An investigation into mental health care deficits in South Africa: exploring an alternative intervention strategy

This study investigates mental health care deficits in South Africa and explores an alternative intervention strategy that promotes an integrated community-based intervention model to reach the vulnerable majority living with the debilitating consequences of mental illness. The research is grounded in human rights, empowerment and human scale development theories. A mixed-methods research design consisting of a dominant quantitative methodology complemented by a qualitative methodology was adopted. The research design was carried out in three sequential phases. The first phase of the study involved an online survey with 19 mental health professionals employed at State psychiatric facilities and 90 social workers at 17 mental health non-government organisations. The second phase involved 5 focus group discussions with a total of 40 mental health service users from the Western Cape, Eastern Cape, KwaZulu-Natal, Northern Cape and Limpopo Provinces. The third and final phase of the study involved telephonic interviews with two key informants, using a semi-structured interview guide. Purposive sampling procedures were used to recruit respondents from all nine provinces in South Africa. Findings indicate that less than half of the mental health professionals (49%, n=53) reported that the National Mental Health Policy Framework and Strategic Plan 2013‒2020 is a very good policy, whereas 42.6% (n=46) agreed that the policy is highly appropriate for a developing country. The Chi-square test showed a significant relationship between respondents’ perceptions of a good policy and its appropriateness for mental health care in South Africa [χ² (9, n=109) = 120.5, p <.000]. The focus group findings indicated that only a few service users were aware of the policy as a 'strategic plan’ whilst the majority of focus group participants were unfamiliar with the policy and thought that it should be summarised in clear language and disseminated. The issue of stigma experienced and confirmed by service users was regarded as a major barrier to mental health care – the majority (89.9%, n=98) of respondents indicated that mental illness remains one of the most highly stigmatised conditions in South Africa. There is a significant relationship between how well mental illness is understood and the stigma associated with mental illness [χ² (16, n=109) = 40.7, p<.001]. The Chi-square test indicated a significant association between mental health professionals’ perception about vulnerability and the discrimination against mental health service users [χ² (9, n=109) = 25.0, p<.003]. These findings were confirmed by the focus group participants who said: “As long as there is stigma – we as mental health patients get judged by our community, by our families and people around you – then nothing will change”. The majority (94.5%, n=103) of respondents agreed that people with mental illness are more vulnerable to abuse by society than those without mental illness. The majority (80.7%, n=88) of mental health professionals reported that the medical model is the dominant approach to diagnosis and treatment of mental illness in South Africa. The focus group participants were keenly aware that “just taking your medication isn’t always balancing out”. The majority of mental health professionals (83.5%, n=91) agreed that poor socio-economic conditions increased mental illness, whereas 73.4% (n=80) agreed that there was a direct link between poverty and the increase in demand for mental health services. The Chi-square test indicated that there is a significant association between poor socio-economic conditions and the increased demand for mental health services in South Africa [χ² (16, n=109) = 199.2, p<.001]. Focus group discussions confirmed this link between poverty and mental illness with participants highlighting the constraints of meagre grants and their inability to find jobs. Findings from the key informants concur with the aforementioned main findings. Conclusions drawn from the triangulated findings show the major deficits in treatment; the lack of resources and funding; the lack of community-based mental health interventions and the exclusion of mental health service users as significant role-players. Finally this study both recommended and designed a comprehensive patient-centred, integrated community-based mental health service model that is aligned with South Africa’s National Mental Health Policy. The proposed model took into account the perspectives of mental health professionals, mental health service users, and findings from the survey respondents, as well as ideas from 'best practice models’ found in Zimbabwe, Uganda, Brazil and India – and was corroborated by key informants

An investigation of the-training offered to community-based rehabilitation workers with particular reference to the field of mental handicap in the Western Cape

