likelihood of reported contact (OR 1.32, 95% CI 1.13, 1.53). Statistically significant interactions between year and age suggest the campaign had more impact on the attitudes of the target age group (25–45) than those aged over 65 or under 25. Women's reported contact with people with mental health problems increased more than did men's. Conclusion The results provide support for the effectiveness of TTC

Use of Guided Wave Inspections to Monitor the Integrity of Nuclear Power Station Boilers

This paper describes a ground-breaking application of guided wave testing for the nuclear power industry. Hartlepool and Heysham 1 power stations in the UK contain boilers of a unique ‘pod’ design in which the spiral boiler tubes are supported from above by a central vertical ‘spine’, which is a tubular component approximately 520mm in diameter and 21m long with complex changes in cross-section and attachments along its length. There are 32 boilers in the two stations. The gas which has passed through the reactor core flows down over the boiler tubes, heating the water inside. Only the top 2m of each spine is accessible above the top of the boiler pod. Plant Integrity Ltd was engaged by to inspect these ‘spine’ supports in 2003 using its Teletest guided wave system at statutory outages, which occur on a 3-year interval for each reactor. The Teletest tool was positioned in the only accessible place, just below the inlet header which protrudes approximately 2m from the top of the boiler. A procedure was developed to enable the full 21m length of the spine inside the boiler pod itself to be examined. During one of the regular Teletest inspections, at Heysham 1 power station in September 2013, a significant change in response was detected from the central part of one of the boiler spines. As a result, two of the eight boilers at Heysham 1 Reactor 1 were shut down pending further investigations. The indication was confirmed to be a structurally significant crack in the spine concerned. The crack detected was at the exact position and of the approximate extent reported by Teletest, which had detected the flaw from some 10m away. All four reactors at Hartlepool and Heysham 1 power stations were shut down in the latter part of 2014 while a new safety case for return to service of the remaining boilers was made. There is currently no viable alternative to guided wave inspection for monitoring the integrity of these boiler spines and a significant programme of work has been carried out to demonstrate the performance of Teletest for detection of flaws in these components under a variety of circumstances in order to support the safety case for operation. This has involved theoretical modelling, review of information contained in historical inspection data, practical tests on a full scale mock-up component, development of high temperature Teletest tooling to allow in- service tests and production of automated Teletest data collection equipment to allow real time in-service monitoring of the spines. TWI’s and Plant Integrity’s support enabled all four reactors to be returned to service before the end of 2014

Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study

The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation. A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services. Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives. Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs

Evidence for effective interventions to reduce mental Healthrelated stigma and discrimination in the medium and long term : Systematic review

Publisher Copyright: Copyright © 2015 The Royal College of Psychiatrists, unless otherwise stated.Background Most research on interventions to counter stigma and discrimination has focused on shortterm outcomes and has been conducted in highincome settings. Aims To synthesise what is known globally about effective interventions to reduce mental illnessbased stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in lowand middleincome countries (LMICs). Method We searched six databases from 1980 to 2013 and conducted a multilanguage Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact. Results Eighty studies (n = 422 653) were included in the review. For studies with medium or longterm followup (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and-0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middleincome countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies. Conclusions There is modest evidence for the effectiveness of antistigma interventions beyond 4 weeks followup in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigmareducing interventions.Peer reviewe