Promoting posttraumatic growth among the refugee population in Spain: A community‐based pilot intervention

Various international organisations have identified the development of programmes that mitigate the negative impact that forced displacement has on refugees’ mental health as a priority intervention area. From this perspective, this study seeks to lend empirical support to a community‐based pilot intervention aimed at promoting posttraumatic growth (PTG) among refugee adults arrived to Seville, the capital of Andalucía (southern Spain). PTG constitutes a mental health indicator that refers to the positive personal transformations refugees undergo as a consequence of experiencing forced displacement. This concept does not negate the undeniable personal suffering forced displacement causes for refugees; rather, it focuses on the positive changes this event has the potential to bring about. Forty‐seven individuals (age, M = 33 years; 20 women) from several countries in conflict participated in the intervention over 15 weeks (March–June 2017). The implementation process comprised two phases: (a) training a group of settled refugees to become peer mentors; and (b) holding cultural peer‐support group sessions made up of newly arrived refugees led by the mentors. Following quantitative and qualitative data collection (using the ‘Posttraumatic Growth Inventory’ (PTGI; Tedeschi & Calhoun, Journal of Traumatic Stress, 1996, 9, 455) and participants’ written evaluations and comments, respectively), and adopting a pretest‐posttest evaluation design, significant improvements were found in four of the five PTG factors: ‘appreciation of life’, ‘personal strength’, ‘relating to others’ and ‘new possibilities’. However, no significant differences were observed for ‘spiritual change’. We also documented implementation outcomes which revealed high intervention acceptability, appropriateness and feasibility. This study highlights how PTG shown by the refugee population can be actively improved through a community‐based intervention, specifically by creating supportive community settings that adopt a mentorship and peer‐based approach. The limitations and contributions of this research that address the current challenges behind promoting the mental health of refugees in places of settlement are discussed.     

Implementing a community‐based self care training initiative: a process evaluation

Within the UK, there is growing recognition that individuals will need to take increased responsibility for managing their own health for there to be improvements in population health. The current evidence base on self care interventions reflects an interest in enhancing self care knowledge, skills and behaviour in relation to the management of long‐term conditions. In contrast, this paper reports on a community‐based self care initiative that was designed to promote self care approaches in the general population. The principal component was a self care skills training course delivered to groups of lay people in community and workplace settings. Self Care for People was piloted in three primary care trusts and a process evaluation was undertaken. The aim of this paper is to examine the feasibility, relevance and acceptability of the initiative. Qualitative interviews were conducted with a sample of stakeholders involved in implementation including coordinators, trainers and key informants from organisations hosting the course. In total 40 interviews and two focus groups were conducted from 2006 to 2008 and the data were analysed thematically. The evaluation found that implementation was relatively straightforward with few major barriers reported. Recruitment to the self care skills training course took place in both workplace and community group settings, including in organisations supporting socially excluded groups. The course was seen to provide a valuable space for contemplation on personal health, however, participation could raise sensitive issues that needed to be dealt with by skilled facilitators. Motivations for involvement differed markedly in host organisations and different strategies for marketing were adopted. The paper concludes by suggesting that while Self Care for People was both feasible and relevant to different stakeholder groups, there needs to be flexibility in responding to the needs of participants in different settings.     

Expanding the meaning of ‘being a peer leader’: qualitative findings from a Canadian community‐based cervical and breast cancer screening programme

