Meeting minority health needs through special MCH projects

The maternal and child health programs of the Public Health Service have always been directed to minority populations; however, the recent surges of immigrants from Asian and Central American countries have caused the agency to appraise its efforts to meet the special health needs of these people. Through grants for special projects of regional and national significance (SPRANS), the Office of Maternal and Child Health is funding projects to break down language, culture, and access barriers to health services for pregnant women, infants, and children. Recent and current SPRANS projects have taken innovative approaches to solving the special health problems of the minority populations. They range from a breastfeeding initiative in the Commonwealth of the Northern Mariana Islands to an areawide genetic service program in the Virgin Islands. Examples of projects that have been conducted are presented.     

Organizing mental health services: an evidence-based approach

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.     

Access and effectiveness in psychological therapies: self-help as a routine health technology

The ability of psychological treatment services to deliver effective and accessible mental healthcare, as demanded by the National Service Framework for mental health, is compromised by the traditional configuration of psychological therapy services, powerful gatekeeping by these services and the difficulties which exist in engaging primary care in mental healthcare. Although a number of service models have been suggested, most address access from the perspective of secondary care service providers. In particular, self-help, a powerful ideology and a clinically effective health technology, is given insufficient prominence in psychological therapy services. Self-help is often only considered for mild problems or as an adjunct to therapy, and it is assumed that mental health professionals with traditional therapeutic skills are needed to support self-help. Following a review of access and self-help in psychological therapies, the present authors propose criteria against which services could be designed in order to fully utilise self-help as a powerful health technology in psychological therapies. Accompanying these criteria is a research framework drawn from recent work on access and illness self-management that can be used to evaluate the performance of services attempting to improve access to psychological therapies.     

Applying the recovery approach to the interface between mental health and child protection services

There is a range of theoretical approaches which may inform the interface between child protection and adult mental health services. These theoretical perspectives tend to be focused on either child protection or mental health with no agreed integrating framework. The interface continues to be identified, in research, case management reviews and inquiry reports, as complex and problematic. This article proposes that more positive, integrated approaches to service user engagement, risk assessment and management may lead to better outcomes in working with families experiencing parental mental health problems and child protection concerns. It is proposed that the recovery approach, increasingly used in mental health services, can inform the processes of engagement, assessment and intervention at the mental health and child protection interface. The article provides a critical overview of the recovery approach and compares it with approaches typifying interventions in child protection work to date. Relevant research and inquiries are also examined as a context for how to more effectively respond to cases where there are issues around parental mental health problems and child protection. The article concludes with case material to illustrate the potential application of the recovery approach to the interface between mental health and child protection services.     

以标化工作量为基础的基层医疗机构绩效管理*

近期,天津市全面推进基层医疗卫生机构标准化全科门诊建设,采取科室整合、服务流程再造等措施,推广预约就诊、定向分诊、诊前健康管理服务、诊间履约服务和诊后复诊预约的标准化服务流程。流程改造带来了家庭医生团队成员之间的服务协作和医疗、预防及康复服务之间的融合,概括来说是"先服务,后诊疗"的服务模式。这种服务模式对"以经济收入"为主要参考的绩效管理方式提出了挑战。因此,以标化工作量为基础考核"服务"岗位与"诊疗"岗位绩效,对调动广大医务人员工作的积极性具有重要意义。本研究将基层医疗机构工作岗位(除部分行政岗位)分为一般诊疗类项目、健康管理类项目和医技检验类项目,根据项目的不同特色进行标化,为服务模式转型后的基层医疗机构绩效管理提供借鉴。     

Working with an Aboriginal community liaison worker

FPA Health (Family Planning NSW) has conducted two integrated clinical and health promotion projects with Aboriginal communities in western NSW, Australia. The first was in Coonamble, a small rural community which had been selected as a pilot site for the Royal Australian College of General Practitioners Women's Aboriginal and Torres Strait Islander Project and was managed by FPA Health with support from the Dubbo/Plains Division of General Practice and Macquarie Area Health Service. The second was in Dubbo, a regional city where FPA Health had an existing centre and which had funding support from the Rio Tinto Aboriginal Foundation. The aim of this article was to share the learning and knowledge gained in managing these projects and to describe the experience of working with Aboriginal Community Liaison Workers who belong to and are supported by, the local Aboriginal community. The article aimed to illustrate the role and value of utilising these workers within a mainstream health service. The beneficial outcomes include improving service provision to Aboriginal women, adding to community knowledge about reproductive and sexual health issues and increasing the cultural knowledge and competency of a mainstream health service organisation.     

