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There is limited evidence of the safety and impact of task-shared care for people with severe mental illnesses (SMI; psychotic disorders and bipolar disorder) in low-income countries. The aim of this study was to evaluate the safety and impact of a district-level plan for task-shared mental health care on 6 and 12-month clinical and social outcomes of people with SMI in rural southern Ethiopia.
In the Programme for Improving Mental health carE, we conducted an intervention cohort study. Trained primary healthcare (PHC) workers assessed community referrals, diagnosed SMI and initiated treatment, with independent research diagnostic assessments by psychiatric nurses. Primary outcomes were symptom severity and disability. Secondary outcomes included discrimination and restraint.
Almost all (94.5%) PHC worker diagnoses of SMI were verified by psychiatric nurses. All prescribing was within recommended dose limits. A total of 245 (81.7%) people with SMI were re-assessed at 12 months. Minimally adequate treatment was received by 29.8%. All clinical and social outcomes improved significantly. The impact on disability (standardised mean difference 0.50; 95% confidence interval (CI) 0.35–0.65) was greater than impact on symptom severity (standardised mean difference 0.28; 95% CI 0.13–0.44). Being restrained in the previous 12 months reduced from 25.3 to 10.6%, and discrimination scores reduced significantly.
An integrated district level mental health care plan employing task-sharing safely addressed the large treatment gap for people with SMI in a rural, low-income country setting. Randomised controlled trials of differing models of task-shared care for people with SMI are warranted.
Current coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment.
To identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.
In the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country's disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options.
Key challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries.
Including mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities.
Declaration of interest
D.C. is a staff member of the World Health Organization.
Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking.
To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda).
A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The ‘Performance of Routine Information Systems’ framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants.
Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability.
Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services.
Strengthening of mental health systems in low- and middle-income countries (LMICs) requires the involvement of appropriately skilled and committed individuals from a range of stakeholder groups. Currently, few evidence-based capacity-building activities and materials are available to enable and sustain comprehensive improvements.
Within the Emerald project, the goal of this study was to evaluate capacity-building activities for three target groups: (a) service users with mental health conditions and their caregivers; (b) policymakers and planners; and (c) mental health researchers.
We developed and tailored three short courses (between 1 and 5 days long). We then implemented and evaluated these short courses on 24 different occasions. We assessed satisfaction among 527 course participants as well as pre–post changes in knowledge in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). Changes in research capacity of partner Emerald institutions was also assessed through monitoring of academic outputs of participating researchers and students and via anonymous surveys.
Short courses were associated with high levels of satisfaction and led to improvements in knowledge across target groups. In relation to institutional capacity building, all partner institutions reported improvements in research capacity for most aspects of mental health system strengthening and global mental health, and many of these positive changes were attributed to the Emerald programme. In terms of outputs, eight PhD students submitted a total of 10 papers relating to their PhD work (range 0–4) and were involved in 14 grant applications, of which 43% (n = 6) were successful.
The Emerald project has shown that building capacity of key stakeholders in mental health system strengthening is possible. However, the starting point and appropriate strategies for this may vary across different countries, depending on the local context, needs and resources.
There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).
To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.
Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.
Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.
Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.
There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The ‘Emerging mental health systems in low- and middle-income countries (LMICs)’ (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.
To provide a set of proposed recommendations for mental health system strengthening in LMICs.
The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012–2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.
The proposed recommendations align closely with the World Health Organization's key health system strengthening ‘building blocks’ of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.
These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.
In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC.
A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect – with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6–9 months afterwards.
Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements.
This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy.
The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare.
A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice.
To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries.
We focused on the involvement of policy planners, managers, patients and carers.
Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project.
This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.
The literature on mass gatherings has expanded over the last decade. However, no readily accessible curriculum exists to prepare and support event medical leaders. Such a curriculum has the potential to align event medical professionals on improving event safety, standardizing emergency response, and reducing community impacts.
We organized collaborative expert focus groups on the proposed “core curriculum” and “electives.”
Key features of a mass gathering medical curriculum include operations-focused, evidence-informed, best-known practices offered via low barrier, modular, flexible formats with interactive options, and a multi-national focus.
