Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Impact of duration of chest tube drainage on pain after cardiac surgery.

OBJECTIVE: This study was designed to analyze the duration of chest tube drainage on pain intensity and distribution after cardiac surgery. METHODS: Two groups of 80 cardiac surgery adult patients, operated on in two different hospitals, by the same group of cardiac surgeons, and with similar postoperative strategies, were compared. However, in one hospital (long drainage group), a conservative policy was adopted with the removal the chest tubes by postoperative day (POD) 2 or 3, while in the second hospital (short drainage group), all the drains were usually removed on POD 1. RESULTS: There was a trend toward less pain in the short drainage group, with a statistically significant difference on POD 2 (P=0.047). There were less patients without pain on POD 3 in the long drainage group (P=0. 01). The areas corresponding to the tract of the pleural tube, namely the epigastric area, the left basis of the thorax, and the left shoulder were more often involved in the long drainage group. There were three pneumonias in each group and no patient required repeated drainage. CONCLUSIONS: A policy of early chest drain ablation limits pain sensation and simplifies nursing care, without increasing the need for repeated pleural puncture. Therefore, a policy of short drainage after cardiac surgery should be recommended.

Social Security of Labour in the New Indian Economy

Globalisation has many facets and its impact on labour is one of the most significant aspects.Though its influence is worldwide,it is much more significant in a transforming economy like India.The right of workers to social security is seen recognised under the Constitution of India and other welfare legislations.But,after adoption of the new economic policy of liberalisation and privatisation by the Government of India,the labour is exposed to new set of challenges.They are posed mainly due to economic restructuring affected in employment relationship,coupled with the increase in unprotected informal labour force.This study is an attempt to analyse the new challenges stemming up in employment relation,efficacy of the existing measures for social security of labour in the present economic condition and the suggestions for securing workers'right to social security in the trade regime.

Model Development and Validation for Studying Consumer Preferences of Car Owners

Globalization and liberalization, with the entry of many prominent foreign manufacturers, changed the automobile scenario in India, since early 1990‟s. Manufacturers such as Ford, General Motors, Honda, Toyota, Suzuki, Hyundai, Renault, Mitsubishi, Benz, BMW, Volkswagen and Nissan set up their manufacturing units in India in joint venture with their Indian counterpart companies, by making use of the Foreign Direct Investment policy of the Government of India, These manufacturers started capturing the hearts of Indian car customers with their choice of technological and innovative product features, with quality and reliability. With the multiplicity of choices available to the Indian passenger car buyers, it drastically changed the way the car purchase scenario in India and particularly in the State of Kerala. This transformed the automobile scene from a sellers‟ market to buyers‟ market. Car customers started developing their own personal preferences and purchasing patterns, which were hitherto unknown in the Indian automobile segment. The main purpose of this paper is to come up with the identification of possible parameters and a framework development, that influence the consumer purchase behaviour patterns of passenger car owners in the State of Kerala, so that further research could be done, based on the framework and the identified parameters

Dominant partial least square factors of consumer purchase behaviour of passenger cars

Globalization and liberalization, with the entry of many prominent foreign manufacturers, changed the automobile scenario in India, since early 1990’s. World Leaders in automobile manufacturing such as Ford, General Motors, Honda, Toyota, Suzuki, Hyundai, Renault, Mitsubishi, Benz, BMW, Volkswagen and Nissan set up their manufacturing units in India in joint venture with their Indian counterpart companies, by making use of the Foreign Direct Investment policy of the Government of India, These manufacturers started capturing the hearts of Indian car customers with their choice of technological and innovative product features, with quality and reliability. With the multiplicity of choices available to the Indian passenger car buyers, it drastically changed the way the car purchase scenario in India and particularly in the State of Kerala. This transformed the automobile scene from a sellers’ market to buyers’ market. Car customers started developing their own personal preferences and purchasing patterns, which were hitherto unknown in the Indian automobile segment. The main purpose of this paper is to develop a model with major variables, which influence the consumer purchase behaviour of passenger car owners in the State of Kerala. Though there are innumerable studies conducted in other countries, there are very few thesis and research work conducted to study the consumer behaviour of the passenger car industry in India and specifically in the State of Kerala. The results of the research contribute to the practical knowledge base of the automobile industry, specifically to the passenger car segment. It has also a great contributory value addition to the manufacturers and dealers for customizing their marketing plans in the State