Equity of access to health care services: theory and evidence from the UK

The pursuit of equity of access to health care is a central objective of many health care systems. This paper first sets out a general theoretical framework within which equity of access can be examined. It then applies the framework by examining the extent to which research evidence has been able to detect systematic inequities of access in UK, where equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity between socio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored in each of five service areas: general practitioner consultations; acute hospital care; mental health services; preventative medicine and health promotion; and long-term health care. The paper concludes that there appear to be important inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate, making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turn limits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings.     

The quest for choice and the need for relational care in mental health work

Since the revolutionary mood of the 1960s, patient-centered mental health care and a research emphasis on service users as experts by experience have emerged hand in hand with a view of service users as consumers. What happens to knowledge derived from firsthand experience when mental health users become experts and actively choose care? What kind of perspective do service users pursue on psychological distress? These are important questions in a field where psychiatric expertise on mental illness is socially structured and constrained as an intra-personal disturbance of the mind. We argue that experience experts have lost a coherent perspective on care and health. We illustrate this by rationally reconstructing how the interpersonal view of mental health first gained and then lost coherence between the conception of mental health, the practice of mental health care, and the user experience. Harry Stack Sullivan’s interpersonal theory was a paradigm case for such coherence. The inclusion of mental health consumers as ‘experts by experience’ in the mental health field took place at the cost of Sullivan’s coherent interpersonal theory. Service users who interact side by side with medical experts as experience experts are constrained by the evidence-based imperative and consumerism. Service users are caught up in a race among experts to gain knowledge about mental problems from a third-person perspective instead of from first-person experience. To make a contribution service users have more to gain from a research approach that appreciates that they are persons among persons rather than experts among experts.     

Decentralisation of general management within the New Zealand health system.

The radical organisation changes implemented in the New Zealand health system in recent years are discussed and analysed in this study which is based upon a review of documents and interviews with general managers of area health boards. Service management, which involves the decentralisation of general management to programme or product groupings (medicine, child health etc) has been widely implemented in almost all boards completely replacing the traditional disciplinary hierarchies. It is also leading to a population-rather than an institutional-based system of management. General managers report positively on the achievements of service management including greater accountability and commitment of clinical staff, innovation and team building, improved performance and service quality, the integration of hospital and community-based care and a customer rather than an occupational orientation. There is an increasing trend towards the recognition of primary health care as a key service entity.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

The treatment of psychological problems experienced by the children of police officers in Northern Ireland

This paper will discuss the recent establishment of the Police Rehabilitation and Retraining Trust's Child and Adolescent Therapy Service. This service was set up in response to an expressed need within the police family to provide evidenced-based psychological therapies for child and adolescent psychopathology caused either directly by service-related incidents or indirectly via parental psychopathology. Officers receiving treatment within the Trust's Adult Psychological Therapies Service frequently expressed distress and guilt regarding the impact their service and related symptoms had on their children. In addition, officers reported a reluctance to utilise existing statutory child and adolescent mental health services.

The impact of the constantly changing political landscape on this population will be examined as the general decrease of an overt terrorist threat allows an opportunity for police families to count the cost the 'troubles' have had on their mental health and to assess what support is required. But the uncertainty of what level of covert threat remains continues to impact directly on family life.

This paper will examine the clinical approaches adopted by this specialist service, in particular Cognitive Behavioural Therapy and Eye Movement Desensitisation and Reprocessing. It will examine how an ongoing and current threat of further trauma impacts on treatment provision and on the establishment of the therapeutic alliance. Primary and secondary stressors unique to this population will be explored, and their impact on treatment, along with how these trauma-related problems might manifest themselves in a variety of disorders.