This study investigates the training offered to community-based rehabilitation workers in the field of mental handicap to ascertain whether the training provided has been perceived as appropriate in assisting with their tasks and functions. Further investigation is done into the underlying theoretical approaches used in training, curricula designs, training objectives, location and training periods, the community-based rehabilitation workers level of participation and involvement in planning of the training programme, and whether creative, pragmatic and participatory training methods, techniques and materials were used. The nature of supervision was also explored. The historical development of community-based rehabilitation, the lack of trained personnel, and the disparity in the provision of services in South Africa and the function of the community-based rehabilitation are discussed. It is against this background that the historical emergence and need for training of community-based rehabilitation workers are highlighted. Different theoretical approaches to the development and presentation of training are discussed due to the considerable influence they have on the value base upon which training programmes are built. This includes an overview of the philosophy of Paulo Freire. The research method used is of a qualitative nature. The researcher employs an exploratory - descriptive design to gain insight into an area which is relatively uninvestigated. By using this design, the researcher hopes to build a foundation of ideas and tentative theories which could later be tested through more complex methods. The first population chosen included the total population of community-based rehabilitation workers employed at the South African Christian Leadership Assembly Health Project, (seven) and Cape Mental Health Society (two). The second population were the trainers associated with these organisations and the specific projects in which the community-based rehabilitation workers are employed. One trainer from each organisation was included. Both organisations chosen are engaged in direct service delivery to the mentally handicapped in socially deprived communities in the Western Cape. The primary source of data collection was acquired in two phases:- Phase one - An interview schedule which included structured & unstructured questions was administered by the researcher to the community - based rehabilitation workers. The information was gathered with the assistance of an interpreter. Phase two - A detailed self-administered, semi-structured questionnaire was completed by the trainers. The data in these two phases was presented in a descriptive manner due to the size of the population. The study found that there is no consensus regarding appropriate training models. Courses are often loosely structured with no theoretical base. A comprehensive-generic approach which includes promotive, curative, preventative, and rehabilitative aspects is suggested. In this study, the course focused mainly on curative and rehabilitative aspects to assist with tasks while promotive and preventative skills were neglected. No prescribed training period can be stipulated. Constraints of distance and location would determine the duration of the training while the location of training should be within the confines of the community to prevent isolation and an unnatural environment. More creative and pragmatic methods and techniques should be carefully selected. All components of supervision should be given priority and provided regularly in pragmatic and innovative ways. Furthermore, trainers, trainees and communities need to have equal participation and involvement in all spheres of training

Long-term labour market and economic consequences of school exclusions in England:Evidence from two counterfactual approaches

Background: Previous research suggests that school exclusion during childhood is a precursor to social exclusion in adulthood. Past literature on the consequences of school exclusion is, however, scarce and mainly focused on short-term outcomes such as educational attainment, delinquency, and mental health in early adolescence. Moreover, this evidence is based primarily on descriptive and correlational analysis, whereas robust causal evidence is required to best inform policy. Aims: We aimed to estimate the mid-to-long-term impact of school exclusion on labour market and economic outcomes. Sample: The sample included 6,632 young people who at the age of 25/26 in the year 2015 participated in the Next Steps survey of whom 86 were expelled from school and 711 were suspended between the ages of 13/14 and 16/17. Method: Using high quality existing longitudinal data, we utilized four approaches to evaluate the impact of school exclusion: logistic regression-adjustment models, propensity score matching, school fixed-effects analysis, and inverse propensity weighting. The latter two counterfactual approaches were used to estimate causal effects. Results: We found that school exclusion increased the risk of becoming NEET at the age of 19/20, and then remaining economically inactive at the age of 25/26, as well as experiencing higher unemployment risk and earning lower wages also at the age of 25/26. Conclusion: School exclusion has pervasive negative effects into adulthood. Policy interventions should focus on both prevention and mitigating its negative effects. Interventions aimed at re-integrating excluded individuals into education or vocational training could be key in reducing the risk of poor socio-economic outcomes and social exclusion

The impact of school exclusion in childhood on health and well-being outcomes in adulthood:Estimating causal effects using inverse probability of treatment weighting

BackgroundPrevious evidence has suggested a strong association between school exclusion and health outcomes. However, as health risks are themselves related to the risk of experiencing a school exclusion, it has been challenging to determine the extent to which school exclusion impacts later health outcomes, as opposed to reflecting a marker for pre-existing risks.AimThe aim of the current study was to address this challenge in estimating the medium-to-long-term impact of school exclusion of health and well-being outcomes.MethodsTo this end, we used an inverse propensity weighting approach in the Next Steps data set (N = 6534, from wave 1, 2014, to wave 8, 2015).ResultsWe found that after weighting for propensity of treatment scores estimated based on a wide range of factors, including previous health indicators, there was a significant effect of school exclusion on a wide range of health and well-being outcomes.DiscussionThese results provide some of the most robust evidence to date that school exclusion harms long-term health outcomes.ConclusionThe findings suggest that policies should aim to reduce exclusion and ensure access to preventative health support for those who experience a school exclusion

