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The management and treatment of mental disorders in primary care is a fundamental step which enables the largest number of people to get easier and faster access to services. Primary health care systems are increasingly relied upon to deliver a myriad of health services, especially in situations of scarcity. In low- and middle- income countries, where poverty and sickness are high, and access to health care is low, health professionals and policy makers have emphasized approaches that integrate the diverse roles of health care and social systems. For HIV programs, integration has enabled shared use of space and staffing through training of healthcare workers and standardizing procedures, increasing the number of people who have receive care. Integration to primary care was one of the World Health Organization's (WHO's) 10 recommendations in the World Health Report 2001 on mental health.
The migration process will be affected by personality characteristics and other factors such as education, socio-economic status, previous experience of migration and the social capital which people bring with them when they migrate. Several biological, psychological and social environmental and cultural factors interact and lead to the development of a bio-psycho-social model of aetiology and management. Individuals are born into a culture and not with a culture. Cultures are dynamic and keep changing as a result of coming into contact with other cultures, through direct or indirect contact. Social factors such as unemployment, poor housing, urbanisation, over-crowding and changes in family structure have been shown to be related to poor mental health. Poor educational background will influence pre- and post-migration experiences. After migration, the possibility of cultural bereavement, culture shock or cultural conflict will play a role in adjustment to the new culture.
Treatment of trauma has been already covered in this journal (Adshead, 1995) and elsewhere (Davidson, 1992; Kleber & Brom, 1992; Wilson & Raphael, 1993). However, there are situations where the trauma can become extensive and chronic, sometimes called Type II trauma (Terr, 1991), necessitating additional therapeutic considerations. Such situations are not uncommon in the world today, frequently occurring during wars that are typically ‘low-intensity’ conflicts involving poor, Third World countries. It has been estimated that there have been over 150 such wars since 1945, in which 90% of all casualties are civilians. According to Summerfield (1996), what predominates is the use of terror to exert social control, if necessary by disrupting the social, economic and cultural structures. The target is often population rather than territory and psychological warfare is the central element. Atrocities, including civilian massacres, reprisals, bombing, shelling, mass displacements, disappearances and torture are the norm. The consequences for mental health, not to mention the social, economic, cultural and other costs, can be substantial.
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