Employment rehabilitation schemes for people with mental health problems

Although work and employment are important elements in the lives of people recovering from psychiatric illness, their access to meaningful occupation and paid employment is limited. A number of state and voluntary vocational rehabilitation schemes provide training or retraining for open employment but whether this is a realistic aim in the current economic climate has been questioned. This study, using direct observation and informal interviewing, explored the interaction between the staff and trainees of one such rehabilitation workshop. It sought to elicit information about the role of the workshop from both the trainer and trainee perspectives. The results indicate a number of differences between the staff and trainee models and illustrate the problems faced by the workshop in balancing its smooth operation against the needs and expectations of its staff and trainees. In particular, its organization around a relaxed interpretation of the ‘through-put’ concept of rehabilitation did not meet the requirements of all the trainees. We consider how employment rehabilitation schemes can achieve the dual role of both helping service users move into employment or other forms of meaningful occupation, and providing work and work substitutes for long-term users.     

Ends and means in public health policy in developing countries

International discussions of public health policy strategies in developing countries have been characterized by strong and conflicting positions. Differences regarding the means of health sector improvement can often be traced to differences about the ends, that is, the goals of the health sector. Three types of health sector goals are reviewed: health status improvement, equity and poverty alleviation, and individual welfare (utility) improvement. The paper argues that all three must be considered in developing health sector reform strategies in all countries. Highly normative policy positions often can be attributed a unidimensional affiliation with one health sector goal and denial of the relevance of the others. The current global interest in using cost-effectiveness analysis to set national health priorities is assessed in light of this eclectic approach. Examples are provided of how a health sector strategy based on cost-effectiveness would give sub-optimal solutions. These examples include situations where a private health care sector exists and provides some degree of substitution for publicly provided services; significantly high income elasticities exist for health care such that higher income beneficiaries may differentially capture public subsidies; and market failures exist in insurance. It is argued that these conditions are virtually universal in developing countries. Thus, rational policy development should explicitly consider multiple goals for the health sector.     

Linking public health research with policy and practice in three European countries

Aim

To transform knowledge from public health and health services research into actual improvement of services is highly relevant for spending public research resources effectively. Fostering stakeholder interaction throughout the entire research process is one potential avenue towards this aim. The objective of this paper is to look for established practices with the aim to promote the usability of research in policy and practice through interaction.

Subject and methods

We conducted 11 semi-structured telephone-interviews with senior experts from the same number of public health and health services research institutions in the Netherlands, the United Kingdom and Norway.

Results

Practice patterns are manifold, but three key domains were identified:

1. Research implementation is explicitly part of the organisation’s mission. Research commissioning institutions serve as intermediaries between research, policy and practice.
2. Funds are earmarked for implementation activities. In regular evaluation cycles special consideration is given to the impact of research.
3. Multiple forums for interaction support the ability of researchers to actively communicate with stakeholders. Network-building skills are developed alongside scientific competence.

Conclusion

Promising initiatives can be found in practice. Further research is needed into what difference it makes how the exchange between research and policy is organised.     

Support services for carers of people with mental health problems: building an evidence base to inform policy decisions

In Great Britain, over 1.5 million people look after someone with a mental disability. The UK government has shown an increasing awareness of the value of carers' contribution to society and of carers' need for support, information and care. As part of a recent scoping study, the current evidence for support services for mental health carers was reviewed and key stakeholders were consulted. This paper elucidates issues arising from the study and explores ways towards a more evidence-based future.     

Models of specialist employment for people with mental health problems

There is a growing interest in work schemes for people with mental health problems. They appear to offer great promise, both in the delivery of community care and in social re-integration. However, the models operating in Britain are diverse and little is known about their operation, much less their effectiveness. In this paper the characteristics of nine models of specialist employment are described, and their similarities and differences are portrayed on three dimensions: productivity, integration, and permanence. Within this proto-typology it is hoped that clearer distinctions may be made between work schemes and what they have to offer. Recognition of fundamental differences between work opportunities should aid matching needs to services, facilitate more effective use of rehabilitation resources, and guide the commissioning of mental health services.     

