Medico-religious collaboration: a model for mental health care in a resource poor country

Background: Reducing the treatment gap for the treatment of people with psychiatric disorders (also known as the ‘mental health gap’) is of increasing importance worldwide. In Low and Middle Income Countries (LMICs) human and material resources for orthodox (‘western’) mental health care are severely inadequate. As such, alternative mental health practices tend to thrive. Such alternative systems of care could be formally linked with western services to achieve a more integrated pattern of care in order to improve access for all users of mental health services in these communities, while ensuring a reduction in harm and promoting the human rights of people with mental health problems.Aim: To describe a medico-religious mental health care collaborative model in a rural community in Nigeria, which may be suitable for scaling up mental health care in LMICs as a whole.Methods: This is a descriptive report of a psychiatric service in collaboration with a Christian religious settlement, based in Ogun State, Western Nigeria. Questionnaires, focus group discussions and direct observation were employed. Client records from the religious center and from the visiting psychiatric team were also examined, and all the data from all sources were synthesized.Results: Interactions between the medical and religious mental health care providers improved consistently over the study period. Acceptance of medical services and understanding of the need for collaboration increased. Increased utilization by people with mental illness from the nearby settlement was observed. In the course of collaboration, the occurrence of harmful practices(though still much in practice), reduced considerably as evidenced by stoppage of prolonged sleep and food deprivation (in form of night vigils and fasting) and flagellation, while physical restrictions with chains, especially for newly admitted sufferers still continued unabated despite the discouragement of such practice by medical practitioners.Conclusions: A structured collaborative arrangement between medical and religious health care practitioners offers a great possibility towards the scaling up of mental health care in a resource poor setting such as Nigeria. In addition, it offers potential benefits to services users, such as: improved access to proven reliable medical care, better continuity of care, and reduction in harmful traditional practices usually used to treat these groups of people. Challenges of fundamental human rights abuse and funding are important areas for local mental health policies to address in such settings. In addition, institutional support is still inadequate and there is need for program sustainability.Keywords: Collaboration, Medico-religion, Mental health, Resource poor, LMI

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

Background Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. Methods We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). Findings In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683–0·717]). Interpretation In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. Funding British Journal of Surgery Society