Impacts of Covid-19 on mental health service provision in the Western Cape, South Africa:The MASC study

In the context of an already large treatment gap in South Africa, this study aimed to examine how Covid-19 and the related lockdown measures affected the availability, accessibility, quality, and continuity of mental health services in the Western Cape province in South Africa. A mixed-methods design was employed, using narrative surveys, quantitative surveys, and qualitative semi-structured interviews, with 17 public mental health providers, and secondary data from the District Health Information System. We analysed and combined the data using descriptive statistics, template analysis and methodological triangulation. Results showed that Covid-19 and the lockdowns had negative impacts on mental health service provision at all levels of care, such as reduced access to services, increased stigma and discrimination, disrupted medication supply, increased workload and stress for providers, and the closure of psychosocial and therapeutic services. Innovations used by providers to mitigate these impacts included telehealth, online training, peer support groups, and community outreach. The study concludes that Covid-19 and the lockdowns exposed and exacerbated the existing gaps and challenges in mental health service provision in South Africa. Key recommendations for policy formation and response to future pandemics in the public mental health sector include: classifying psychological treatments as essential services, establishing an intersectoral mental health emergency response plan, involving mental health care users in the development of pandemic responses, creating policies for managing health emergencies in psychiatric facilities, and increasing resources for the mental health sector in South Africa. These recommendations are relevant for South Africa and other LMICs in ensuring adequate mental health care during public health emergencies

Impacts of Covid-19 on mental health service provision in the Western Cape, South Africa:The MASC study

In the context of an already large treatment gap in South Africa, this study aimed to examine how Covid-19 and the related lockdown measures affected the availability, accessibility, quality, and continuity of mental health services in the Western Cape province in South Africa. A mixed-methods design was employed, using narrative surveys, quantitative surveys, and qualitative semi-structured interviews, with 17 public mental health providers, and secondary data from the District Health Information System. We analysed and combined the data using descriptive statistics, template analysis and methodological triangulation. Results showed that Covid-19 and the lockdowns had negative impacts on mental health service provision at all levels of care, such as reduced access to services, increased stigma and discrimination, disrupted medication supply, increased workload and stress for providers, and the closure of psychosocial and therapeutic services. Innovations used by providers to mitigate these impacts included telehealth, online training, peer support groups, and community outreach. The study concludes that Covid-19 and the lockdowns exposed and exacerbated the existing gaps and challenges in mental health service provision in South Africa. Key recommendations for policy formation and response to future pandemics in the public mental health sector include: classifying psychological treatments as essential services, establishing an intersectoral mental health emergency response plan, involving mental health care users in the development of pandemic responses, creating policies for managing health emergencies in psychiatric facilities, and increasing resources for the mental health sector in South Africa. These recommendations are relevant for South Africa and other LMICs in ensuring adequate mental health care during public health emergencies

Energy aware software evolution for wireless sensor networks

Wireless Sensor Networks (WSNs) are subject to high levels of dynamism arising from changing environmental conditions and application requirements. Reconfiguration allows software functionality to be optimized for current environmental conditions and supports software evolution to meet variable application requirements. Contemporary software modularization approaches for WSNs allow for software evolution at various granularities; from monolithic re-flashing of OS and application functionality, through replacement of complete applications, to the reconfiguration of individual software components. As the nodes that compose a WSN must typically operate for long periods on a single battery charge, estimating the energy cost of software evolution is critical. This paper contributes a generic model for calculating the energy cost of the reconfiguration in WSN. We have embedded this model in the LooCI middleware, resulting in the first energy aware reconfigurable component model for sensor networks. We evaluate our approach using two real-world WSN applications and find that (i.) our model accurately predicts the energy cost of reconfiguration and (ii.) component-based reconfiguration has a high initial cost, but provides energy savings during software evolution