Engagement of community members to act as peer workers is a key feature of many community‐centred health promotion programmes. However, little is known about their experiences beyond the commonly reported themes of fulfilment through helping people in need and improvement of personal confidence, self‐esteem and self‐care. This gap in the literature is of particular interest given increasing involvement of peer workers in community‐centred programmes addressing health disparities, such as uptake of cancer screening. This paper aims to explore experiences of the peer leaders who worked for the Cancer Awareness: Ready for Education and Screening (CARES) project to promote awareness, knowledge, and uptake of breast and cervical cancer screening among under‐/never‐screened women who belonged to ethnic minority, recent immigrant and low‐income communities in Toronto, Canada. In 2013, three focus groups were conducted with 14 peer leaders to explore their experiences. All were immigrant women between 30 and 50 years of age. All discussions were audio recorded and transcribed verbatim. We used situational maps and analysis to create a visual representation of the data, and to investigate peer leaders experiences. Situational analysis was chosen to bring to light dominant and also silent underlying aspects which define the meaning of being a peer leader. The first level of analysis identified main themes that characterised peer leaders' experience: (i) Helping others (women, friends and family) and themselves by improved self‐confidence, self‐awareness and self‐care and (ii) Redefining professional and social positions through their project activities leading to professional development and networking. The second level of analysis explored the redefining process and identified some peer leaders' negotiations in relation to knowledge (science vs. myth), beliefs (fear vs. assurance) and boundaries (private vs. work). Adding to the literature on the peer workers' experience, the findings are discussed in relation to empowerment of peer workers, training implications and theoretical contributions.     

Understanding the limitations of “quasi‐mandatory” approaches to enrolment in community‐based health insurance: Empirical evidence from Tanzania

In recent decades, a growing number of low‐income countries (LICs) have experimented with voluntary community‐based health insurance (CBHI), as an instrument to extend social health protection to the rural poor and the informal sector. While modest successes have been achieved, important challenges remain with regard to the recruitment and retention of members, and the regular collection of membership fees. In this context, there is a growing consensus among policymakers that there is a need to experiment with mandatory approaches towards CBHI. In some localities in Tanzania, local actors in charge of community health funds (CHFs) are now relying on what is best described as quasi‐mandatory enrolment strategies, such as increasing user fees for non‐members, automatically enrolling beneficiaries of cash transfer programmes and enrolling the exempted groups (people who are entitled to free healthcare). We find that, while these quasi‐mandatory enrolment strategies may temporarily increase enrolment rates, dropout and the non‐payment of contributions remain important problems. These problems are at least partly related to supply side issues, notably to inadequate benefit packages. Overall, these findings indicate the limitations of any strategy to increase enrolment into CBHI, which is not coupled to clear improvements in the supply and quality of healthcare.     

Catalyzing the scale‐up of community‐based primary healthcare in a rural impoverished region of northern Ghana

Ghana's Community‐based Health Planning and Services (CHPS) initiative develops accessible healthcare with participatory community support, using strategies developed and tested by a project of the Navrongo Health Research Centre. In 1996, the project was expanded to a district‐wide four‐celled trial. In response to evidence that strategies could reduce fertility and childhood mortality, a replication project was launched to develop methods for scale‐up. Based on experience gained, CHPS scale‐up was launched in 2000. Although CHPS now reaches all of Ghana's districts, the pace of scale‐up within districts has been slow. In response, the Ministry of Health conducted a review of factors that constrain CHPS scale‐up and problems that detract from its original evidence‐based design. To resolve problems that were identified, a project was launched in 2010 to test means of accelerating CHPS scale‐up and expand its range of care. Known as the Ghana Essential Health Interventions Program (GEHIP), the project provided catalytic revenue to four treatment district managers for 3 years, in conjunction with implementation of strategies for comprehensive leadership development and community partnership. Monitoring systems were developed to gauge CHPS coverage time trends in all nine study districts. GEHIP successfully accelerated CHPS implementation, producing 100% of its targeted community coverage within 5 years of implementation. Coverage in comparison districts also improved. However, the rate of coverage and per cent of the population reached by CHPS in comparison districts was only half that of GEHIP districts. GEHIP success in completing CHPS coverage represents the initial stage of a national program for strengthening community health systems in Ghana. Copyright © 2015 John Wiley & Sons, Ltd.     