Event Medical Planning - “The Seven Steps” - (1.) Assessment and Environmental Scan - Event Emergency Action Plan, (2.) Human Resources, (3.) Equipment/Supplies, (4.) Infrastructure/Logistics, (5.) Transportation (To, On, From), (6.)Communication (Pre, During, Post), and (7.) Administration/Medical Direction
Event After-Action Reporting
Electives mirror Core outline and serve as expanded case-studies of specific event categories. Initially proposed electives include:
Obstacle Adventure Courses
Staged Wilderness Courses
Political Gatherings & Orations
Religious Gatherings & Pilgrimages
Community Gatherings (e.g., Parades, Fireworks, etc.)
Complex team learning to standardize real-world approaches has been accomplished in other medical domains (e.g., ACLS, AHLS, ATLS, PALS, etc.). A course for event medicine should not re-teach medical content (i.e. first aid, paramedicine, nursing, medicine); it should make available a commonly understood, systematic approach to planning, execution, and post-event evaluation vis a vis health services at events. A ‘train the trainer’ model will be required, with business operations support for sustainable course delivery. The author team seeks community feedback at WCDEM 2019 in creating ‘the ACLS’ of Event Medicine.
Introduction: September 2017 saw the launch of the British Columbia (BC) Emergency Medicine Network (EM Network), an innovative clinical network established to improve emergency care across the province. The intent of the EM Network is to support the delivery of evidence-informed, patient-centered care in all 108 Emergency Departments and Diagnostic & Treatment Centres in BC. After one year, the Network undertook a formative evaluation to guide its growth. Our objective is to describe the evaluation approach and early findings. Methods: The EM Network was evaluated on three levels: member demographics, online engagement and member perceptions of value and progress. For member demographics and online engagement, data were captured from member registration information on the Network's website, Google Analytics and Twitter Analytics. Membership feedback was sought through an online survey using a social network analysis tool, PARTNER (Program to Analyze, Record, and Track Networks to Enhance Relationships), and semi-structured individual interviews. This framework was developed based on literature recommendations in collaboration with Network members, including patient representatives. Results: There are currently 622 EM Network members from an eligible denominator of approximately 1400 physicians (44%). Seventy-three percent of the Emergency Departments and Diagnostic and Treatment Centres in BC currently have Network members, and since launch, the EM Network website has been accessed by 11,154 unique IP addresses. Online discussion forum use is low but growing, and Twitter following is high. There are currently 550 Twitter followers and an average of 27 ‘mentions’ of the Network by Twitter users per month. Member feedback through the survey and individual interviews indicates that the Network is respected and credible, but many remain unaware of its purpose and offerings. Conclusion: Our findings underscore that early evaluation is useful to identify development needs, and for the Network this includes increasing awareness and online dialogue. However, our results must be interpreted cautiously in such a young Network, and thus, we intend to re-evaluate regularly. Specific action recommendations from this baseline evaluation include: increasing face-to-face visits of targeted communities; maintaining or accelerating communication strategies to increase engagement; and providing new techniques that encourage member contributions in order to grow and improve content.
Tactical Emergency Medical Response (TEMS) originated in the 1990s in Finland. It is a nationally standardized joint-effort with EMS and police special units, such as SWAT.
To describe a national system of TEMS in Finland.
In Finland, TEMS is a national response system of specially trained paramedics and pre-hospital doctors, working normally in HEMS or a local physician staffed rapid response car. There is a two-tier selection to get accepted in the basic course. The police run background checks for all participants before they are accepted to the course. The course itself is four days and it covers the basics of police tactics, protective gear, penetrating wounds, evacuation, etc. After graduating from the basic course, the paramedic/doctor is qualified to participate in missions. Although healthcare professionals are involved, a TEMS mission is under the police command and is used as one of the police’s special teams to operate in areas where normal EMS cannot be allowed for safety reasons. TEMS does not carry any weapons. The Police provide the teams with the same protective equipment that the SWAT/CTU has. After some years, there is a three-day refresher course for active TEMS service. In this course, the main training points are working in austere environments, such as helicopters, boats, and in urban environments wearing civilian clothing. Police pay for the usage of TEMS in missions, but they do not pay for training days.
