Implementation of the Mental Health Care Act (2002) at district hospitals in South Africa: Translating principles into practice

Legislation prior to 2002 tended to reinforce the alienation, stigmatisation and disempowerment of mentally ill patients in South Africa. In line with international developments in mental health legislation, the Mental Health Care Act (2002) was promulgated in South Africa. Its core principles--human rights for users; decentralisation and integration of mental health care at primary, secondary and tertiary levels of care; and a focus on care, treatment and rehabilitation--are progressive and laudable. However, the task of implementing the requirements of the Act at community and district hospital levels is fraught with problems. Lack of infrastructure, inadequate skills and poor support and training undermine its successful implementation. Health workers already burdened with enormous workloads and inadequate resources struggle to manage mentally ill patients at district hospitals. The 72- hour observation is a particular area of difficulty throughout the country. This paper outlines the rationale and sense behind this legislation, discusses the problems encountered at the 'rock face', and offers solutions to the problem of translating principles into practice.     

Unique PTSD Clusters Predict Intention to Seek Mental Health Care and Subsequent Utilization in US Veterans with PTSD Symptoms

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.     

Environmental scan of mental health supports across Canadian burn centers: A healthcare providers’ perspective

BackgroundEarly mental health care and psychosocial support after burn injury provided by a variety of specialists and non-mental health professionals is instrumental in prevention of long-term mental health sequalae such as post-traumatic stress, depressive or substance use disorders. Diversity of mental health supports available to burn survivors vary across geography, resulting in variation of long-term mental health outcomes following burn injury.MethodsA mixed-methods study utilizing a semi-structured questionnaire to explore resources available for burn survivors in Canada as an inpatient, outpatient, and more broadly in the aftercare community. Interviews were completed with 17 Canadian burn centers, with a variety of burn care professionals.ResultsIn the continuum of burn care, a lack of available mental health professionals in certain regions and in the outpatient and community phases was observed. Emerging themes demonstrated the need for regular screening for mental health concerns among burn survivors and providing up to date discharge resources. In addition, increasing educational opportunities available to burn care staff with respect to burn survivor mental health was emphasized. Lastly, the importance of proactive and prolonged psychological support for burn survivors as they progress through an outpatient, rehabilitation and community setting was underlined.ConclusionsIdentification of burn care practices and resources across Canada provides the opportunity to compare, unify and improve gaps in care that exist across the Canadian burn network.     

Readiness for Change Predicts VA Mental Healthcare Utilization Among Iraq and Afghanistan War Veterans

Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment‐seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care.     

Staff/bed and staff/patient ratios in South African public sector mental health services.

OBJECTIVES: To document staff/bed and staff/patient ratios in public sector mental health services in South Africa. DESIGN: Cross-sectional survey. METHOD: A questionnaire was distributed to provincial mental health co-ordinators requesting numbers of full-time equivalent (FTE) staff who provide mental health care at all service levels; numbers of psychiatric beds; and numbers of patients who attend outpatient departments, clinics and community health centres. The information was supplemented by consultations with mental health co-ordinators in each of the nine provinces. RESULTS: The staff/bed ratio for the country as a whole was 0.3 staff per bed. For the provinces, the staff/bed ratios were as follows: Eastern Cape 0.30, Free State 0.50, Gauteng 0.22, KwaZulu-Natal 0.34, Mpumalanga 0.89, North-West 0.27, Northern Cape 0.26, Northern Province 0.26, and Western Cape 0.59. For the country as a whole, the staff/bed ratios for each category of staff were as follows: total nursing staff 0.25, occupational therapists 0.01, occupational therapy assistants 0.01, social workers 0.01, community health workers 0.00, psychologists 0.00, intern psychologists 0.00, psychiatrists 0.00, psychiatric registrars 0.01, and medical officers 0.00. The ratio of ambulatory psychiatric service staff to daily patient visits (DPV) for the country as a whole was 0.6. CONCLUSIONS: Staff/bed ratios in South African mental health care are low relative to developed countries. Staff/DPV ratios highlight both the need to develop ambulatory care personnel for mental health care, and problems associated with monitoring the delivery and utilisation of mental health services within an integrated health system at primary level.     