Introducing mental health and substance use screening into a community‐based health service in Australia: usefulness and implications for service change

Mental health issues such as depression or anxiety and alcohol or other drug (AOD) problems often remain undiagnosed and untreated despite their prevalence in the community. This paper reports on the implementation and evaluation of an AOD and depression/anxiety screening programme within two Community Health Services (CHS) in Australia. Study 1 examined results from 5 weeks of screening (March–April 2008) using the Patient Health Questionnaire (two‐ and nine‐item, Kroenke et al. 2001, 2003 ), the Conjoint Screen for Alcohol and other Drug Problems ( Brown et al. 2001 ) and the Alcohol, Smoking and Substance Involvement Screening Test ( Humeniuk & Ali 2006 ). Of the 55 clients screened, 33% were at risk of depression or anxiety, 22% reporting moderate‐severe depression. Thirteen per cent were at risk of substance use disorders. A substantial proportion of at‐risk clients were not currently accessing help for these issues from the CHS and therefore screening can facilitate identification and treatment referral. However, the majority of eligible clients were not screened, limiting screening reach. A second study evaluated the screening implementation from a process perspective via thematic analysis of focus group data from six managers and 14 intake/assessment workers (April 2008). This showed that when screening occurred, it facilitated opportunities for education and intervention with at‐risk clients, although cultural mores, privacy concerns and shame/stigma could affect accuracy of screen scores at times. Importantly, the evaluation revealed that most decisions not to screen were made by workers, not by clients. Reasons for non‐screening related to worker discomfort in asking sensitive questions and/or managing client distress, and a reluctance to spend long periods of time screening in time‐pressured environments. The evaluation suggested that these problems could be resolved by splitting screening responsibilities, enhancing worker training and expanding follow‐up screening. Findings will inform any community‐based health system considering introducing screening.     

Factors associated with the physical and mental health of drug users participating in community‐based drug rehabilitation programmes in China

Since the promulgation and implementation of a new anti‐drug law in 2008, the Chinese central government has encouraged local governments to carry out community‐based drug rehabilitation programmes. This study explores the association between community‐based drug rehabilitation programmes and drug users’ physical and mental health. This study collected data between October 2018 and February 2019 from a community‐based rehabilitation programme in a community in Foshan Municipality in Guangdong Province of China. A total of 162 drug users participating in a community‐based drug rehabilitation program were selected to complete a self‐administered and anonymous questionnaire. A cover letter interpreting the purpose of the study and a self‐administered questionnaire was provided to the drug users. Ethics approval for this study was obtained from the Academic Committee of School of Public Administration, JiNan University, Guangzhou, China. All participants gave verbal informed consent. Four multiple linear regression models were used to explain social services that influence drug users’ physical and mental health. The findings show that the number of service items provided by the social service organization was significantly associated with physical and mental health among drug users. Particularly, the employment assistance service influenced the drug user's physical and mental health status significantly.     

Oral health problems and support as experienced by people with severe mental illness living in community‐based subsidised housing – a qualitative study

The purpose of this study was to explore how persons with severe mental illness (SMI) experience oral health problems (especially dry mouth), and weigh the support they received in this regard from professionals and staff at community‐based congregate housing through a controlled intervention programme. Oral health problems and dry mouth are found in association with apathy and indifference, cognitive deficits, and long‐term medication with psycho‐pharmacological drugs. The present study describes the results from one part of a longitudinal intervention programme, which sought effective ways of mitigating dry mouth through increased support with oral health problems. This part consists of 67 informal interviews with ten participants in two community‐based urban housing projects between November 2006 and June 2007, with a follow‐up session in December 2007. Content analysis of the results yielded five categories: The shame of having poor dental health, history of dental care, experiences of self‐care, handling of oral health problems, and experiences of staff support. Poor oral health caused shame and limited participation in social activities. Participants avoided oral health issues by such circumventions as denial of a tooth ache or dental infections, or postponing oral problems with the hope that they would die away. Offers of support were frequently resisted because of unsatisfactory prior encounters with dental professionals and staff. Our findings suggest that self‐care needs to be facilitated in an unobtrusive manner with minimal staff involvement, and clients should be referred to dental care providers experienced in treating people with SMI.     