Scoping the field: services for carers of people with mental health problems

Mental ill health is very common. Most people with mental health problems live in the community, and as many as 1.5 million people in the UK may be involved in caring for a relative or friend with a mental illness or some form of dementia. Recent legislation and policy initiatives such as the National Strategy for Carers, and the National Service Frameworks for Mental Health and Older People emphasise the importance of providing support for this particular group of carers. The present paper reports the findings of a scoping study to identify what the research tells us about the effectiveness and cost-effectiveness of interventions for the carers of people with mental health problems, and also where there are gaps in the knowledge base. Some 204 evaluation studies were included in the review, just 13 of which had an economic component. The majority of studies were conducted in the USA, and were aimed at carers of people with Alzheimer disease or other forms of dementia. Overall, there was a lack of strong evidence to support any specific interventions, although almost all studies were able to identify some positive outcomes of services provided. In contrast to the relatively narrow approach to effectiveness adopted in most of the studies reviewed, the contributors to a consultation exercise perceived this concept in a far more rounded and holistic way. For them, the process of service delivery was as important as the outcome. There was relatively little research evaluating interventions and services singled out in UK policy initiatives as potentially useful in supporting this group of carers, and further evaluation studies are needed.     

Engagement with health and social care services: perceptions of homeless young people with mental health problems

The present qualitative study describes and discusses the perspectives and experiences of young homeless people with mental health problems in relation to their interactions with health and social care services. Working in partnership with Streetlink, a supported accommodation assistance programme in Adelaide, Australia, the authors interviewed 10 homeless young people, aged from 16 to 24 years of age, who had experienced mental health problems. In-depth interviews elicited accounts of the best and worst of the participants' experiences of health and social care services. Access to services was not identified as being a significant problem in comparison with the participants' concerns regarding the quality of the services encountered. The central findings stress the importance of a respectful and supportive climate in relation to the qualities of service provision that the young people identified as valuable for their continuing treatment or consultation.     

Primary healthcare for people with mental health problems or learning disabilities

The physical health inequalities experienced by people with mental health problems or learning disabilities are well established, though comprehensive data for England and Wales have not previously been available. Nor have the reasons for inequalities been examined in detail. The Disability Rights Commission in Great Britain set out to examine such inequalities in relation to primary healthcare and to establish what remedial actions are needed. A range of data-gathering mechanisms was used, including clinical data analysis, qualitative research, structured feedback from service users and professionals, and a high-level inquiry panel which took evidence from government departments and agencies and from national organisations. The data provide detailed evidence about inequalities and this paper sets out key recommendations for change.     

Child abuse: current problems and key public health challenges

Child abuse has recently been recognized by the World Health Organization as a major worldwide health problem impairing the health and welfare of children and adolescents. This paper attempts to look at child abuse from a public health perspective taking into account the vast cultural diversity in which children and adolescents live focusing on the issue of abuse and violence in a broad public health perspective, and trying to highlight the need for greater attention to be given to possible country-specific interventions.     

Young people supporting parents with mental health problems: experiences of assessment and support

The explosion of interest in young people as carers over the last decade and a half conceals the fact that there are still no reliable estimates of the number of young people with caregiving responsibilities. This is even more problematic in circumstances where the 'looked after' person has a mental health problem. In this study, we reflect on what can be done to identify, assess and support young people in these circumstances. We draw on selected findings from a study that has been examining the constituents of good assessment practice in work with family carers supporting relatives with mental health problems. The study embraces different carer groups but this paper concentrates on the experiences of young carers at one study site where Barnardo's and partner organisations had developed a joint initiative targeting young people who are looking after parents and relatives with mental health problems. Following a review of the literature about young people as carers, the paper describes how Barnardo's worked to support them through its young carers projects. Based on face-to-face interviews with the young people (N = 10) caring for a mother with mental health problems, the main part of the paper provides an account of how they talk about, make sense of and evaluate the support they have received through this combined initiative. The findings underscore the value of one particular young carers project, and provide clues about what lessons may be transferable to other similar projects.     