Dominant Mean Percentage Score Factors Of The Consumer Purchase Behaviour Of Passenger Cars

Globalization and liberalization, with the entry of many prominent foreign manufacturers, changed the automobile scenario in India, since early 1990’s. World Leaders in automobile manufacturing such as Ford, General Motors, Honda, Toyota, Suzuki, Hyundai, Renault, Mitsubishi, Benz, BMW, Volkswagen and Nissan set up their manufacturing units in India in joint venture with their Indian counterpart companies, by making use of the Foreign Direct Investment policy of the Government of India, These manufacturers started capturing the hearts of Indian car customers with their choice of technological and innovative product features, with quality and reliability. With the multiplicity of choices available to the Indian passenger car buyers, it drastically changed the way the car purchase scenario in India and particularly in the State of Kerala. This transformed the automobile scene from a sellers’ market to buyers’ market. Car customers started developing their own personal preferences and purchasing patterns, which were hitherto unknown in the Indian automobile segment. The main purpose of this paper is to come up with the identification of possible parameters and a framework development, that influence the consumer purchase behaviour patterns of passenger car owners in the State of Kerala, so that further research could be done, based on the framework and the identified parameters.

Policy Improvement for POMDPs Using Normalized Importance Sampling

We present a new method for estimating the expected return of a POMDP from experience. The estimator does not assume any knowle ge of the POMDP and allows the experience to be gathered with an arbitrary set of policies. The return is estimated for any new policy of the POMDP. We motivate the estimator from function-approximation and importance sampling points-of-view and derive its theoretical properties. Although the estimator is biased, it has low variance and the bias is often irrelevant when the estimator is used for pair-wise comparisons.We conclude by extending the estimator to policies with memory and compare its performance in a greedy search algorithm to the REINFORCE algorithm showing an order of magnitude reduction in the number of trials required.

Effects of Air Pollution Control on Climate

Urban air pollution and climate are closely connected due to shared generating processes (e.g., combustion) for emissions of the driving gases and aerosols. They are also connected because the atmospheric lifecycles of common air pollutants such as CO, NOx and VOCs, and of the climatically important methane gas (CH4) and sulfate aerosols, both involve the fast photochemistry of the hydroxyl free radical (OH). Thus policies designed to address air pollution may impact climate and vice versa. We present calculations using a model coupling economics, atmospheric chemistry, climate and ecosystems to illustrate some effects of air pollution policy alone on global warming. We consider caps on emissions of NOx, CO, volatile organic carbon, and SOx both individually and combined in two ways. These caps can lower ozone causing less warming, lower sulfate aerosols yielding more warming, lower OH and thus increase CH4 giving more warming, and finally, allow more carbon uptake by ecosystems leading to less warming. Overall, these effects significantly offset each other suggesting that air pollution policy has a relatively small net effect on the global mean surface temperature and sea level rise. However, our study does not account for the effects of air pollution policies on overall demand for fossil fuels and on the choice of fuels (coal, oil, gas), nor have we considered the effects of caps on black carbon or organic carbon aerosols on climate. These effects, if included, could lead to more substantial impacts of capping pollutant emissions on global temperature and sea level than concluded here. Caps on aerosols in general could also yield impacts on other important aspects of climate beyond those addressed here, such as the regional patterns of cloudiness and precipitation.