Qualitative evaluation of a community‐based intervention to reduce social isolation among older people in disadvantaged urban areas of Barcelona

This study analyses participants' and coordinators' perceptions of the implementation process and perceived benefits of a community‐based intervention to reduce social isolation among older adults. The ‘School of Health for Older People’ is a weekly community intervention that promotes resources among individuals and communities in order to enhance their ability to identify problems and activate solutions, encouraging participation in the community. A qualitative approach was employed, based on semi‐structured interviews and focus groups (FGs). This study was carried out in Barcelona. Two coordinators (community nurses) and 26 community‐dwelling people aged 65 and over who attended the School of Health for Older People in the neighbourhoods of Besòs and Guineueta, participated in in‐depth interviews and FGs between January and February 2016. Views and experiences about the intervention were explored. The main perceived effects of the intervention were expanding knowledge of health issues and of community activities, encouraging participants to go out, giving them a feeling of being heard, and peer relationships, increasing participants' contacts and knowledge while the main negative features were related to repetition of certain contents. The benefits identified included learning something about health and their own neighbourhood and breaking the habit of staying at home. Social isolation might be prevented by increasing the number of contacts with peers and sharing a common interest, since it could help to give them a sense of belonging to a community .     

A U‐statistics based approach to sample size planning of two‐arm trials with discrete outcome criterion aiming to establish either superiority or noninferiority

In current practice, the most frequently applied approach to the handling of ties in the Mann–Whitney‐Wilcoxon (MWW) test is based on the conditional distribution of the sum of mid‐ranks, given the observed pattern of ties. Starting from this conditional version of the testing procedure, a sample size formula was derived and investigated by Zhao et al. (Stat Med 2008). In contrast, the approach we pursue here is a nonconditional one exploiting explicit representations for the variances of and the covariance between the two U‐statistics estimators involved in the Mann–Whitney form of the test statistic. The accuracy of both ways of approximating the sample sizes required for attaining a prespecified level of power in the MWW test for superiority with arbitrarily tied data is comparatively evaluated by means of simulation. The key qualitative conclusions to be drawn from these numerical comparisons are as follows:

• With the sample sizes calculated by means of the respective formula, both versions of the test maintain the level and the prespecified power with about the same degree of accuracy.
• Despite the equivalence in terms of accuracy, the sample size estimates obtained by means of the new formula are in many cases markedly lower than that calculated for the conditional test.

Perhaps, a still more important advantage of the nonconditional approach based on U ‐statistics is that it can be also adopted for noninferiority trials. Copyright © 2016 John Wiley & Sons, Ltd.     

The contributions of persons in the work environment to the self‐identity of persons with mental health problems: a study in Israel

This study explores the contribution of others in the workplace to the self‐identity and job integration of persons with severe mental health problems. Thematic content analysis of in‐depth, semi‐structured interviews conducted in 2009 with 15 Israelis with severe mental health problems who work in a variety of frameworks (protected and supported employment and open market) revealed three main themes: (i) dissatisfaction with the protected work settings in which they were initially employed; (ii) the importance they attributed to their relationships with others in their workplace; and (iii) the change in self‐identity they underwent from persons defined by their mental health problems to persons who had worth, abilities and being beyond their illness. The findings underscore the important role of managers and colleagues in integrating persons with mental health problems at work and in strengthening the self‐identity of those individuals.     

Challenges to developing diabetes self‐management skills in a low‐income sample in North Carolina,USA

High rates of diabetes diagnosis and poor diabetes outcomes are particularly significant in low‐income, socially disadvantaged populations. Although many social and economic predictors of poor self‐management outcomes are known, few studies have examined how these elements impact the ability to develop self‐management capacities in low‐income populations. This article presents new insights into low‐income women's challenges and successes to becoming more adept self‐managers. Interview data were collected in 2012 with a sample of low‐income, middle‐age women with type II diabetes recruited from a non‐profit medical clinic serving low‐income clients in North Carolina, United States. Data were analysed using a grounded theory approach. Developing self‐management skills within disadvantaged life contexts involved negotiating three related, overlapping sub‐processes: negotiating access to care systems, negotiating disruptions to diabetes self‐management patterns, and negotiating self‐care knowledge. Developing diabetes self‐management skills is a long and arduous process. Data and analysis presented here help explain how disadvantaged life contexts can impact self‐managers' efforts to develop self‐management skills and why continued support is important for reducing and preventing future problems. These initial findings suggest that future studies and intervention development on the topic are warranted.