TEMS has good national coverage. In 2017, there were 131 TEMS activations. The normal response to a mission is a team of one or two TEMS operators.
TEMS has achieved good national coverage and is deployed often. TEMS has also channeled information and training, such as TECC, to normal EMS personnel and raised their preparedness as well.
Research on events and mass gatherings is hampered by a lack of standardized and central reporting of event data and metrics. While there is work currently being done on report standardization, this will require a plan for recording, storing, and safeguarding a repository of event data. A global event data registry would further the work of standardized reporting by allowing for the collection and comparison of events on a larger scale.
To characterize the considerations, challenges, and potential solutions to the implementation of a global event data registry.
A review of the academic and grey literature on the current understanding and practical considerations in the creation of data registries, with a specific focus on an application to mass gathering events.
Findings were grouped under the following domains: (1) stakeholder identification and consultation, (2) research goals and clinical objectives, (3) technological requirements (ie hosting, format, maintenance), (4) funding (budget, affiliations, sponsorships), (5) ethics (privacy, protection, jurisdictions), (5) contribution facilitation (advertising, support), and (6) data stewardship and registry access for researchers.
This work outlines key considerations for undertaking and implementing an event data registry in the mass gathering space, and compliments ongoing work on the standardization of data collected at mass gathering events. If practical and ethical considerations are appropriately identified and managed, the creation of an event data registry has the potential to make a major impact on our understanding of events and mass gatherings.
The science supporting event medicine is growing rapidly. In order to improve the ability of researchers to access event data and improve the quality of publishing mass gathering cases, it would be of benefit to standardize event reports to permit the comparison of similar events across local and national boundaries. These data would support the development of practice standards across settings.
The authors propose the creation of a publication guideline to support authors seeking to publish in this field.
Method: Derivation study via analysis of published case reports using the Delphi process.
Data elements were inconsistently reported within published case reports. Categories of variables included: event demographics (descriptors of date, time, genre, activity, risks), attendance and population demographics, data related to climate and weather conditions, composition and deployment of an onsite medical team, highest level of care available onsite, patient demographics, patient presentations and measures of impact on the local health care system such as transfer to hospital rates. Of note, there was a high incidence of “missing” variables that would be of central interest to researchers.
Approaches to standardizing the collection and reporting of data are often discussed in the health care literature. The benefits of consistent, structured data collection are well understood. In the context of mass gathering event case reporting, the time is ripe for the introduction of a guideline (with accompanying guidance notes and dictionary). The proposed guideline requires the input of subject matter experts (in progress) to enhances its relevance and uptake. This work is timely as there is ongoing work on improving an international event medicine registry. If the evolution of both proceeds in lockstep, there is a good chance that access to a rigorous data set will become a reality.
The use of recreational substances is a contributor to the risk of morbidity and mortality at music festivals. One of the aims of onsite medical services is to mitigate substance-related harms. It is known that attendees’ perceptions of risk can shape their planned substance use; however, it is unclear how attendees perceive the presence of onsite medical services in evaluating the risk associated with substance use at music festivals.
A questionnaire was administered to a random sample of attendees entering a multi-day electronic dance music festival.
There were 630 attendees approached and 587 attendees completed the 19 item questionnaire. Many confirmed their intent to use alcohol (48%, n=280), cannabis (78%, n=453), and recreational substances other than alcohol and cannabis (93%, n=541) while attending the festival. The majority (60%, n=343) stated they would still have attended the event if there were no onsite medical services available. Some attendees agreed that the absence of medical services would have reduced their intended use of alcohol (30%, n=174) and recreational substances other than alcohol and cannabis (46%, n=266).
In the context of a music festival, plans for recreational substance use appear to be substantially altered by attendees’ knowledge about the presence or absence of onsite medical services. This contradicts our initial hypothesis that medical services are independent of planned substance use and serve solely to reduce any associated harms. Additional exploration and characterization of this phenomenon at various events would further clarify the understanding of perceived risks surrounding substance use and the presence of onsite medical services.
