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.

Becoming Peer Health Leaders: A Mixed-Methods Evaluation of a Youth Leadership Camp Preparing Peer Leaders for Participation in a Health Promotion Initiative.

Youth are critical partners in health promotion, but the process of training young people to become meaningfully involved is challenging. This mixed-methods evaluation considered the impact of a leadership camp in preparing 42 grade seven students to become peer health leaders in a ‘heart health’ initiative. The experiences of participants and their sense of agency were explored. Data were collected from pre and post camp surveys, focus groups, student journals and researcher observations. Findings indicate that relationships with peers and adults were key to agency development, and participants appeared to broaden their perspectives on the meanings of ‘health’ and ‘leadership.’ Significant changes on two sub-scales of the Harter Perceived Competence Scale for Children were also found. Suggestions for practice and further research are provided.

Determining the Effectiveness of the Therapeutic Recreation Specialist - Certified Training at Baycrest Health Sciences

The purpose of this study was to determine the effectiveness of the “Champion” training of the Therapeutic Recreation Specialist – Certified (TRSC) at Baycrest Health Sciences (BHS). BHS recently implemented a new model for Therapeutic Recreation Services that employs the model of champion for implementation of both best and next practices within the organization. This mixed methods study used both case study and program evaluation in order to understand whether the training that comprised of five different topics allowed the six participants to develop the skills needed to be champions. The results supported that learning did occur during the training and that the experience was positive for the participants. The overall finding from this study is that while the training was useful, the participants did not feel confident about utilizing these skills without further training; hence, this training can only be considered an introduction to the concepts presented.

Can a computerised training paradigm assist people with intellectual disabilities to learn cognitive mediation skills? A randomised experiment

Aims: The aim was to examine whether specific skills required for cognitive behavioural therapy (CBT) could be taught using a computerised training paradigm with people who have intellectual disabilities (IDs). Training aimed to improve: a) ability to link pairs of situations and mediating beliefs to emotions, and b) ability to link pairs of situations and emotions to mediating beliefs. Method: Using a single-blind mixed experimental design, sixty-five participants with IDs were randomised to receive either computerised training or an attention-control condition. Cognitive mediation skills were assessed before and after training. Results: Participants who received training were significantly better at selecting appropriate emotions within situation beliefs pairs, controlling for baseline scores and IQ. Despite significant improvements in the ability of those who received training to correctly select intermediating beliefs for situation-feelings pairings, no between-group differences were observed at post-test. Conclusions: The findings indicated that computerised training led to a significant improvement in some aspects of cognitive mediation for people with IDs, but whether this has a positive effect upon outcome from therapy is yet to be established. (C) 2015 Elsevier Ltd. All rights reserved.

Effects of swimming training on tissue glycogen content in experimental thyrotoxic rats

Thyrotoxicosis, a condition in which there is an excessive amount of circulating thyroid hormones, leads to reduced glycogen content in different tissues. In this study we analyzed the effects of aerobic swimming training on liver, heart, and skeletal muscle glycogen content in experimentally induced thyrotoxicosis. Wistar male rats were divided into euthyroid sedentary (ES, n = 12), euthyroid trained (ET, n = 11), thyrotoxic sedentary (TS, n = 12), and thyrotoxic trained (TT, n = 10) groups. Thyrotoxic groups received daily i.p. doses of T4 (sodium levothyroxine, 25 mu g/100 g body mass) through the experimental period, and trained groups swam for 1 h at 80% of the aerobic-anaerobic transition intensity, 5 days/week for 4 weeks. Heart and liver glycogen stores were similar to 30% lower in T4 treated compared with nontreated groups, but were not changed by training status. on the other hand, glycogen content in mixed fiber type gastrocnemius of TT was 1.5- to 2.3-fold greater than those in other groups, whereas no significant differences were found for the slow soleus muscle. Increased gastrocnemius but not soleus, liver, or heart glycogen indicates that in mild long-term thyrotoxicosis chronic swimming affects glycogen stores in a tissue-specific manner.