The City Passing by the River. The San Francisco River Canalization and Construction of Avenida Jiménez de Quesada in Bogota at the Beginning of the 20th Century

The document refers to the San Francisco river canalization and subsequent construction of the Avenida Jiménez de Quesada. Understanding that the project was ascribed to the modernizing policy of the time, the investigation identifies the different stages in the canalization process, and shows its relations with the spatial structure of the city and the local conditions that developed on the river surroundings. The financing of the project through the “property increase duty” permits an illustration of the progress of canalization and construction of the Jiménez Avenue process, providing a less technical and more social meaning to the sequence in which the project executed. Consequently, the document approaches the shaping dynamics of Bogotá´s spatial structure at the beginning of the XX century.

Trouble Ahead: The Cocaleros of Peru

Este artículo es una versión reducida del original publicado en la Revista Current History, Vol. 105, No. 688, febrero, 2006, pp. 79-86. La revista Desafíos ha decidido publicar apartes por considerarlo de interés para la discusión sobre los efectos y resultados de la política de erradicación de cultivos ilícitos en Colombia. – This article is an abbreviated reproduction of the article published in the Current History Journal, Vol. 105, Nr. 688, Februrary, 2006, pp. 79-86. Desafíos Journal decided to publish parts of it due to the consideration of its interest for the discussion on consequences and results of the eradication policy of ilegal crops in Colombia.An anti-narcotics policy that ignores the social consequences of drug crops eradication only manages to further radicalize and isolate the population in areas in which lawlessness and potential terrorist activity thrive. It also strengthens the bond between disaffected social groups and guerrilla organizations in these areas. Washington cannot continue to be blind to the fact that the three current US policies on counterterrorism, anti-narcotics, and democratization in Peru and elsewhere in Latin America, are not working in harmony. Paradoxically, the eradication of drug crops —the core of Peru’s US-sponsored anti-narcotics policy— enlarges pockets of poverty and fuels anger against the government. It also perpetuates the proverbial quagmire of alienation in which terrorism breeds. Instead of strengthening the State, drug eradication, particularly in the way it is currently carried out in the Andean countries, increases the risk of State failure.-----El efecto de una política antinarcóticos que ignora las consecuencias de la erradicación de cultivos de coca es radicalizar y aislar aún más la población en aquellas zonas donde prosperan la anarquía y el terrorismo. Además, fortalece los lazos entre los descontentos sociales y los grupos guerrilleros en esas mismas áreas. Washington no puede seguir ciega al hecho de que las tres políticas actuales de Estados Unidos —antiterrorismo, antinarcóticos y democratización en el Perú y otras regiones en América Latina— no están funcionando armónicamente. Resulta paradójico que la erradicación de cultivos de coca -eje de la política antinarcóticos peruana respaldada por Estados Unidos- ensanche las bolsas de miseria y aliente la ira contra el gobierno, además de perpetuar los proverbiales miasmas de marginación en las que se engendra el terrorismo. En vez de fortalecer al Estado, la erradicación de cultivos de coca, tal y como se está llevando a cabo en los países andinos, incrementa las posibilidades de su fracaso.

'To move or not to move': Reflections on the resettlement of artisanal miners in the western region of Ghana

This article critically reflects upon the shortcomings of the 'Prestea Action Plan', an ambitious initiative undertaken to facilitate the resettlement of artisanal miners operating in the Western Region of Ghana. The aim of the exercise was to identify viable areas for the thousands of operators who were working illegally in the town of Prestea, an area under concession to the US-based multinational, Golden Star Resources Ltd. At the time of its launch, it was one of the few support initiatives to target artisanal miners, whose claims to land are generally not recognized by governments. It was a particularly significant exercise in Ghana because it suggested that the authorities, who traditionally have exercised a policy of non-negotiation with such groups, had finally recognized that dialogue was needed if the growing rift between the country's indigenous artisanal miners, foreign mining companies and government bodies was to be bridged. It soon emerged, however, that despite its commendable policy objectives, the Plan was fundamentally flawed-problems which would undermine the entire exercise.

