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This systematic review compiled evidence on interventions to reduce mental health-related stigma among medical and nursing students in low- and middle-income countries (LMICs). Primary outcomes were stigmatising attitudes and discriminatory behaviours.
Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, professional students in medicine and nursing, and LMICs. A qualitative analysis of all included full texts was done with the software MAXQDA. Full texts were analysed with regard to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a methodological quality assessment was undertaken.
A total of nine studies from six countries (Brazil, China, Malaysia, Nigeria, Somaliland and Turkey) were included. All studies reported significant results in at least one outcome measure. However, from the available literature, it is difficult to draw conclusions on the most effective interventions. No meta-analysis could be calculated due to the large heterogeneity of intervention content, evaluation design and outcome measures. Studies with contact interventions (either face-to-face or video) demonstrated attitudinal change. There was a clear lack of studies focusing on discriminatory behaviours. Accordingly, training of specific communication and clinical skills was lacking in most studies, with the exception of one study that showed a positive effect of training interview skills on attitudes. Methods for cultural adaptation of interventions were rarely documented. The methodological quality of most studies was relatively low, with the exception of two studies.
There is an increase in studies on anti-stigma interventions among professional students in LMICs. Some of these studies used contact interventions and showed positive effects. A stronger focus on clinical and communication skills and behaviour-related outcomes is needed in future studies.
Leucites are silicate framework structures with some of the silicon framework cations partially replaced by divalent or trivalent cations. A monovalent extraframework alkali metal cation is also incorporated to balance the charges. We have previously reported Pbca leucite structures with the stoichiometries Cs2X2+Si5O12 (X = Mg, Mn, Co, Ni, Cu, Zn, Cd) and Rb2X2+Si5O12 (X = Mg, Mn, Ni, Cd). These orthorhombic leucite structures have all the silicon and non-silicon framework cations completely ordered onto separate crystallographic sites. This structure has five distinct Si sites and 1 X site; there are also two distinct sites for the extra-framework Cs or Rb. We have recently synthesised leucite analogues with two different extra-framework cations, these have the stoichiometry RbCsX2+Si5O12 (X = Mg, Ni, Cd). The initial Rietveld refinements assumed 50% Cs and 50% Rb on each of the two extra-framework cation sites. The refined structures for X = Ni and Cd have (within error limits) complete extra-framework cation site disorder. However, for X = Mg there is partial ordering of the extra-framework cation sites, the site occupancies are:- Cs1 0.37(3), Rb1 0.63(3), Cs2 0.63(3), Rb2 0.37(3).
The US Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program sponsors the development of systematic reviews to inform clinical policy and practice. The EPC program sought to better understand how health systems identify and use this evidence.
Representatives from eleven EPCs, the EPC Scientific Resource Center, and AHRQ developed a semi-structured interview script to query a diverse group of nine Key Informants (KIs) involved in health system quality, safety and process improvement about how they identify and use evidence. Interviews were transcribed and qualitatively summarized into key themes.
All KIs reported that their organizations have either centralized quality, safety, and process improvement functions within their system, or they have partnerships with other organizations to conduct this work. There was variation in how evidence was identified, with larger health systems having medical librarians and central bureaus to gather and disseminate information and smaller systems having local chief medical officers or individual clinicians do this work. KIs generally prefer guidelines, especially those with treatment algorithms, because they are actionable. They like systematic reviews because they efficiently condense study results and reconcile conflicting data. They prefer information from systematic reviews to be presented as short digestible summaries with the full report available on demand. KIs preferred systematic reviews from reputable entities and those without commercial bias. Some of the challenges KIs reported include how to resolve conflicting evidence, the generalizability of evidence to local needs, determining whether the evidence is up-to-date, and the length of time required to generate reviews. The topics of greatest interest included predictive analytics, high-value care, advance care planning, and care coordination. To increase awareness of AHRQ EPC reviews, KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available and making reports easier to find in common search engines.
Systematic reviews are valued by health system leaders. To be most useful they should be easy to locate and available in different formats targeted to the needs of different audiences.
Since 2008 England's anti-stigma programme Time to Change has lobbied media outlets about stigmatising coverage and worked with them to promote accurate and non-stigmatising coverage. While this may have an impact on coverage and hence attitudes, it is also possible that coverage can change in response to improving attitudes, through the creation of a market demand for less stigmatising coverage. This study evaluates English newspaper coverage of mental health topics between 2008 and 2016.