Aerobic training, but not creatine supplementation, alters the gluteus medius muscle

The aim of the present study was to investigate the effect of oral supplementation of creatine on the muscular responses to aerobic training. Twelve purebred Arabian horses were submitted to aerobic training for 90 d, with and without creatine supplementation, and evaluated with respect to BW and BCS and to the area and frequency of the different types of muscle fibers in the gluteus medius. Supplementation consisted of the daily administration of 75 g of creatine monohydrate mixed into the ration for the 90 d of training. Physical conditioning was conducted on a high-performance treadmill, and training intensity was stipulated by calculating the velocity at which blood lactate reaches 4 mmol/L, determined monthly for each animal. The individual intensity of physical force at 80% of aerobic threshold was established. Morphometry of glutens medius muscle fibers was performed on frozen sections processed for histochemical analysis of myosin adenosine triphosphatase and immunohistochemistry of slow-contracting myosin. The results demonstrated that the animals maintained a moderate BCS without alteration of BW during the course of training, providing evidence of equilibrium between food intake and caloric expenditure during the study period. The present study demonstrated that aerobic training for 90 d caused hypertrophy of fiber types I (P = 0.04), IIA (P = 0.04), and IIX (P = 0.01), as well as an increase in the relative area occupied by type I fibers (P = 0.02) at the expense of type IIX fibers (P = 0.03), resulting in modifications of the contractile and metabolic characteristics of the gluteus medius muscle. It was not possible to show any beneficial effect from creatine on the skeletal muscle characteristics examined.

Aerobic Training, But Not Creatine, Modifies Longissimus Dorsi Muscle Composition

The goal of this study was to investigate by means of an ultrasound examination the composition of the longissimus dorsi muscle in 12 purebred Arabian horses submitted to aerobic training for 90 days, with and without creatine supplementation. Creatine supplementation was carried out by daily administration of 75 g creatine monohydrate mixed into the ration during 90 days of training. Physical conditioning was conducted on a high-performance treadmill, and training intensity was stipulated by calculating the velocity at which blood lactate reaches 4 mmol/l, determined monthly for each animal. The individual intensity of physical force was established at 80% of velocity that resulted in a blood lactate level of 4 mmol/l. The cross-sectional area and the thickness of the layer of fat of the longissimus dorsi muscle were measured for each group at the end of 8 months of inactivity and after 30, 60, and 90 days of training without (control groups) or with creatine supplementation (experimental groups). The results showed that aerobic training combined with or without creatine supplementation caused significant longissimus dorsi hypertrophy and reduction in the thickness of the fat layer. No beneficial effect from prolonged creatine supplementation on the body composition of horses was detected. © 2007 Elsevier Inc. All rights reserved.

Environmental training in organisations: From a literature review to a framework for future research

Although the research on the relationship between human factors and environmental sustainability is slowly progressing, environmental training has attracted the most attention from researchers and practitioners. However, there remains a lack of research that integrates and systematises the available knowledge on organisational environmental training. Environmental training is fundamental to any successful activity of environmental management, conservation and recycling of resources. Thus, the aim of this paper was to present the results of a systematic literature review on environmental training in organisations. The main studies in this area were classified and coded, and a research agenda with 9 recommendations that may advance the field was presented. As a result of the gaps in the current literature, a framework was proposed aiming guide and strengthens the state-of-the-art research on environmental training. Additionally, results show that more research is needed on environmental training, combining training and green human resource management and defining/measuring the objectives of the environmental training actions. Future studies should also consider mixed methodologies and comparative perspectives. © 2013 Elsevier B.V. All rights reserved.

