Has implementation of integrated mental health services in primary care programs positively impacted health outcomes among the mentally ill in developing countries?

Objective. The World Health Organization (WHO) estimates that nearly 450 million people suffer from a mental disorder in the world. Developing countries do not have the health system structure in place to support the demand of mental health services. This study will conduct a review of mental health integration in primary care research that is carried out in low-income countries identified as such from the World Bank economic analysis. The research follows the standard of care that WHO has labeled appropriate in treatment of mental health populations. Methods. This study will use the WHO 10 principles of mental health integration into primary care as the global health standard of care for mental health. Low-income countries that used these principles in their national programs will be analyzed for effectiveness of mental health integration in primary care. Results. This study showed that mental health service integration in primary care did have an effect on health outcomes of low-income countries. However, information did not lead to significant quantitative results that determined how positive the effect was. Conclusion. More ethnographic research is needed in low-income countries to truly assess how effective the program is in integrating with the health system currently in place.^ ^

Identifying characteristics of mentally ill homeless individuals who are successfully linked to health and social services post-incarceration via the jail inreach project

Healthcare for the Homeless—Houston (HHH) received a research grant from The Medallion Foundation, Inc. in March 2006 to pilot The Jail Inreach Project, an intensive “inreach” initiative to assess the impact of providing continuity of mental and primary health care services for homeless individuals who suffer from mental illness and/or substance abuse being released from jail. This pilot project was initiated by HHH, in collaboration with the Harris County Sheriff’s Office and the Mental Health Mental Retardation Authority of Harris County (MHMRA). Those who are flagged as “frequent flyers” and who are diagnosed with a mental illness are referred to the Jail Inreach Project. In order to maximize the effectiveness of the discharge plan, case managers offer the option of meeting the client at the time of release and bring them to the HHH clinic located four blocks from the jail. Participation in both the program and the option for direct release to the care of a case manager are voluntary.^ The purpose of this study is to determine the outcomes of the Jail Inreach Project and addresses the following objectives: (1) to evaluate the characteristics of inmates that chose to be released from jail to the direct care of an HHH case manager versus those who opt for self release and (2) to determine the number and percent of inmates that are linked to services and relationship with type of release (direct versus indirect), (3) to determine if there is a relationship between outcomes and characteristics and (4) to determine what outcomes are a function of release, controlling for characteristics. Statistical analysis, including frequencies, cross tabulations, chi-square and logistical regression, found that those who opt for self release are six times less likely to be successfully linked to services and that gender is the most significant predictor of choosing self release. Men are far more likely to opt for self release than women engaged in this program. These findings help inform policy and program design and development that addresses the difference in service utilization and successful linkage to services post-incarceration. Successful linkage to services, thus continuity of and access to care, further impact the effects of the revolving door phenomenon of mentally ill homeless individuals cycling between the streets, jails and hospital emergency centers.^

A descriptive study of comprehensive and categorical services for pregnant and parenting adolescents in West Dallas

This study evaluates the effectiveness of the Children and Youth Projects' Adolescent Family Life Program, a comprehensive program serving pregnant and parenting adolescents in the economically disadvantaged area of West Dallas. The underlying question asked is what are the relative contributions of the comprehensive, school-linked Adolescent Family Life (AFL) Program compared with the Maternal Health and Family Planning Program (MHFPP), a categorical provider of family planning and reproductive services, towards meeting the immediate and intermediate term needs of adolescent mothers. Also addressed are the protective effects of participation in the Dallas Independent School District Health Special Program, a segregated school for pregnant adolescents.^ A cohort of 339 West Dallas adolescent mothers who delivered babies during a two-year period, 1986 through 1987, are monitored by linking records from Parkland Hospital, the primary provider to hospital services to indigent women in Dallas, the Dallas Independent School District, and the prenatal care providers, the AFL and MHFP Programs. Information is collected on each teen describing her demographic, fertility, service utilization and educational characteristics.^ The study tests the hypothesis that adolescents receiving services from the comprehensive AFL program will be less likely to have a repeat birth and to discontinue school during the 24 month study period, compared with categorical provider clients. Although the study finds that there are no statistically significant differences in repeat deliveries, using survival analysis, or in school continuation between programs, important findings are revealed about the ethnic differences. Black and Hispanic fertility and educational behaviors are compared, and their implications for program design and evaluation discussed. ^

Social support, health status and health services utilization among the noninstitutionalized elderly: An analysis of the Supplement on Aging to the 1984 national health interview survey