Articles covering mental health in 27 newspapers were retrieved using keyword searches on two randomly chosen days each month in 2008–2016, excluding 2012 and 2015 due to restricted resources. Content analysis used a structured coding framework. Univariate logistic regression models were used to estimate the odds of each hypothesised element occurring in 2016 compared with 2008 and Wald tests to assess the overall statistical significance of the year variable as the predictor.
The sample retrieved almost doubled between 2008 (n = 882) and 2016 (n = 1738). We found a significant increase in the proportion of anti-stigmatising articles (odds ratio (OR) 2.26 (95% confidence interval (CI) 1.86–2.74)) and a significant decrease in stigmatising articles (OR 0.62 (95% CI 0.51–0.75)). Reports on all diagnoses except for schizophrenia were more often anti-stigmatising than stigmatising.
This is the first clear evidence of improvement in coverage since the start of Time to Change. However, coverage of schizophrenia may be less affected by this positive shift than that of other diagnoses. The increase in the level of coverage identified in 2016 requires further investigation, as it may also influence public conceptualisation of what constitutes mental illness, attitudes to mental illness in general and/or specific diagnoses. While most anti-stigma programmes are not diagnosis specific, we suggest their evaluation would benefit from a diagnosis specific approach to allow fuller interpretation of their effects. This could include media analysis driven by hypotheses based on diagnoses to ascertain whether variations by diagnosis over time occur both in the nature and in the proportion of coverage.
Recovery Colleges are opening internationally. The evaluation focus has been on outcomes for Recovery College students who use mental health services. However, benefits may also arise for: staff who attend or co-deliver courses; the mental health and social care service hosting the Recovery College; and wider society. A theory-based change model characterising how Recovery Colleges impact at these higher levels is needed for formal evaluation of their impact, and to inform future Recovery College development. The aim of this study was to develop a stratified theory identifying candidate mechanisms of action and outcomes (impact) for Recovery Colleges at staff, services and societal levels.
Inductive thematic analysis of 44 publications identified in a systematised review was supplemented by collaborative analysis involving a lived experience advisory panel to develop a preliminary theoretical framework. This was refined through semi-structured interviews with 33 Recovery College stakeholders (service user students, peer/non-peer trainers, managers, community partners, clinicians) in three sites in England.
Candidate mechanisms of action and outcomes were identified at staff, services and societal levels. At the staff level, experiencing new relationships may change attitudes and associated professional practice. Identified outcomes for staff included: experiencing and valuing co-production; changed perceptions of service users; and increased passion and job motivation. At the services level, Recovery Colleges often develop somewhat separately from their host system, reducing the reach of the college into the host organisation but allowing development of an alternative culture giving experiential learning opportunities to staff around co-production and the role of a peer workforce. At the societal level, partnering with community-based agencies gave other members of the public opportunities for learning alongside people with mental health problems and enabled community agencies to work with people they might not have otherwise. Recovery Colleges also gave opportunities to beneficially impact on community attitudes.
This study is the first to characterise the mechanisms of action and impact of Recovery Colleges on mental health staff, mental health and social care services, and wider society. The findings suggest that a certain distance is needed in the relationship between the Recovery College and its host organisation if a genuine cultural alternative is to be created. Different strategies are needed depending on what level of impact is intended, and this study can inform decision-making about mechanisms to prioritise. Future research into Recovery Colleges should include contextual evaluation of these higher level impacts, and investigate effectiveness and harms.
There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal.
Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12).
In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%).
PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.
Flexible laryngoscopy is a commonly performed procedure in otolaryngology. Although this procedure is not considered painful, many patients describe it as uncomfortable. This study investigated the role of visual distraction as a form of pain relief during flexible laryngoscopy.
The study included patients undergoing flexible laryngoscopy at the University Hospital Southampton. Patients were self-allocated to one of four groups: with or without co-phenylcaine anaesthetic spray; and with and without visual distraction. Visual distraction involved the patient watching the procedure concurrently with the clinician, via a video monitor. Pre- and post-procedural discomfort was assessed using a visual analogue scale.
The use of topical anaesthetic spray was not associated with significantly reduced discomfort scores (p > 0.05). Discomfort scores were significantly reduced in the visual distraction groups (p = 0.04), irrespective of the use of topical anaesthetic spray.