Aerobic training attenuates nicotinic acetylcholine receptor changes in the diaphragm muscle during heart failure

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Aerobic training attenuates nicotinic acethylcholine receptor changes in the diaphragm muscle during heart failure

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Dual dispatch early defibrillation in out-of-hospital cardiac arrest in a mixed urban–rural population

Aims The effects of a system based on minimally trained first responders (FR) dispatched simultaneously with the emergency medical services (EMS) of the local hospital in a mixed urban and rural area in Northwestern Switzerland were examined. Methods and results In this prospective study 500 voluntary fire fighters received a 4-h training in basic-life-support using automated-external-defibrillation (AED). FR and EMS were simultaneously dispatched in a two-tier rescue system. During the years 2001–2008, response times, resuscitation interventions and outcomes were monitored. 1334 emergencies were included. The FR reached the patients (mean age 60.4 ± 19 years; 65% male) within 6 ± 3 min after emergency calls compared to 12 ± 5 min by the EMS (p < 0.0001). Seventy-six percent of the 297 OHCAs occurred at home. Only 3 emergencies with resuscitation attempts occurred at the main railway station equipped with an on-site AED. FR were on the scene before arrival of the EMS in 1166 (87.4%) cases. Of these, the FR used AED in 611 patients for monitoring or defibrillation. CPR was initiated by the FR in 164 (68.9% of 238 resuscitated patients). 124 patients were defibrillated, of whom 93 (75.0%) were defibrillated first by the FR. Eighteen patients (of whom 13 were defibrillated by the FR) were discharged from hospital in good neurological condition. Conclusions Minimally trained fire fighters integrated in an EMS as FR contributed substantially to an increase of the survival rate of OHCAs in a mixed urban and rural area.

Mechanisms of protein regulation in rat skeletal muscle during resistance exercise and training

The cellular mechanisms through which adult rat skeletal muscle protein is regulated during resistance exercise and training was investigated. A model of non-voluntary resistance exercise was described which involves the electrically-stimulated contraction of the lower leg muscles of anesthetized rats against a weighted pulley-bar. Muscle protein synthesis rates were measured by in vivo constant infusion of $\sp3$H-leucine following a single bout of resistance exercise. Specific messenger RNA levels were determined by dot-blot hybridization analysis using $\sp{32}$P-labelled DNA probes after a single bout and multiple bouts of phasic training. The effects of phasic training on increasing skeletal muscle mass was assessed. Between 12 and 36 hours following a single resistance exercise bout (24-192 contractions), total mixed and myofibril protein synthesis rates were significantly increase (32%-65%) after concentric (gastrocnemius m.) and eccentric (tibialis anterior m.) contractions. Eccentric contractions had greater effects on myofibril synthesis with more prolonged increases in synthesis rates. Lower numbers of eccentric than concentric contractions were required to increase synthesis. Cellular RNA was increased after exercise but the relative levels of skeletal $\alpha$-actin and cytochrome c mRNAs were unchanged. Since increases in synthesis rates exceeded increases in RNA, post-transcriptional mechanisms may be primarily responsible for increased protein synthesis after a resistance exercise bout. After 10-22 weeks of phasic eccentric resistance training, muscle enlargement (16%-30%) was produced in the tibialis anterior m. after all training paradigms examined. In contrast, gastrocnemius m. enlargement after phasic concentric training occurred after moderate (24/bout) but not after high (192/bout) repetition training. The absence of muscle growth in the gastrocnemius m. after high repetition training despite increased synthesis rates after the initial bout and RNA and possibly mRNA accumulation during training suggests a role for post-translational mechanisms (protein degradation) in the control of muscle growth in the gastrocnemius m. It is concluded that muscle protein during resistance exercise and training is regulated at several cellular levels. The particular response may be influenced by the exercise intensity and duration, the training frequency and the type of contractile work (eccentric vs. concentric) performed. ^

Neural change following different memory training approaches in very preterm born children - A pilot study.