The association between Social Support, Health Status, and Health Services Utilization of the elderly, was explored based on the analysis of data from the Supplement on Aging to the National Health Interview Survey, 1984 (N = 11,497) using a modified framework of Aday and Andersen's Expanded Behavioral Model. The results suggested that Social Support as operationalized in this study was an independent determinant of the use of health services. The quantity of social activities and the use of community services were the two most consistent determinants across different types of health services use.^ The effects of social support on the use of health services were broken down into three components to facilitate explanations of the mechanisms through which social support operated. The Predisposing and Enabling component of Social Support had independent, although not uniform, effects on the use of health services. Only slight substitute effects of social support were detected. These included the substitution of the use of senior centers for longer stay in the hospital and the substitution of help with IADL problems for the use of formal home care services.^ The effect of financial support on the use of health services was found to be different for middle and low income populations. This differential effect was also found for the presence of intimate networks, the frequencies of interaction with children and the perceived availability of support among urban/rural, male/female and white/non-white subgroups.^ The study also suggested that the selection of appropriate Health Status measures should be based on the type of Health Services Utilization in which a researcher is interested. The level of physical function limitation and role activity limitation were the two most consistent predictors of the volume of physician visits, number of hospital days, and average length of stay in the hospital during the past year.^ Some alternative hypotheses were also raised and evaluated, when possible. The impacts of the complex sample design, the reliability and validity of the measures and other limitations of this analysis were also discussed. Finally, a revised framework was proposed and discussed based on the analysis. Some policy implications and suggestions for future study were also presented. ^

Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

Ethnographic and epidemiologic approaches for the programming of prenatal and birth services in Mesa los Hornos, Mexico

The investigator conducted an action-oriented investigation of pregnancy and birth among the women of Mesa los Hornos, an urban squatter slum in Mexico City. Three aims guided the project: (1) To obtain information for improving prenatal and maternity service utilization; (2) To examine the utility of rapid ethnographic and epidemiologic assessment methodologies; (3) To cultivate community involvement in health development.^ Viewing service utilization as a culturally-bound decision, the study included a qualitative phase to explore women's cognition of pregnancy and birth, their perceived needs during pregnancy, and their criteria of service acceptability. A probability-based community survey delineated parameters of service utilization and pregnancy health events, and probed reasons for decisions to use medical services, lay midwives, or other sources of prenatal and labor and delivery assistance. Qualitative survey of service providers at relevant clinics, hospitals, and practices contributed information on service availability and access, and on coordination among private, social security, and public assistance health service sectors. The ethnographic approach to exploring the rationale for use or non-use of services provided a necessary complement to conventional barrier-based assessment, to inform planning of culturally appropriate interventions.^ Information collection and interpretation was conducted under the aegis of an advisory committee of community residents and service agency representatives; the residents' committee formulated recommendations for action based on findings, and forwarded the mandate to governmental social and urban development offices. Recommendations were designed to inform and develop community participation in health care decision-making.^ Rapid research methods are powerful tools for achieving community-based empowerment toward investigation and resolution of local health problems. But while ethnography works well in synergy with quantitative assessment approaches to strengthen the validity and richness of short-term field work, the author strongly urges caution in application of Rapid Ethnographic Assessments. An ethnographic sensibility is essential to the research enterprise for the development of an active and cooperative community base, the design and use of quantitative instruments, the appropriate use of qualitative techniques, and the interpretation of culturally-oriented information. However, prescribed and standardized Rapid Ethnographic Assessment techniques are counter-productive if used as research short-cuts before locale- and subject-specific cultural understanding is achieved. ^

The impact of traditional psychiatric services and case management services on the functioning of people with schizophrenia: A cross-national study in Nova Scotia and Texas

The purpose of this study was to determine the impact of traditional psychiatric services with case management services on the functioning of people with schizophrenia. Traditional services were defined as routine clinic services consisting of medication follow-along, psychotherapy, and support services. Case management consisted of activities involved in linking, planning, and monitoring services for the outpatient client who has schizophrenia. The target population was adult schizophrenics who had been receiving outpatient clinic services for a minimum of six months. Structured interviews were conducted using standardized scales (e.g., Quality of Life, Self-Efficacy, and Brief Symptom Inventory) with 78 outpatient client volunteers from two sites: Nova Scotia (Canada) and Texas (USA). The researcher tested for differences in psychiatric symptomatology, recidivism, and quality of life for persons with schizophrenia receiving traditional psychiatric services in Nova Scotia and traditional plus case management services in Texas. Data were collected from the structured interviews and medical records review forms. Types of services were blocked into low and high levels of Intensity (frequency x minutes) and compared to determine the relative contribution of each. Finally, the role of clients' self-efficacy was tested as an intervening variable. Although the findings did not support the hypotheses in the direction anticipated, there were some interesting and useful results. From the Nova Scotia site, clients who received low levels of services were hospitalized less compared to the Texas site. The more psychotic a patient was the higher their involvement in medication follow-along and the more monitoring they received. The more psychotherapy received, the lower the reported satisfaction with social relationships. Of particular interest is the role that self-efficacy played in improved client outcomes. Although self-efficacy scores were related to improved functioning, the mechanism for this still needs to be clarified through subsequent research. ^

