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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.
Introduction: Access block is a pervasive problem, even during times of minimal boarding in the ED, suggesting suboptimal use of ED stretchers can contribute. A tracking board utility was embedded into the electronic health record in Calgary, AB, allowing MDs and RNs to consider patients who could be relocated from a stretcher to a chair. Objectives of this study were to evaluate the feature's impact on total stretcher time (TST) and ED length of stay (LOS) for patients relocated to a chair. We also sought to identify facilitators and barriers to the tool's use amongst ED MDs and RNs. Methods: A retrospective cohort design was used to compare TST between those where the tool was used and not used amongst patients relocated to a chair between September 1 2017 and August 15 2018. Each use of the location tool was time-stamped in an administrative database. Median TST and ED LOS were compared between patients where the tool was used and not used using a Mann-Whitney U Test. A cross sectional convenience sample survey was used to determine facilitators and barriers to the tool's use amongst ED staff. Response proportions were used to report Likert scale questions; thematic analysis was used to code themes. Results: 194882 patients met inclusion criteria. The tool was used 4301 times, with “Ok for Chairs” selected 3914(2%) times and “Not Ok for Chairs” selected 384(0.2%) times; 54462(30%) patients were moved to a chair without the tool's use. Mean age, sex, mode of arrival and triage scores were similar between both groups. Median (IQR) TST amongst patients moved to a chair via the prompt was shorter than when the prompt was not used [142.7 (100.5) mins vs 152.3 (112.3) mins, p < 0.001], resulting in 37574 mins of saved stretcher time. LOS was similar between both groups (p = 0.22). 125 questionnaires were completed by 90 ED nurses and 35 ED MDs. 95% of staff were aware of the tool and 70% agreed/strongly agreed the tool could improve ED flow; however, 38% reported only “sometimes” using the tool. MDs reported the most common barrier was forgetting to use the tool and lack of perceived action in relocating patients. Commonly reported nursing barriers were lack of chair space and increased workload. Conclusion: Despite minimal use of the tracking board utility, triggering was associated with reduced TST amongst ED patients eventually relocated to a chair. To encourage increased use, future versions should prompt staff to select a location.
Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries.
To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.
We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982).
Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies.
Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission.
Declaration of interest
D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression.
To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression.
Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme – Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6).
There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI −4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar.
Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care.
Introduction: EMS time factors such as total prehospital, activation, response, scene and transport intervals have been used as a measure of EMS system quality with the assumption that shorter EMS time factors save lives. The objective was to assess in adults and children accessing ground EMS (population), whether operational time factors (intervention and control) were associated with survival at hospital discharge (outcome). Methods: Medline, EMBASE, and CINAHL were searched up to January 2015 for articles reporting original data that associated EMS operational time factors and survival. Conference abstracts and non-English language articles were excluded. Two investigators independently assessed the candidate titles, abstracts, and full text with discrepant reviews resolved by consensus. Risk of bias was assessed using GRADE. Results: A total of 10,151 abstracts were screened for potential inclusion, 199 articles were reviewed in full-text, and 73 met inclusion criteria. Amongst included studies, 49 investigated response time, while 24 investigated other time factors. All articles were observational studies. Amongst the 14 (28.6%) studies where response time was the primary analysis, statistically significant associations between shorter response time and increased survival were found in 5 of 7 cardiac arrest, 1 of 5 general EMS population, and 0 of 2 trauma studies. Other time factors were reported in the primary analysis in 10 (41.7%) studies. One study reported shorter combined scene and transport intervals associated with increased survival in acute heart failure patients. Two studies in trauma patients had somewhat conflicting results with one study reporting shorter prehospital interval associated with increased survival whereas the other reported increased survival associated with longer scene and transport intervals. Study design, analysis, and methodological quality were of considerable variability, and thus, meta-analyses were not possible. Conclusion: There is a substantial body of literature describing the association between EMS time factors and survival, but evidence informing these relationships are heterogeneous and complex. Important details such as patient population, EMS system characteristics, and analytical approach must be taken into consideration to appropriately translate these findings to practice. These results will be important for EMS leaders wishing to create evidence-based time policies.
The World Health Organization (WHO)’s Mental Health Atlas series has established itself as the single most comprehensive and most widely used source of information on the global mental health situation. The data derived from the latest Mental Health Atlas survey carried out in 2014 describes the availability and delivery of mental health services in the WHO's Member States, focussing on differences by country's income level.
The data contained in this paper are mainly derived from questions relating to mental health service availability and uptake, as well as on financial and human resources for mental health. Results are presented as median values and analysed by World Bank income group. Interquartile ranges are also provided as measures of statistical dispersion.