Sport for all: Some public health policy issues and problems

This paper has two central objectives: (1) to examine critically the assumption underlying a central objective of many ‘Sport for all’ programmes, namely to improve people's health; (2) to illustrate, via the use of two recent British case studies, some of the complexities involved in the administration of sports policy and in coordinating sports policy with health policy. It is argued that almost all the studies which are cited to support the idea that sport is good for health refer not to sport but to physical activity or exercise. But physical activity and sport are not the same. The paper explores some of the key social differences between sport and physical activity–for example the fact that sport is inherently competitive and that many sports are mock battles in which aggression and the use of physical violence are central characteristics–and examines some of the health consequences of these social differences, for example in the terms of the injury risks. It is argued that if ‘Sport for all’ policies are intended to improve people's health, then more thought should be given to the kinds of physical activities we wish to encourage. The complexity and fragmentation of policy making in relation to sport and the lack of coordination with health policy are illustrated by two case studies: (1) the Sport: Raising the Game policy announced by the Government in 1995 and (2) the implementation within schools of a programme of health-related exercise (HRE) as part of the National Curriculum in Physical Education.     

Tobacco taxation and public health: ethical problems, policy responses

This article aims to describe the major ethical issues surrounding tobacco taxation, and to identify policy responses to minimise any ethical dilemmas. It uses the standard ethical framework for biomedicine (covering beneficence, non-maleficence, respect for autonomy and justice), in conjunction with relevant data on tobacco taxation from various developed countries. Tobacco taxation contributes substantial benefits at the population level by protecting health (i.e., by deterring the uptake of smoking by youth, by promoting quitting, and by reducing harm from exposure to second-hand smoke (SHS)). However, tobacco taxes can contribute to financial hardship among low-socioeconomic status populations where smoking persists. Such taxes can contribute to autonomy, by reducing SHS exposure to non-smokers, and by allowing freedom from nicotine-dependency for those who quit smoking or do not start regular smoking as a result of high tobacco prices. Furthermore, increases in tobacco taxation may reduce health inequalities and so contribute to justice. Nevertheless, the additional tax burden imposed on smokers who wish to continue to smoke, or are unable to quit, can be considered unjust. The autonomy of such smokers may be partly impaired. Although tobacco tax can be regarded as ethically justifiable because of its substantial overall benefit to society, there is substantial scope for policy changes to further reduce any harms and injustices for those populations who continue to smoke.     

Bioethical principles in public health: limitations and proposals

We propose to analyze the specificity of ethical problems in public health issues and to elucidate the applicability of principlism as a problem-solving strategy in this realm. Although well-established in clinical ethics, principlism is not an adequate model to be used in public health, since it is basically intended to serve as a moral guide in the physician-patient encounter. We discuss the possible adequacy of principles like "solidarity", "ontic responsibility" (as proposed by Jonas), and "caring or diaconal responsibility" as presented by Lévinas. Solidarity appears to be insufficiently specified, whereas the other two perspectives may be adapted to public health issues by bringing together Jonas' ontological and Lévinas' transcendental concerns to form a principle of protection that might better serve the purposes of such an ethics. This principle would help to identify more clearly the goals and agents involved in the implementation of public policies that are expected to be both morally correct and pragmatically effective.     

Social control agents or front-line carers for people with mental health problems: police and mental health services in Sydney,Australia

The relationship between mental health services and police and people who have mental health problems, are suicidal or are drug- and/or alcohol-affected is examined in this paper. A survey of 131 police officers in Sydney, Australia, revealed that more than 10% of police time is spent dealing with people with mental health problems. Nevertheless, police felt unsupported in this role, unprepared for it and torn between the competing demands experienced in their work. A lack of confidence in dealing with suicidal people and a belief that work with mentally disturbed people does not constitute valid police work are also reported. Managing people with mental disturbance is a major concern for police. Specifically, there are difficulties relating to: inadequate training and education; deficiencies in services/resources; time and resource over-utilization; communication, liaison and feedback problems, and frustration related to accessing mental health facilities/services. It is argued that police work involving mentally disturbed people is a valid and necessary role that complements law enforcement. In order to facilitate this aspect of police work, recommendations are made regarding education and collaborative working relationships between police and mental health professionals, which, in turn, could improve the care of mentally disturbed people in the community.