MEETING THE NEEDS OF HANDICAPPED CHILDREN: A STUDY OF EDUCATIONAL AND HEALTH CARE SERVICES PROVIDED TO PRE-KINDERGARTEN CHILDREN IN THE HOUSTON INDEPENDENT SCHOOL DISTRICT EARLY CHILDHOOD PROGRAM FOR THE HANDICAPPED (PARENT SATISFACTION, FUNCTIONAL STATUS, PSYCHOSOCIAL DEVELOPMENT)

The Education for All Handicapped Children Act of 1975, P.L. 94-142, created a new challenge for the nation's public school systems. During 1982-1983, a national study, called the "Collaborative Study of Children with Special Needs", was conducted in 5 metropolitan school districts to evaluate the effectiveness of education and health care services of children in kindergarten to 6th grade being provided under P.L. 94-142 programs. This dissertation (the Substudy) was undertaken to augment the findings of the Collaborative Study. The purpose of this study was to develop a database to provide descriptive information on the demographic, service and health characteristics of a small group of 3 and 4 year old handicapped children served by the Houston Independent School District (HISD) during 1982-1983.^ The study involved a stratified sample of 105 three and four year old children divided into 3 groups according to type of handicapping condition.^ The results of the study gave a clearer picture of the demographic characteristics of these Pre-K children. Specifically, sex ratio was approximately one, lower than the national norm. Family and socioeconomic characteristics were assessed.^ The study used an independence/dependence index composed of 11 items on the parent questionnaire to assess the level of functional independence of each child. An association was found between index scores and parent-reported effects of the child on family activity. Parents who said that their child's condition had affected the family's job situation, housing accomodations, vacation plans, marriage, choice of friends and social activities were also more likely to report less independence in the child. In addition, many of the Substudy children had extensive care-taking needs reflected in specific components of the index such as dressing, feeding, toileting or moving about the house.^ In general the results of the Pre-K Substudy indicate that at the early childhood level, the HISD special education program is functioning well in most areas and that parents are very satisfied with the program. (Abstract shortened with permission of author.)^

A COMPARISON OF COUNTY HOSPITAL UTILIZATION BEFORE AND AFTER INTERVENTION BY THE HOSPITAL'S ALCOHOLISM SERVICES PROGRAM

This study examines the reduction in hospital utilization of 393 public hospital patients who were referred to the hospital's alcoholism screening program for intervention. The 393 patients were the total patient population of the alcoholism screening program for the period of September through December, 1982. Medical records of these patients were investigated to assess the total number of hospital days six months before and six months after intervention. The findings support the hypothesis of decreased utilization. The total number of hospital days for 393 patients before intervention of the alcoholism program was 3,458, with a mean length of stay of 8.80 days. The total number of hospital days after intervention was 458 days, with a mean length of stay of 6.50 days. The average individual difference (decrease) was 7.63 days for one year. From a total of 393 patients counseled by the alcoholism program, 106 (27%) went to treatment for their alcoholism. Other aims were to examine the referral sources (physicians, nurses, social workers and the MAST); study the impact of familial history of alcoholism on referrals, and explore the MAST scores of patients successfully referred. Implications of the study are that it would benefit the public hospital, with their disproportionate numbers of alcoholics, to intervene in the behavioral patterns of alcoholism. Such intervention would be a factor in reducing the overall hospitalization of the alcoholic. ^

THE EFFECTS OF COST-SHARING ON USE OF SERVICES AND CONSUMER CHARACTERISTICS IN A STATE'S CRIPPLED CHILDREN'S DIVISION

The present study analyzed some of the effects of imposing a cost-sharing requirement on users of a state's health service program. The study population consisted of people who were in diagnosed medical need and included, but was not limited to, people in financial need.^ The purpose of the study was to determine if the cost-sharing requirement had any detrimental effects on the service population. Changes in the characteristics of service consumers and in utilization patterns were analyzed using time-series techniques and pre-post policy comparisons.^ The study hypotheses stated that the distribution of service provided, diagnoses serviced, and consumer income levels would change following the cost-sharing policy.^ Analysis of data revealed that neither the characteristics of service users (income, race, sex, etc.) nor services provided by the program changed significantly following the policy. The results were explainable in part by the fact that all of the program participants were in diagnosed medical need. Therefore, their use of "discretionary" or "less necessary" services was limited.^ The study's findings supported the work of Joseph Newhouse, Charles Phelps, and others who have contended that necessary service use would not be detrimentally affected by reasonable cost-sharing provisions. These contentions raise the prospect of incorporating cost-sharing into programs such as Medicaid, which, at this writing, do not demand any consumer payment for services.^ The study concluded with a discussion of the cost-containment problem in health services. The efficacy of cost-sharing was considered relative to other financing and reimbursement strategies such as HMO's, self-funding, and reimbursement for less costly services and places of service. ^