There is currently no standardized approach to collecting mass gathering health data, which makes comparisons across or between events challenging. From 2013 onward, an international team of researchers from Australia and Canada collaborated to develop a Minimum Data Set (MDS) for Mass Gathering Health (MGH).
The process of developing the MDS has been reported on previously at the 2015 and 2017 World Congresses on Disaster and Emergency Medicine, and this presentation will present a final MDS on MGH.
This study drew from literature, including the 2015 Public Health for Mass Gatherings key considerations, previous event/patient registry development, expert input, and the results of the team’s work. The authors developed an MDS framework with the aim to create an online MGH data repository. The framework was populated with an initial list of data elements using a modified Delphi technique.
The MDS includes the 41 data elements in the following domains: community characteristics, event characteristics, venue characteristics, crowd characteristics, event safety considerations, public health considerations, and health services. Also included are definitions and preliminary metadata.
The development of an MGH-MDS can grow the science underpinning this emerging field. Future input from the international community is essential to ensure that the proposed MDS is fit-for-purpose, i.e., systematic, comprehensive, and rigorous, while remaining fluid and relevant for various users and contexts.
Music festivals are globally attended events that bring together performers and fans for a defined period of time. These festivals often have onsite medical care to help reduce the impact on local healthcare systems. Historically, the literature suggests that patient transfers offsite are frequently related to complications of substance use. However, there is a gap in understanding as to why patients are transferred to a hospital when an onsite medical team, providing a higher level of care (HLC), is present.
To better understand the causes that necessitate patient transportation to the hospital during festivals that have onsite physician-led coverage.
De-identified patient data from a convenience sample of four, large-scale Canadian festivals (over two years) were extracted. Patient encounters that resulted in transfers to hospital, by ambulance, non-emergency transport vehicle (NETV), or self-transportation were analyzed for this study.
Each festival had an onsite medical team that included physicians, nurses, and paramedics. During 34 event days, there were 10,406 patient encounters, resulting in 156 patients requiring transfer to a hospital. A patient presentation rate of 16.5/1,000 was observed. The ambulance transfer rate was 0.12/1,000 of attendees. The most common reason for transport was musculoskeletal injuries (54%) that required imaging.
The presence of onsite teams capable of treating and releasing patients impacted the case mix of patients transferred to a hospital, and may reduce the number of transfers for intoxication. Confounding preconceptions, patients in the present study were transferred largely for injuries that required imaging. Results suggest that a better understanding of the specific effects onsite medical teams have on avoiding off-site transfers will aid in improving planning for music festivals. Findings also identify areas for further improvement in care, such as onsite radiology, which could potentially further reduce the impact of music festivals on local health services.
Music and sporting events are mass gatherings with unique risks related to participation. “All-ages” events, which include participants below the age of majority (18 in many jurisdictions), have been observed to have an over-representation of patient presentations in the youth category. Peer helpers may lower the barrier to seeking on-site care. Youth (peer-aged) volunteerism provides opportunities for exposure to new environments, skills, and mentorship. Medical volunteerism may promote personal satisfaction through prosocial behavior (i.e., helping others), community engagement and immersion into a potential health professions career path.
We conducted an observational pilot feasibility study with feedback forms and semi-structured interviews. The pilot program paired youth with parents/guardians/responsible adults as health care volunteers at special events.
Youth/adult dyads volunteered for a variety of events in Canada during the 2018 event season. All participants in the “Juniors Program” completed at least a Standard First Aid course, including orientation to personal safety and confidentiality. Each pair worked in one of two areas: first aid or Festival Health (the harm reduction space at music events) providing peer-to-peer and “all-ages” support. Post-event feedback from the dyads revealed many positive experiences and universally called for more opportunities.
A strong volunteer base is an asset to any community. In this pilot study, the volunteer experiences were supervised by a team of credentialed health care professionals. The authors report on qualitative feedback in themes based on patient perspective, volunteer perspective, team perspective, and event management perspective. More research is needed to measure the outcomes of the Junior’s Program. More Investigation is needed to determine not only the long-term benefits of participation on event medical teams, but also to identify factors that shape a positive experience for youth, their parents, and the event participants that they support.