This small study showed that visual distraction should be considered as a simple and cost-effective alternative to local anaesthetic for flexible laryngoscopy.
The structural relations of solid solutions in the series (Sr1−xBax)Al2O4 were studied using room- and high-temperature X-ray methods, infra-red spectroscopy, and DTA. At room temperature, SrAl2O4 and solid solutions with x up to 0.31 are monoclinic, between x = 0.31 and 0.43 monoclinic and hexagonal forms coexist, and between x = 0.43 and 1.0 only hexagonal forms occur. On heating, a member of the monoclinic series of solid solutions transforms to hexagonal symmetry over a range of temperature within which both monoclinic and hexagonal forms coexist. The proportion of the hexagonal form increases instantaneously as the temperature is raised. The transformation temperature decreases with increasing BaAl2O4 in solid solution and, in addition, the temperature width of the region of coexistence is markedly enlarged. SrAl2O4 transforms over the range 665–705 °C and (Sr0.7Ba0.3)Al2O4 over 170–405 °C. The DTA trace for SrAl2O4 shows a peak at 677 °C. On cooling, the transformations show hysteresis of 15 to 25 °C.
The coexisting monoclinic and hexagonal forms are believed to be isochemical, and discontinuities in cell parameters occur within the region of coexistence both in the compositional series at room temperature and in the elevated temperature transformation experiments. The low-to-high transformation is accompanied by a volume change of −0.2 to −0.3 %, and is believed to be first-order displacive with additional characteristics similar to those of martensitic transformations.
The thermal expansion behaviour of structures in the (Sr,Ba)Al2O4, series indicates that two tilt systems are operative: co-operative rotation of tetrahedra about the c-axis, and tilting of tetrahedra relative to the 0001 plane.
The results for the (Sr,Ba)Al2O4 series are shown to be invaluable in reinterpreting the structural behaviour of members of the nepheline and leucite groups of minerals.
Background:ATP8A2 mutations have only recently been associated with human disease. We present the clinical features from the largest cohort of patients with this disorder reported to date. Methods: An observational study of 9 unreported and 2 previously reported patients with biallelic ATP8A2 mutations was carried out at multiple centres. Results: The mean age of the cohort was 9.4 years old (range: 2.5-28 yrs). All patients demonstrated developmental delay, severe hypotonia and movement disorders: chorea/choreoathetosis (100%), dystonia (27%) or facial dyskinesia (18%). Hypotonia was apparent at birth (70%) or before 6 months old (100%). Optic atrophy was observed in 75% of patients who had a funduscopic examination. MRI of the brain was normal for most patients with a small proportion showing mild cortical atrophy (30%), delayed myelination (20%) and/or hypoplastic optic nerves (20%). Epilepsy was seen in two older patients. Conclusions:ATP8A2 gene mutations have emerged as a cause of a novel phenotype characterized by developmental delay, severe hypotonia and hyperkinetic movement disorders. Optic atrophy is common and may only become apparent in the first few years of life, necessitating repeat ophthalmologic evaluation. Early recognition of the cardinal features of this condition will facilitate diagnosis of this disorder.
Distinguishing temporal patterns of depressive symptoms during pregnancy and after childbirth has important clinical implications for diagnosis, treatment, and maternal and child outcomes. The primary aim of the present study was to distinguish patterns of chronically elevated levels of depressive symptoms v. trajectories that are either elevated during pregnancy but then remit after childbirth, v. patterns that increase after childbirth.
The report uses latent growth mixture modeling in a large, population-based cohort (N = 12 121) to investigate temporal patterns of depressive symptoms. We examined theoretically relevant sociodemographic factors, exposure to adversity, and offspring gender as predictors.
Four distinct trajectories emerged, including resilient (74.3%), improving (9.2%), emergent (4.0%), and chronic (11.5%). Lower maternal and paternal education distinguished chronic from resilient depressive trajectories, whereas higher maternal and partner education, and female offspring gender, distinguished the emergent trajectory from the chronic trajectory. Younger maternal age distinguished the improving group from the resilient group. Exposure to medical, interpersonal, financial, and housing adversity predicted membership in the chronic, emergent, and improving trajectories compared with the resilient trajectory. Finally, exposure to medical, interpersonal, and financial adversity was associated with the chronic v. improving group, and inversely related to the emergent class relative to the improving group.