OBJECTIVE There is mixed evidence regarding neural change following cognitive training. Brain activation increase, decrease, or a combination of both may occur. We investigated training-induced neural change using two different memory training approaches. METHODS Very preterm born children (aged 7-12 years) were randomly allocated to a memory strategy training, an intensive working memory practice or a waiting control group. Before and immediately after the trainings and the waiting period, brain activation during a visual working memory task was measured using fMRI and cognitive performance was assessed. RESULTS Following both memory trainings, there was a significant decrease of fronto-parietal brain activation and a significant increase of memory performance. In the control group, no neural or performance change occurred after the waiting period. CONCLUSION These pilot data point towards a training-related decrease of brain activation, independent of the training approach. Our data highlight the high training-induced plasticity of the child's brain during development.

Systematic interpretation of molecular beacon polymerase chain reaction for identifying rpoB mutations in Mycobacterium tuberculosis isolates with mixed resistant and susceptible bacteria

Detection of multidrug-resistant tuberculosis (MDR-TB), a frequent cause of treatment failure, takes 2 or more weeks to identify by culture. RIF-resistance is a hallmark of MDR-TB, and detection of mutations in the rpoB gene of Mycobacterium tuberculosis using molecular beacon probes with real-time quantitative polymerase chain reaction (qPCR) is a novel approach that takes ≤2 days. However, qPCR identification of resistant isolates, particularly for isolates with mixed RIF-susceptible and RIF-resistant bacteria, is reader dependent and limits its clinical use. The aim of this study was to develop an objective, reader-independent method to define rpoB mutants using beacon qPCR. This would facilitate the transition from a research protocol to the clinical setting, where high-throughput methods with objective interpretation are required. For this, DNAs from 107 M. tuberculosis clinical isolates with known susceptibility to RIF by culture-based methods were obtained from 2 regions where isolates have not previously been subjected to evaluation using molecular beacon qPCR: the Texas–Mexico border and Colombia. Using coded DNA specimens, mutations within an 81-bp hot spot region of rpoB were established by qPCR with 5 beacons spanning this region. Visual and mathematical approaches were used to establish whether the qPCR cycle threshold of the experimental isolate was significantly higher (mutant) compared to a reference wild-type isolate. Visual classification of the beacon qPCR required reader training for strains with a mixture of RIF-susceptible and RIF-resistant bacteria. Only then had the visual interpretation by an experienced reader had 100% sensitivity and 94.6% specificity versus RIF-resistance by culture phenotype and 98.1% sensitivity and 100% specificity versus mutations based on DNA sequence. The mathematical approach was 98% sensitive and 94.5% specific versus culture and 96.2% sensitive and 100% specific versus DNA sequence. Our findings indicate the mathematical approach has advantages over the visual reading, in that it uses a Microsoft Excel template to eliminate reader bias or inexperience, and allows objective interpretation from high-throughput analyses even in the presence of a mixture of RIF-resistant and RIF-susceptible isolates without the need for reader training.^

Low-status monkeys “play dumb” when learning in mixed social groups

Many primates, including humans, live in complex hierarchical societies where social context and status affect daily life. Nevertheless, primate learning studies typically test single animals in limited laboratory settings where the important effects of social interactions and relationships cannot be studied. To investigate the impact of sociality on associative learning, we compared the individual performances of group-tested rhesus monkeys (Macaca mulatta) across various social contexts. We used a traditional discrimination paradigm that measures an animal’s ability to form associations between cues and the obtaining of food in choice situations; but we adapted the task for group testing. After training a 55-member colony to separate on command into two subgroups, composed of either high- or low-status families, we exposed animals to two color discrimination problems, one with all monkeys present (combined condition), the other in their “dominant” and “subordinate” cohorts (split condition). Next, we manipulated learning history by testing animals on the same problems, but with the social contexts reversed. Monkeys from dominant families excelled in all conditions, but subordinates performed well in the split condition only, regardless of learning history. Subordinate animals had learned the associations, but expressed their knowledge only when segregated from higher-ranking animals. Because aggressive behavior was rare, performance deficits probably reflected voluntary inhibition. This experimental evidence of rank-related, social modulation of performance calls for greater consideration of social factors when assessing learning and may also have relevance for the evaluation of human scholastic achievement.