In total, 171 out of WHO's 194 Member States were able to at least partially complete the Atlas questionnaire. The results highlight a wide gap between high and low-medium income countries in a number of areas: for example, high-income countries have 20 times more beds in community-based inpatient units and 30 times more admissions; the rate of patients cared by outpatient facilities is 40 times higher; and there are 66 times more community outpatient contacts and 15 times more mental health staff at outpatient level. Overall resources for mental health are not distributed efficiently: globally about 60% of financial resources and over two-thirds of all available mental health staff are concentrated in mental hospitals, which serve only a small proportion of patients. Results indicate that outpatient care is the only effective means of increasing the coverage for mental disorders and is expanding, but it is strongly influenced by country income level. Two elements of the network of mental health facilities are particularly scarce in low- and middle-income countries: day treatment facilities and community residential facilities.
The WHO Mental Health Atlas 2014 survey provides basic mental health information at the level of WHO's Member States, concerning mental health resources and activities. Atlas promotes the use of information, usually underestimated not only in low- and middle-income countries but also in high-income countries. Information is needed not only for monitoring the scaling up of the mental health system at country level, but also for improving transparency and accountability for users, families and the public.
Although financing represents a critical component of health system strengthening and also a defining concern of efforts to move towards universal health coverage, many countries lack the tools and capacity to plan effectively for service scale-up. As part of a multi-country collaborative study (the Emerald project), we set out to develop, test and apply a fully integrated health systems resource planning and health impact tool for mental, neurological and substance use (MNS) disorders.
A new module of the existing UN strategic planning OneHealth Tool was developed, which identifies health system resources required to scale-up a range of specified interventions for MNS disorders and also projects expected health gains at the population level. We conducted local capacity-building in its use, as well as stakeholder consultations, then tested and calibrated all model parameters, and applied the tool to three priority mental and neurological disorders (psychosis, depression and epilepsy) in six low- and middle-income countries.
Resource needs for scaling-up mental health services to reach desired coverage goals are substantial compared with the current allocation of resources in the six represented countries but are not large in absolute terms. In four of the Emerald study countries (Ethiopia, India, Nepal and Uganda), the cost of delivering key interventions for psychosis, depression and epilepsy at existing treatment coverage is estimated at US$ 0.06–0.33 per capita of total population per year (in Nigeria and South Africa it is US$ 1.36–1.92). By comparison, the projected cost per capita at target levels of coverage approaches US$ 5 per capita in Nigeria and South Africa, and ranges from US$ 0.14–1.27 in the other four countries. Implementation of such a package of care at target levels of coverage is expected to yield between 291 and 947 healthy life years per one million populations, which represents a substantial health gain for the currently neglected and underserved sub-populations suffering from psychosis, depression and epilepsy.
This newly developed and validated module of OneHealth tool can be used, especially within the context of integrated health planning at the national level, to generate contextualised estimates of the resource needs, costs and health impacts of scaled-up mental health service delivery.
The turkey (Meleagris gallopavo) was independently domesticated in Mesoamerica and the Southwest, the latter as the only case of Native American animal domestication north of Mexico. In the upland (non-desert) portion of the American Southwest, distinctive closely related mtDNA lineages belonging to haplogroup H1 (thought to indicate domestication) occur from ca. 1 A.D. (Basketmaker II period) through early historic times. At many sites, low frequencies of lineages belonging to haplogroup H2 also occur, apparently derived from the local Merriam’s subspecies. We report genetic, stable isotope, and coprolite data from turkey remains recovered at three early sites in SE Utah and SW Colorado dating to the Basketmaker II, III, and early Pueblo II periods. Evidence from these and other early sites indicates that both the H1 and H2 turkeys had a predominantly maize-based diet similar to that of humans; prior to late Pueblo II times, the birds were kept primarily to provide feathers for blankets and ritual uses; and ritualized burials indicate turkeys’ symbolic value. We argue that viewing individuals from the H1 and H2 haplogroups as “domestic” versus “wild” is an oversimplification.
Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.
To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.
Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.
The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation.
To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.
This paper examines the intentions, successes and failures of remarkable Romano-Libyan floodwater farmers who settled the arid Libyan pre-desert and used complexes of walls to manage the occasional floodwater as well as the desert's soils, sediments and biota. The paper presents and analyses a near ‘total’ data-set on the determinable locational properties of these ancient walls within one wadi — the 10 km long Wadi Umm el-Kharab. The organisation of these wall systems is shown to alter along the wadi according to changes in topographic, geomorphic and hydrological factors, as well as in relation to what are regarded in this paper as design and settlement factors. The organisation of the walls changes at confluences and distinctive topographic features. An analysis of the shape of enclosed areas indicates that the wadi can be divided into three broad sectors, each of which can be identified by differences in the shapes of the areas enclosed by walls. The enclosed shapes, as well as the general properties of the walls themselves do not vary in any simple linear manner along the wadi. Precise field mapping, as well as statistical displays of wall-related data, indicate the presence of similar ‘gaps’ in both the frequencies of settlement and of walls along the wadi. These gaps are, in part, explicable as the secondary consequences of hypothesised past flood-management problems associated with the confluences within the wadi system. They are also interpreted in this paper as some type of land use or other territorial ‘break’ created between the ancient community groups who occupied the wadi. This study has demonstrated the existence of distinct ‘preferences’ in the distances between walls, the areas enclosed between walls, and the thicknesses of walls. Overall, the types of organisation, and presumed functions of walls in this wadi are similar to those established from elsewhere in the Libyan pre-desert, but the balance is different in the Wadi Umm el-Kharab. The emphasis of wall-design in the Wadi Umm el-Kharab appeared to be upon the containment and management of floodwater, rather than the maximisation of the input of waters to the wadi floor, as deduced elsewhere. The long-term robustness and the environmental sophistication of these wall-systems are evident.