There are distinct temporal patterns of depressive symptoms during pregnancy, after childbirth, and beyond. Most women show stable low levels of depressive symptoms, while emergent and chronic depression patterns are separable with distinct correlates, most notably maternal age, education levels, adversity exposure, and child gender.
The livestock sector is one of the fastest growing subsectors of the agricultural economy and, while it makes a major contribution to global food supply and economic development, it also consumes significant amounts of natural resources and alters the environment. In order to improve our understanding of the global environmental impact of livestock supply chains, the Food and Agriculture Organization of the United Nations has developed the Global Livestock Environmental Assessment Model (GLEAM). The purpose of this paper is to provide a review of GLEAM. Specifically, it explains the model architecture, methods and functionality, that is the types of analysis that the model can perform. The model focuses primarily on the quantification of greenhouse gases emissions arising from the production of the 11 main livestock commodities. The model inputs and outputs are managed and produced as raster data sets, with spatial resolution of 0.05 decimal degrees. The Global Livestock Environmental Assessment Model v1.0 consists of five distinct modules: (a) the Herd Module; (b) the Manure Module; (c) the Feed Module; (d) the System Module; (e) the Allocation Module. In terms of the modelling approach, GLEAM has several advantages. For example spatial information on livestock distributions and crops yields enables rations to be derived that reflect the local availability of feed resources in developing countries. The Global Livestock Environmental Assessment Model also contains a herd model that enables livestock statistics to be disaggregated and variation in livestock performance and management to be captured. Priorities for future development of GLEAM include: improving data quality and the methods used to perform emissions calculations; extending the scope of the model to include selected additional environmental impacts and to enable predictive modelling; and improving the utility of GLEAM output.
We consider the problem of routing and admission control in a loss system featuring two classes of arriving jobs (high-priority and low-priority jobs) and two types of servers, in which decision-making for high-priority jobs is forced, and rewards influence the desirability of each of the four possible routing decisions. We seek a policy that maximizes expected long-run reward, under both the discounted reward and long-run average reward criteria, and formulate the problem as a Markov decision process. When the reward structure favors high-priority jobs, we demonstrate that there exists an optimal monotone switching curve policy with slope of at least −1. When the reward structure favors low-priority jobs, we demonstrate that the value function, in general, lacks structure, which complicates the search for structure in optimal policies. However, we identify conditions under which optimal policies can be characterized in greater detail. We also examine the performance of heuristic policies in a brief numerical study.
Mental health stigma and discrimination are significant problems. Common coping orientations include: concealing mental health problems, challenging others and educating others. We describe the use of common stigma coping orientations and explain variations within a sample of English mental health service users.
Cross-sectional survey data were collected as part of the Viewpoint survey of mental health service users’ experiences of discrimination (n = 3005). Linear regression analyses were carried out to identify factors associated with the three stigma coping orientations.
The most common coping orientation was to conceal mental health problems (73%), which was strongly associated with anticipated discrimination. Only 51% ever challenged others because of discriminating behaviour, this being related to experienced discrimination, but also to higher confidence to tackle stigma.
Although stigma coping orientations vary by context, individuals often choose to conceal problems, which is associated with greater anticipated and experienced discrimination and less confidence to challenge stigma. The direction of this association requires further investigation.
A new protocol for the quantitative determination of zeolite-group mineral compositions by electron probe microanalysis (wavelength-dispersive spectrometry) under ambient conditions, is presented. The method overcomes the most serious challenges for this mineral group, including new confidence in the fundamentally important Si-Al ratio. Development tests were undertaken on a set of natural zeolite candidate reference samples, representing the compositional extremes of Na, K, Cs, Mg, Ca, Sr and Ba zeolites, to demonstrate and assess the extent of beam interaction effects on each oxide component for each mineral. These tests highlight the variability and impact of component mobility due to beam interaction, and show that it can be minimized with recommended operating conditions of 15 kV, 2 nA, a defocused, 20 μm spot size, and element prioritizing with the spectrometer configuration. The protocol represents a pragmatic solution that works, but provides scope for additional optimization where required. Vital to the determination of high-quality results is the attention to careful preparations and the employment of strict criteria for data reduction and quality control, including the monitoring and removal of non-zeolitic contaminants from the data (mainly Fe and clay phases). Essential quality criteria include the zeolite-specific parameters of R value (Si/(Si + Al + Fe3+), the 'E%' charge-balance calculation, and the weight percent of non-hydrous total oxides. When these criteria are applied in conjunction with the recommended analytical operating conditions, excellent inter-batch reproducibility is demonstrated. Application of the method to zeolites with complex solid-solution compositions is effective, enabling more precise geochemical discrimination for occurrence-composition studies. Phase validation for the reference set was conducted satisfactorily with the use of X-ray diffraction and laser-ablation inductively-coupled plasma mass spectroscopy.