While the Child and Adolescent Therapy Service exists specifically to provide treatment for police children, the service aims to establish links with statutory services in an attempt to ensure that police families will be able to utilise existing resources, gradually moving away from the feelings of community isolation expressed by some police families.     

Disseminating clinical and fiscal practices across the New York State behavioral healthcare system

In order to facilitate the adoption of innovative practices in the mental health service system, providers require access to both new information and methodologies, and ongoing training, supervision and consultation. Technical Assistance centers have been proposed as a way to disseminate effective interventions through the provision of resources including information, ongoing training and consultation. The purpose of this study is to describe the New York State Technical Assistance Center’s reach across the child public mental health service system and variations in characteristics of training activities, including dosage, content and method of format. Between 2011 and 2015, 460 (92.6%) of all New York State mental health clinics attended a training. The most highly attended events focused on business practices, followed by evidence-based treatments and clinic practices, and trauma-informed care. All were delivered via a webinar format, and were less than one day in duration. The behavioral health service system must be equipped to adapt to changing clinical and business practices in order to provide quality care and remain fiscally viable. New York State’s TA center reached the majority of child mental health service providers across the state. Next steps are to closely examine the impact of TA supports upon adoption and sustained use of practices. Implications of these findings and additional future directions are presented.     

Child mental health differences amongst ethnic groups in Britain: a systematic review

Background  

Inter-ethnic differences have been reported for many mental health outcomes in the UK, but no systematic review on child mental health has been published. The aim of this review is to compare the population-based prevalence of child mental disorders between ethnic groups in Britain, and relate these findings to ethnic differences in mental health service use.     

Perceived parental burden and service use for child and adolescent psychiatric disorders.

OBJECTIVES: Pediatric chronic physical illness and adult psychiatric disorders are substantial sources of burden for family care-takers, but little attention has been paid to parental burden resulting from children's or adolescents' psychiatric disorders. This paper describes the predictors of perceived parental burden and its impact on the use of specialty mental health and school services. METHODS: A representative general population sample of 1015 9-, 11-, and 13-year-olds and their parents completed structured psychiatric diagnostic interviews and the Child and Adolescent Burden Assessment. RESULTS: Weighted estimates indicated that 10.7% of parents in the general population perceived burden resulting from their children's symptomatology. Significant predictors of perceived burden were levels of child symptomatology and impairment and parental mental health problems. Children's depressive and anxiety disorders were associated with less burden than other diagnoses. The effects of child disorder severity on specialty mental health service use appeared to be mediated by the level of burden induced. CONCLUSIONS: Substantial levels of parental burden resulted from child psychiatric disorders and were a major reason for specialist mental health service use.     

Measuring key integration outcomes: a case study of a large urban health center

BACKGROUND: Health care reform, through innovative health delivery systems, has been a high priority to address staff shortages, increasingly complex care needs of the aging population, and fragmentation of care. Community health centers have been promoted as one service delivery model with large potential for integration and collaboration. The South Calgary Health Centre (SCHC) opened in June 2004 with the mandate to provide a new model for accessible, accountable, integrated, and community-based health services. PURPOSE: The primary objective was to determine the performance of the SCHC; and further, to establish the value of the evaluation framework used in measuring organizational performance of an integrated service delivery model. METHODOLOGY: Multiple stakeholders were involved in the evaluation in a utilization-focused, participatory way. A comprehensive evaluation framework was developed and implemented to assess the performance of the SCHC at system, provider, and patient levels. Functional, clinical, and community integration were key systems outcomes within this framework. Case-study methodology with mixed methods drawing on multiple data sources (both qualitative and quantitative) was used. FINDINGS: The evaluation findings suggest that the center is functioning well and that staff and client satisfaction are high. Although the model has not achieved all that was originally intended (i.e., fully realized clinical integration), participants felt that the model has been successful and has great potential for integration. The comprehensive evaluation framework developed for this project proved useful in assessing different aspects of integration as well as provider and client perceptions of the center's performance. PRACTICE IMPLICATIONS: Evaluation findings and recommendations have been used to inform operations at the SCHC and for the planning of future health centers. The evaluation framework may help to standardize evaluation approaches across projects and can be used for monitoring progress of the SCHC as well as future evaluations of integrated service delivery models.     