To describe the prevalence, characteristics, and appropriateness of systemic antibiotic use in assisted living (AL) and to conduct a preliminary quality improvement intervention trial to reduce inappropriate prescribing.
Pre-post study, with a 13-month intervention period.
Four AL communities.
All prescribers, all AL staff who communicate with prescribers, and all patients who had an infection during the baseline and intervention periods.
A standardized form for AL staff, an online education course and 5 practice briefs for prescribers, and monthly quality improvement meetings with AL staff.
Monthly inventory of all systemic antibiotic prescriptions; interviews with the prescriber, AL staff member, closest family member, and patient (when capable) regarding 85 antibiotic prescribing episodes (30 baseline, 55 intervention), with data review by an expert panel to determine prescribing appropriateness.
The mean number of systemic antibiotic prescriptions was 3.44 per 1,000 resident-days at baseline and 3.37 during the intervention, a nonsignificant change (P = .30). Few prescribers participated in online training. AL staff use of the standardized form gradually increased during the program. The proportion of prescriptions rated as probably inappropriate was 26% at baseline and 15% during the intervention, a nonsignificant trend (P = .25). Drug selection was largely appropriate during both time periods.
AL antibiotic prescribing rates appear to be approximately one-half those seen in nursing homes, with up to a quarter being potentially inappropriate. Interventions to improve prescribing must reach all physicians and staff and most likely will require long time periods to have the optimal effect.
We report on the interaction of native point defects with commonly observed planar defects in GaN. Using a pair potential model we find a positive binding energy for all native defects to the three boundary structures investigated indicating a preference for native defects to form in these interfaces. The binding energy is highest for the Ga interstitial and lowest for vacancies. Interstitials, which are not thought to occur in significant concentrations in bulk GaN, should form in the (11 0) IDB and the (10 0) SMB and consequently alter the electronic structure of these boundaries.
We report on the interaction of native point defects with commonly observed planar defects in GaN. Using a pair potential model we find a positive binding energy for all native defects to the three boundary structures investigated indicating a preference for native defects to form in these interfaces. The binding energy is highest for the Ga interstitial and lowest for vacancies. Interstitials, which are not thought to occur in significant concentrations in bulk GaN, should form in the (11 20) IDB and the (10 10) SMB and consequently alter the electronic structure of these boundaries.
While bipolar disorder (BD) is a leading cause of disability, and an important contributor to disability in BD is cognitive impairment, there is little systematic research on the longitudinal course of cognitive function and instrumental activities of daily living (IADLs) in late-life. In this report, we characterize the 2-year course of cognitive function and IADLs in older adults with BD.
We recruited non-demented individuals 50 years and older with BD I or BD II (n = 47) from out-patient clinics or treatment studies at the University of Pittsburgh. Comparator subjects (‘controls’) were 22 individuals of comparable age and education with no psychiatric or neurologic history, but similar levels of cardiovascular disease. We assessed cognitive function and IADLs at baseline, 1- and 2-year time-points. The neuropsychological evaluation comprised 21 well-established and validated tests assessing multiple cognitive domains. We assessed IADLs using a criterion-referenced, performance-based instrument. We employed repeated-measures mixed-effects linear models to examine trajectory of cognitive function. We employed non-parametric tests for analysis of IADLs.
The BD group displayed worse cognitive function in all domains and worse IADL performance than the comparator group at baseline and over follow-up. Global cognitive function and IADLs were correlated at all time-points. The BD group did not exhibit accelerated cognitive decline over 2 years.
Over 2 years, cognitive impairment and associated functional disability of older adults with BD appear to be due to long-standing neuroprogressive processes compounded by normal cognitive aging rather than accelerated cognitive loss in old age.
We report the fabrication and superconducting properties of ∼0.5 μm thick, fine-grained polycrystalline coatings of MgB2 on single-crystal substrate surfaces. The films exhibit large critical current densities, implying little effect from the grain boundaries. Analyses for thermal activation effects are inconclusive, and evidence is presented that the irreversibility line is dominated by the combined influences of Hc2 anisotropy and polycrystallinity. Comparative studies of the magnetic persistent currents and electrical transport properties reveal excellent agreement over a wide range of temperature and magnetic field. This result is contrary to similar comparisons on high-temperature cuprates, where disparities arise from the effects of large flux creep and the diverse electric field regimes probed by the two techniques. The MgB2 films exhibit extremely sharp voltage-current relations away from the irreversibility line, in qualitative agreement with observed large Jc values and low rates of magnetic flux creep.