In the field of stigma research, an area of interest is the coping strategies that mental health service users can use in response to discriminatory experiences. As a part of the evaluation of the Time to Change (TTC) anti-stigma programme, the Viewpoint telephone survey was run annually in order to assess service users' reported levels of discrimination and selected coping strategies. The study aim is to test the extent to which experience of TTC programme is a positive predictor of selected coping strategies.
Telephone interview surveys carried out by peer interviewers were conducted annually. ‘Educating others’ and ‘challenging’ coping strategies were assessed alongside anticipated and experienced discrimination.
During 2011–2014, 3903 mental health service users were interviewed. Participants more often adopted the ‘educating others’ strategy (2.31 ± 0.01) than the ‘challenging’ strategy (2.15 ± 0.02) (p < 0.001). On the other hand, those who participated in campaign activities endorsed ‘challenging’ more frequently than people who were not aware of TTC (2.78 ± 1.23 v. 2.09 ± 1.08, p < 0.001). According to the multi-variate linear regression model, we found that being actively involved in TTC activities (OR = 0.74, CI: 0.29–1.19; p < 0.05), having a diagnosis of a depressive disorder (OR = 0.20, CI: 0.04–0.36; p < 0.05) or personality disorder (OR = 0.23, CI: 0.04–0.43; p < 0.05) were good predictors of endorsing a ‘challenging’ strategy even after adjusted for confounding variables.
A positive relationship between participating in the TTC programme and using the ‘challenging’ strategy was found. There is still a need to disentangle the complex association between these two coping strategies and the role of anti-stigma campaigns, promoting further local activities led by service users and carers' as well as all others stakeholders' associations.
The objective of this research was to evaluate the survival rate of primiparous heifers within a large sample of herds across the United Kingdom and specifically to assess the association between age at first calving (AFC) on their survival. Data from 437 herds were re-structured for analysis. Descriptive statistics were calculated, and a multilevel logistic regression model was used to explore factors associated with the risk of first lactation culling. Potential explanatory variables included AFC, herd size, culling rate within the whole herd, calving season, herd mean 305-day yield and herd mean calving interval. The mean within-herd culling rate for the primiparous heifers was 15.9%. The mean within-herd AFC was 29.6 months, with 35.9% of heifers having an AFC >30 months of age. Multivariable analysis revealed a negative association between survival rate of primiparous heifers and increasing AFC, and also associations with herd culling rate in older cows and calving season. This study highlights the importance of AFC for survival of primiparous heifers, as well as the need to address heifer wastage in herds with high culling rates.
Most research on interventions to counter stigma and discrimination has
focused on short-term outcomes and has been conducted in high-income
To synthesise what is known globally about effective interventions to
reduce mental illness-based stigma and discrimination, in relation first
to effectiveness in the medium and long term (minimum 4 weeks), and
second to interventions in low- and middle-income countries (LMICs).
We searched six databases from 1980 to 2013 and conducted a
multi-language Google search for quantitative studies addressing the
research questions. Effect sizes were calculated from eligible studies
where possible, and narrative syntheses conducted. Subgroup analysis
compared interventions with and without social contact.
Eighty studies (n = 422 653) were included in the
review. For studies with medium or long-term follow-up (72, of which 21
had calculable effect sizes) median standardised mean differences were
0.54 for knowledge and −0.26 for stigmatising attitudes. Those containing
social contact (direct or indirect) were not more effective than those
without. The 11 LMIC studies were all from middle-income countries.
Effect sizes were rarely calculable for behavioural outcomes or in LMIC
There is modest evidence for the effectiveness of anti-stigma
interventions beyond 4 weeks follow-up in terms of increasing knowledge
and reducing stigmatising attitudes. Evidence does not support the view
that social contact is the more effective type of intervention for
improving attitudes in the medium to long term. Methodologically strong
research is needed on which to base decisions on investment in