基于扎根理论的社区应用型精神卫生项目评价框架初探

目的:构建社区应用型精神卫生项目评价框架,为项目管理和评价提供依据,引导项目向好发展,促进社区精神卫生工作.方法:2019年7月采用目的抽样和理论抽样方法,对北京市朝阳区和海淀区41名精神卫生领域利益相关者,就社区精神卫生项目应具备的价值开展半结构式访谈,并运用扎根理论深入归纳、分析.结果:梳理自由节点1 467个、树...     

The prevalence of mental health problems among users of NHS stop smoking services: effects of implementing a routine screening procedure

Background

Tobacco dependence among people with mental health problems is an issue that deserves attention both from a clinical and from a public health perspective. Research suggests that Stop Smoking Services often fail to ask clients about underlying mental health problems and thus fail to put in place the treatment adaptations and liaison procedures often required to meet the needs of clients with a mental health condition who want to stop smoking. This study assesses the recording of mental health problems in a large NHS stop smoking service in England and examines the effect of implementing a short screening procedure on recording mental health conditions.

Methods

Treatment records from the Stop Smoking Service covering a period of 13 months were audited. The prevalence of reported mental health problems in the six month period before the implementation of the mental health screening procedure was compared with that of the six month period following implementation. The screening procedure was only implemented in the support services directly provided by the Stop Smoking Service. Comparisons were also made with third-party sections of the service where no such screening procedure was introduced.

Results

The prevalence of reported mental health problems among a total of n = 4999 clients rose from less than 1% before implementation of the screening procedure to nearly 12% in the period following implementation, with the change being statistically significant. No significant rise was observed over the same period in the sections of the service where no screening procedure was implemented.

Conclusions

The absence of standard procedures to record mental health problems among service users in many stop smoking services is currently likely to prevent the detection of co morbidity. Implementing a simple screening procedure appears suitable to increase the routine recording of mental health problems in a stop smoking service, which is an essential step to ensure services can be tailored and delivered appropriately to the client group.     

Predictors of Initial Engagement in Child Anxiety Mental Health Specialty Services

Background

Child and family mental health services remain largely underutilized despite the relatively high rate of youth suffering from mental, emotional, and behavioral disorders. As such, it is important to address challenges and examine factors related to child mental health service use and engagement, especially when it comes to children in need of services for anxiety.

Objective

Informed by the behavioral model of health services use, the present study sought to examine predictors of service use and engagement for families seeking assistance for their anxious children. Initial levels of engagement in culturally tailored services were predicted from predisposing characteristics (e.g., child age, ethnicity), enabling resources (e.g., Spanish services, transportation), and need characteristics (e.g., child clinical severity).

Methods

Participants included Latino (n = 126) and Caucasian (n = 116) families who presented to a specialty clinic due to child emotional and behavior problems related to anxiety. Initial service utilization and engagement was assessed along the following levels toward services care: (1) initiated contact and completed a clinical intake, (2) completed a home screen, and (3) completed an on-site diagnostic assessment. All procedures were culturally tailored to the presenting needs of families.

Results

Predisposing characteristics, enabling resources and need characteristics emerged as significant predictors of child mental health service use, with some variations. Child age, ethnicity, referral source, and enabling resources predicted completion of a home screen. Proximity to services predicted completion of the on-site diagnostic assessment.

Conclusion

Knowledge of factors that predict engagement in child mental health services can help identify avenues to promote service utilization, especially among ethnic minority children and families. Our culturally tailored approach to serving families appears to be promising in bridging the cross-ethnic services gap and therefore has implications for practice.