Stigma and Demographic Correlates of Help‐Seeking Intentions in Returning Service Members

Many U.S. Iraq/Afghanistan‐era veterans return from deployment with posttraumatic stress (PTS) symptoms, but few veterans seek psychological help. Research on barriers to care is growing, but the link between stigma and help‐seeking is understudied. The present study examined anticipated enacted stigma from military and nonmilitary sources, self‐stigma, PTS, perceived likelihood of deploying again, marital status, and history of mental health care engagement as correlates of help‐seeking intentions from a mental health professional or medical doctor/advance practice registered nurse (MD/APRN) in a sample of 165 combat veterans. Using structural equation modeling, results demonstrated that self‐stigma was negatively associated with help‐seeking intentions from a mental health professional and MD/APRN with small‐to‐medium effect sizes. Being married was positively associated with help‐seeking intentions from a mental health professional and MD/APRN with small effect sizes. History of previous mental health care engagement was positively associated with help‐seeking intentions from a mental health professional with a medium effect size, but unrelated to help‐seeking intentions from a MD/APRN. Anticipated enacted stigma from any source, PTS, and greater perceived likelihood of deploying again were unrelated to help‐seeking intentions from a mental health professional and MD/APRN. Implications for interventions aimed at decreasing self‐stigma and increasing intention to seek help are discussed.     

脊髓损伤患儿父母照顾体验的质性研究

目的 深入了解脊髓损伤患儿父母的照顾体验,为促进其身心健康提供参考。方法 采用现象学研究方法,以立意抽样法抽取11名脊髓损伤患儿的父母进行半结构化访谈,运用Colaizzi分析法归纳主题。结果 提炼出4个主题,分别为承受照顾负荷、心理体验复杂、适应角色改变并提高照顾技能、渴望家庭和社会支持。结论 脊髓损伤患儿父母的照顾负荷较重,存在负性心理,医护人员需重视评估患儿父母照顾感受,并提供积极的心理干预指导,必要时提供适当的社会支持,以减轻其照顾负荷,改善其心理状况。     

The impact of perceived lack of support provided by health and social care services to caregivers of people with motor neuron disease

Our objective was to investigate the relationship between support by health and social care services and caregiver well-being. A survey, including a generic health status measure (SF-12), a disease-specific measure for patients (ALSAQ-40), the Carer Strain Index (CSI) for caregivers and questions on experiences of health and social care services, was sent to patient members of the MND Association (UK) and their caregivers. A single 'problem score' was calculated from the experience questions and the relationship between the problem score with caregiver and patient well-being was analysed. Most caregivers reported at least one problem with support from services. The most common problems were services not valuing caregivers' experiences, and caregivers not feeling sufficiently involved in planning care. The problem score significantly increased with increasing caregiver strain and worsening mental health. The problem score was also increased as patient well-being decreased. The results suggest that caregiver strain was higher and mental health lower as the number of problems reported increased. A higher perceived lack of caregiver support was also related to a decrease in patient well-being, suggesting that caregivers' needs increase as the disease progresses. This emphasizes the importance of MND caregivers being appropriately supported by health and social care services in their caregiving role.     

孕期心理保健方案的构建与实践

目的在循证方法学指导下构建孕期心理保健理论及其实践方案。方法在"促进健康的综合干预措施发展和评价框架"的方法学指导下,通过文献评阅确定证据基础,通过逻辑推演和专家咨询形成孕期心理保健方案。根据循证医学原理具化方案中的关键要素,整合形成初步的干预路径和具体方案,根据专家意见修改完善,通过模拟测试,确定最终的适宜干预路径和实践方案。结果构建了以助产士为基础、以多学科合作为支撑的孕期心理保健方案,对不同心理危险等级的孕妇予以普遍性干预、选择性干预、指征性干预。模拟测试期间有4 878名初诊登记孕妇接受了心理筛查,占同期孕妇的97.99%,11.02%的孕妇按照干预路径接受心理保健服务,有6名孕妇全程参与了模拟测试过程。结论所构建的孕期心理保健方案基于实践人员能力,契合干预场所情境,符合心理卫生服务发展趋势。为了充分发挥孕期心理保健方案的潜力,需要全面提高产科医务人员的心理保健能力。     

A district confidential enquiry into deaths due to asthma.