Multi-Messenger Gravitational Wave Searches with Pulsar Timing Arrays: Application to 3C66B Using the NANOGrav 11-year Data Set

When galaxies merge, the supermassive black holes in their centers may form binaries and, during the process of merger, emit low-frequency gravitational radiation in the process. In this paper we consider the galaxy 3C66B, which was used as the target of the first multi-messenger search for gravitational waves. Due to the observed periodicities present in the photometric and astrometric data of the source of the source, it has been theorized to contain a supermassive black hole binary. Its apparent 1.05-year orbital period would place the gravitational wave emission directly in the pulsar timing band. Since the first pulsar timing array study of 3C66B, revised models of the source have been published, and timing array sensitivities and techniques have improved dramatically. With these advances, we further constrain the chirp mass of the potential supermassive black hole binary in 3C66B to less than $(1.65\pm0.02) \times 10^9~{M_\odot}$ using data from the NANOGrav 11-year data set. This upper limit provides a factor of 1.6 improvement over previous limits, and a factor of 4.3 over the first search done. Nevertheless, the most recent orbital model for the source is still consistent with our limit from pulsar timing array data. In addition, we are able to quantify the improvement made by the inclusion of source properties gleaned from electromagnetic data to `blind' pulsar timing array searches. With these methods, it is apparent that it is not necessary to obtain exact a priori knowledge of the period of a binary to gain meaningful astrophysical inferences.Comment: 14 pages, 6 figures. Accepted by Ap

The European road safety decision support system on risks and measures

The European Road Safety Decision Support System (roadsafety-dss.eu) is an innovative system providing the available evidence on a broad range of road risks and possible countermeasures. This paper describes the scientific basis of the DSS. The structure underlying the DSS consists of (1) a taxonomy identifying risk factors and measures and linking them to each other, (2) a repository of studies, and (3) synopses summarizing the effects estimated in the literature for each risk factor and measure, and (4) an economic efficiency evaluation instrument (E3-calculator). The DSS is implemented in a modern web-based tool with a highly ergonomic interface, allowing users to get a quick overview or go deeper into the results of single studies according to their own needs

Efficacy and tolerability of adjunctive lacosamide in pediatric patients with focal seizures

To evaluate efficacy and tolerability of adjunctive lacosamide in children and adolescents with uncontrolled focal (partial-onset) seizures.In this double-blind trial (SP0969; NCT01921205), patients (age ≥4-<17 years) with uncontrolled focal seizures were randomized (1:1) to adjunctive lacosamide/placebo. After a 6-week titration, patients who reached the target dose range for their weight (<30 kg: 8-12 mg/kg/d oral solution; ≥30-<50 kg: 6-8 mg/kg/d oral solution; ≥50 kg: 300-400 mg/d tablets) entered a 10-week maintenance period. The primary outcome was change in focal seizure frequency per 28 days from baseline to maintenance.Three hundred forty-three patients were randomized; 306 (lacosamide 152 of 171 [88.9%]; placebo 154 of 172 [89.5%]) completed treatment (titration and maintenance). Adverse events (AEs) were the most common reasons for discontinuation during treatment (lacosamide 4.1%; placebo 5.8%). From baseline to maintenance, percent reduction in focal seizure frequency per 28 days for lacosamide (n = 170) vs placebo (n = 168) was 31.7% (p = 0.0003). During maintenance, median percent reduction in focal seizure frequency per 28 days was 51.7% for lacosamide and 21.7% for placebo. Fifty percent responder rates (≥50% reduction) were 52.9% and 33.3% (odds ratio 2.17, p = 0.0006). During treatment, treatment-emergent AEs were reported by 67.8% lacosamide-treated patients (placebo 58.1%), most commonly (≥10%) somnolence (14.0%, placebo 5.2%) and dizziness (10.5%, placebo 3.5%).Adjunctive lacosamide was efficacious in reducing seizure frequency and generally well tolerated in patients (age ≥4-<17 years) with focal seizures.NCT01921205.This trial provides Class I evidence that for children and adolescents with uncontrolled focal seizures, adjunctive lacosamide reduces seizure frequency