Issues in language and development in multilingual settings: a case-study of knowledge exchange and teacher education in South Africa

The quality of a country’s human-resource base can be said to determine its level of success in social and economic development. This study focuses on some␣of the major human-resource development issues that surround the implementation of South Africa’s policy of multilingualism in education. It begins by discussing the relationship between knowledge, language, and human-resource, social and economic development within the global cultural economy. It then considers the situation in South Africa and, in particular, the implications of that country’s colonial and neo-colonial past for attempts to implement the new policy. Drawing on the linguistic-diversity-in-education debate in the United Kingdom of the past three decades, it assesses the first phase of an in-service teacher-education programme that was carried out at the Project for Alternative Education in South Africa (PRAESA) based at the University of Cape Town. The authors identify key short- and long-term issues related to knowledge exchange in education in multilingual societies, especially concerning the use of African languages as mediums for teaching and learning.

Optimal tax theory and the taxation of housing in the US and the UK

First, we survey recent research in the application of optimal tax theory to housing. This work suggests that the under-taxation of housing for owner occupation distorts investment so that owner occupiers are encouraged to over-invest in housing. Simulations of the US economy suggest that this is true there. But, the theoretical work excludes consideration of land and the simulations exclude consideration of taxes other than income taxes. These exclusions are important for the US and UK economies. In the US, the property tax is relatively high. We argue that excluding the property tax is wrong, so that, when the property tax is taken into account, owner occupied housing is not undertaxed in the US. In the UK, property taxes are relatively low but the cost of land has been increasing in real terms for forty years as a result of a policy of constraining land for development. The price of land for housing is now higher than elsewhere. Effectively, an implicit tax is paid by first time buyers which has reduced housing investment. When land is taken into account over-investment in housing is not encouraged in the UK either.

Social citizenship, housing wealth and the cost of social care: is the Care Act 2014 'Fair'?

This article assesses the extent to which it is ‘fair’ for the government to require owner-occupiers to draw on the equity accumulated in their home to fund their social care costs. The question is stimulated by the report of the Commission on Funding of Care and Support, Fairer Care Funding (the Dilnot Commission) and the subsequent Care Act 2014. The enquiry is located within the framework of social citizenship and the new social contract. It argues that the individualistic, contractarian approach, exemplified by the Dilnot Commission and reflected in the Act, raises questions when considered from the perspective of intergenerational fairness. We argue that our concerns with the Act could be addressed by inculcating an expectation of drawing on housing wealth to fund older age: a policy of asset-based welfare.

Pippi Longstocking, juvenile delinquent? Hachette, self-censorship and the moral reconstruction of postwar France

This paper looks at the blockages to the publication of children’s literature caused by the intellectual climate of the postwar era, through a case study of the editorial policy of Hachette, the largest publisher for children at this time. This period witnessed heightened tensions surrounding the social and humanitarian responsibilities of literature. Writers were blamed for having created a culture of defeatism, and collaborationist authors were punished harshly in the purges. In the case of children’s literature, the discourse on responsibility was made more urgent by the assumption that children were easily influenced by their reading material, and by the centrality of the young to the discourse on the moral reconstruction of France. As the politician and education reformer Gustave Monod put it: “penser l’avenir, c’est penser le sort des enfants et de la jeunesse.” These concerns led to the expansion of associations and publications dedicated to protecting children and promoting “good” reading matter for them, and, famously, to the 1949 law regulating publications for children, which banned the depiction of crime, debauchery and violence that might demoralise young readers. Using the testimonials of former employees, along with readers’ reports and editorial correspondence preserved in the Hachette archives, this paper will examine how individual editorial decisions and self-censorship strategies were shaped by the 1949 law with its attendant discourse of moral panic on children’s reading, and how national concerns for future citizens were balanced with commercial imperatives.