PREPAID MENTAL HEALTH SERVICES: A NATIONAL PERSPECTIVE

The purpose of this 1982 national survey of all operational prepaid health plans, or PHPs (including health maintenance organizations), was to provide information on the current coverage of PHP mental health and substance abuse services, benefits and service provision, general and mental health organization characteristics, mental health service costs, and physical and mental health service utilization.^ Two survey instruments were designed, pretested and distributed to all operational PHPs throughout the United States. A total of 237 PHPs were surveyed, of which 205 (86.50 percent) completed and returned both questionnaires.^ One result of the rapid growth in the PHP field over the past ten years has been the expansion in both the number of PHPs as well as the organizational characteristics of these PHPs. However, little attention in the research literature has been given to the application of empirical results to the PHP arrangements. This project has attempted to contribute to current knowledge regarding prepaid mental health services from a national perspective, and explore, on a preliminary descriptive basis, the variety of potential service delivery arrangements for physical and mental health services (total services) and for mental health services.^ The study emphasized that PHPs must continue to monitor the costs and utilization of mental health services, particularly in light of the apparent elimination of data collection and statistical summary responsibilities within the federal government regarding PHP activities as well as the proposed legislation to eliminate mandated mental health and substance abuse services from basic health plan benefits for federally qualified PHPs. ^

Use of contraception and contraceptive services among U.S. Hispanic women: 2006--2008

This study investigates the association between race/ethnicity and acculturation variables (language preference and nativity) with use of contraception and contraceptive services among Mexican/Mexican American and “other” Hispanic women aged 15-44 when compared to non- Hispanic white women.^ Data was analyzed from the 2006-2008 National Survey of Family Growth. The sample contained 3357 women aged 15-44. Multivariate logistic regression analysis was used to examine the association between race/ethnicity and acculturation variables and contraceptive-related behaviors adjusted for other known covariates. ^ After multivariate analysis, neither nativity nor language preference were significantly associated with contraception use or contraceptive services. Mexican/Mexican American women did not differ in their contraception-related behaviors when compared to non-Hispanic whites. Other Hispanic women, however, were less likely to obtain contraceptive services than non-Hispanic whites (OR=0.67, 95% CI=0.45-1.00). Women aged 30-39 and 40-44 were less likely to obtain contraception and contraceptive services than those aged 15-19. Single women were less likely to use contraception (OR=0.72, 95% CI=0.56-0.92) and contraceptive services (OR=0.69, 95% CI=0.53-0.89) than married/co-habiting women. Women with healthcare coverage were more likely to use contraception and contraceptive services than uninsured women.^ Among Hispanic women of different origin groups, age, marital status, and healthcare coverage were stronger indicators of contraception-related behavior than race/ethnicity, language preference, and nativity. Reproductive health programs that target increased use of contraception and contraceptive services among Hispanic origin groups should specifically target women who are over 30, single, and uninsured.^

Interpretation services for immigrants in federally qualified health centers: Barriers, best practices, and suggestions for the future

This paper examines the provision of interpretation services to immigrants with limited English proficiency in Federally Qualified Health Centers, through examination of barriers and best practices. The United States is a nation of immigrants; currently, more than 38 million, or 12.5 percent of the total population, is foreign-born. A substantial portion of this population does not have health insurance or speak English fluently: barriers that reduce the likelihood that they will access traditional health care organizations. This service void is filled by FQHCs, which are non-profit, community-directed providers that remove common barriers to care by serving communities who otherwise confront financial, geographic, language, and cultural barriers. By examining the importance and the implementation of medical interpretation services in FQHCs, suggestions for the future are presented.^

Editoriall: A Holistic View of Family Preservation Services

One of the hallmarks of family preservation services is that they are holistic and attend to multiple dimensions of family life. In that spirit, this issue of the Family Preservation Journal provides a holistic view of these services, by offering research from the perspective of children, parents, caseworkers, and students of social work. These articles focus on the effectiveness of services, parents' perceptions of services, and the knowledge, attitudes and behavior of child welfare caseworkers. There should be something here for everyone who serves children and their families.

Post-Permanency: An Assessment for Families’ Needs for Services and Supports

This article reports the results of a qualitative study that sought the perspectives of birth parents and adoptive parents following reunification or adoption of children from foster care. Using a participatory action design that actively involved young adults formerly in foster care and parents in the design and implementation of the study, the study focused on the consumers’ perspectives on several issues related to permanency. The article reports findings from interviews with a subset of 27 birth and adoptive families in New York City who were asked about their post-permanency experiences and from interviews with 38 child welfare professionals who were asked to respond to the parents’ perspectives. The article offers directions for child welfare practice and program development.