BACKGROUND--The aim was to establish a continuing district based confidential enquiry into deaths from asthma. METHODS--A confidential enquiry was conducted in an English health district. Subjects comprised 24 residents of the Norwich health district aged between 16 and 65 years who had died between 1988 and 1991 with asthma as the principal cause of death. RESULTS--Twenty one of the patients (88%) died away from hospital. Overall the routine asthma management was appropriate in all respects in only four patients. In five cases the drug treatment was considered inappropriate, in 10 cases (42%) there was no written evidence that the patient had received advice and education, and only six cases had a written management plan. In 17 patients (71%) the fatal attack of asthma developed rapidly (in under three hours). The medical care during the final attack was found to have been inappropriate in six cases. Seventeen cases (71%) had psychological or social factors that were considered to have been of potential importance. CONCLUSIONS--This study has shown the feasibility of organising a confidential enquiry into asthma deaths within a health district. The distinguishing features of such an enquiry are that it is continuing, that the quality of care given to those patients who died is compared against a recognised standard, and that there is a structured system for feeding back the conclusions of the enquiry to the local medical community.     

Operative surgery at the district hospital

Surgical disease is an important cause of preventable mortality and morbidity, but it is not clear how best to deliver surgical services to under-served rural populations in poorer countries. South Africa's policy is to restructure heath services, with district hospitals and health centres becoming the primary delivery vehicle for quality health care to all South Africans. Among other things this involves defining what services a district hospital should be expected to provide, including the district hospital service package (DHSP). Many felt that the list of district hospital surgical procedures is unrealistic, and it is not clear to what extent the package is deliverable. We therefore studied the operative surgery undertaken at district hospital level in a single region with well-organised primary health care services.     

Knowledge of depression among community members and health care providers in two selected areas of district rawalpindi

Objective: To determine the level of knowledge about depression in two selected areas of district Rawalpindi. Study Design: Cross-sectional survey report. Place and Duration of Study: Union council Rehmatabad and mohalla Sultanpura, Rawalpindi, from June to December 2007. Methodology: Strata of community were interviewed regarding the knowledge about depression using an indigenously developed questionnaire. To determine any association between difference of level of knowledge and different strata of community Chi-square (X)2 tests was applied at 5% level of significance and p-value less than 0.05 was considered significant. Results: Most of the respondents (63%) thought that diabetes was the major health problem in our country. Most of participants thought that drug abuse and addiction (74.3%), adolescent emotional and behavioral problems (66.8%) followed by alcohol abuse (50.3%) and personality disorders (49.2%) were the common mental illnesses. Chi-square (X)2 statistics showed a highly significant association between difference of level of knowledge and the two strata of community i.e. health care providers and community members (p < 0.001). Conclusion: People in the selected areas of district Rawalpindi had a poor knowledge about depression.     

护理SARS病人的护士心理健康状况与应付方式研究

目的了解参与SARS护理工作人员在高危险、高传染性、高强度工作压力下的心理健康状况及应付方式 ,为管理者制定护士心理卫生保健措施提供依据。方法采用症状自评量表 (SCL 90 )、应付方式问卷 (CSQ) ,对参与SARS工作的 96名护士 (SARS护士 )及 6 4名从事急救工作的护士和 73名普通内、外科护士进行心理健康状况及应付方式的调查。结果SARS护士心理健康状况与急救、普通护士比较 ,差异无显著性意义 ;但在应付方式上SARS护士相对优于其他护士 (除幻想因子外 ,均P <0 .0 5 ) ;6 1.4 5 %SARS护士应用成熟型应付方式 ,且心理健康状况相对优于不成熟型和混合型的SARS护士。结论SARS护士心理健康状况良好 ,大部分SARS护士采用最优应付方式。护理管理者应加强整体护理队伍心理素质训练和建立健全护士支持系统 ,提高群体应付水平。     

Operational Stress and Correlates of Mental Health Among Joint Task Force Guantanamo Bay Military Personnel

Military personnel deployed to Joint Task Force Guantanamo Bay (JTF‐GTMO) faced numerous occupational stressors. As part of a program evaluation, personnel working at JTF‐GTMO completed several validated self‐report measures. Personnel were at the beginning, middle, or end of their deployment phase. This study presents data regarding symptoms of posttraumatic stress disorder, alcohol abuse, depression, and resilience among 498 U.S. military personnel deployed to JTF‐GTMO in 2009. We also investigated individual and organizational correlates of mental health among these personnel. Findings indicated that tenure at JTF‐GTMO was positively related to adverse mental health outcomes. Regression models including these variables had R² values ranging from .02 to .11. Occupation at JTF‐GTMO also related to mental health such that guards reported poorer mental health than medical staff. Reluctance to seek out mental health care was also related to mental health outcomes. Those who reported being most reluctant to seek out care tended to report poorer mental health than those who were more willing to seek out care. Results suggested that the JTF‐GTMO deployment was associated with significant psychological stress, and that both job‐related and attitude‐related variables were important to understanding mental health symptoms in this sample.     

Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam

INTRODUCTION: The World Health Organization and the International Association for Trauma Surgery and Intensive Care have published the Guidelines for Essential Trauma Care. This provides recommendations for the human and physical resources needed to provide an adequate, essential level of trauma care services in countries at all economic levels worldwide. We sought to use this set of recommendations as a basis to assess the trauma care capabilities in two locations in Vietnam and thus to identify affordable and sustainable methods to strengthen trauma care nationwide. METHODS: A needs assessment tool was created that incorporated the recommendations of the Guidelines. This was used to conduct in-depth, onsite evaluations of 11 health care facilities in Hanoi and Khanh Hoa Province, including commune health stations, district hospitals, provincial hospitals, and a central hospital. RESULTS: Resources for trauma care were mostly adequate at provincial and central hospitals. There were several deficiencies at the district hospitals and especially at commune health stations. These included low level of trauma related training and shortages of supplies and equipment. In many cases these shortages were of low-cost items. However, in general, capabilities had improved compared with prior evaluations. CONCLUSIONS: This study has identified several low-cost ways in which to strengthen trauma care in Vietnam. These include greater use of continuing education courses for trauma care and more attention to trauma related curriculum in schools of medicine and nursing. These also include defining and assuring the availability of a core set of essential trauma related equipment and supplies. A policy recommendation that follows from the above findings is the need for programs to strengthen the organization and planning for trauma care.     

The risk of mental health disorders among U.S. military personnel infected with human immunodeficiency virus, active component, U.S. Armed Forces, 2000-2011

Mental disorders account for significant morbidity, health care utilization, disability, and attrition from military service; the health care burden associated with mental disorders has increased over the last several years. During the years 2000 through 2011, 936,283 active component service members were diagnosed with at least one mental disorder. Annual counts and rates of incident diagnoses of mental disorders have increased by approximately 65 percent over the last twelve years; this overall increase is largely attributable to diagnoses of adjustment disorders, depressive and anxiety disorders, and post-traumatic stress disorder. Rates of incident mental disorder diagnoses were higher in females than males and in service members under 30 years of age. These findings reinforce previous reports that have documented a rise in demand for mental health services in the active component force and suggest that continued focus on detection and treatment for mental health issues is warranted.     

妇幼专科医院护理带教老师心理健康状况及与社会支持的相关性

目的 调查妇幼专科医院护理带教老师心理健康状况,并探讨其心理健康与社会支持的关系。 方法 采用整群抽样法抽取1所妇幼专科医院护理带教老师288人,采用一般资料问卷、症状自评量表和社会支持评定量表进行调查。 结果 妇幼专科医院护理带教老师心理健康总均分为1.61±0.50,除躯体化外,其抑郁、强迫症状、人际关系敏感、焦虑、敌对、恐怖、偏执及精神病性因子得分与全国护士常模比较,差异有统计学意义（P＜0.05,P＜0.01）;护理带教老师的社会支持总分为41.50±8.39,其社会支持各维度得分及总分与心理健康各维度及总分呈负相关（均P＜0.01）。 结论 妇幼专科医院护理带教老师的心理健康水平及社会支持均有待提高,医院护理管理者可以通过提高护理带教老师社会支持水平促进其心理健康,使其更好地平衡工作压力和自身需求,保证护理工作质量。     

Use of Medical and Mental Health Care by World War II Survivors in The Netherlands

This study examined the mental and medical health care utilization of World War II (WWII) survivors and the characteristics of survivors seeking professional health care. Forty seven years after the end of WW II, a random sample of 4,057 Dutch WW II survivors answered a four-page questionnaire; 1,461 persons subsequently answered an extensive follow-up questionnaire. Twenty-two percent had sought some form of health care for war-related complaints at some time since WW II. Most consultations were made in the 1940s. More consultations were made to general practioners or to medical specialists as opposed to mental health specialists. Although the level of posttraumatic stress disorder (PTSD) symptoms was most important for discriminating between help-seeking and non-help-seeking respondents, 59% of the highly-exposed respondents with PTSD had not sought professional help in the years 1990–1992. The results show the importance of primary health care in recognizing PTSD symptoms and referring survivors to the appropriate professional helper.     

Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in‐depth examination of mental health‐related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S. Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to mental health treatment‐seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected, individuals with probable mental health problems reported more negative mental health‐related beliefs than those without these conditions. Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.