No / This article starts from recognition that child sexual abuse is perpetrated in all communities, but appears to be under-reported to varying degrees in different communities. It acknowledges that children who have been sexually abused will usually benefit from services designed to assist them in moving on from this experience and to provide future protection from perpetrators. It notes, in particular, the apparent disproportionately low take-up of relevant services by members of Asian communities in Britain. It places this in the context of reported responses to child sexual abuse in Pakistan, India and Bangladesh and explores the likely impact of factors arising from cultural norms in relation to family structure and role relationships. It reports on work begun within Asian communities in Bradford to increase awareness of and appropriate responses to child sexual abuse which hopefully address issues which are or relevance elsewhere. In particular, it discusses responses to a preliminary questionnaire, discussions with community groups, a consultation event held in April 2003, and a multilingual information booklet produced as a result. It urges respectful dialogue with women, men, children and young people in Asian communities as being essential to progress regarding appropriate responses to child sexual abuse

The deterioration of health status for immigrants and refugees is mostly observed after their arrival in Canada. Additionally, immigrant and refugee minorities are at a higher risk for mental health problems. Yet, refugees and immigrants in Canada, particularly those from non-European countries tend to underutilize community resources and mental health services. This study uses a participatory arts-based method of photovoice to gain deeper knowledge of the realities and lived experiences of immigrants and refugees who have or are dealing with mental health problems in Winnipeg. Additionally, it will shed light on the barriers faced by immigrant and refugee community, and the context in which they are unable to access services. Six immigrant and refugee individuals volunteered to participate in this photovoice project. The participants discussed structural barriers, non-recognition of non-Canadian credentials, underemployment/ unemployment, poverty, discrimination, stigma, language barriers, lack of culturally inclusive services, inequality, lack of social network, and marginalization. The findings have implications for social work and future research is discussed. / February 2017

This dissertation concerns the family context of self-determination in adults with intellectual disabilities (ID) during life transitions. Although self-determination is interpreted in different ways in different disciplines, the construct is frequently used to describe the attitudes and behaviours that allow people to feel autonomous and causal in their lives. Research on self-determination in adolescents and adults with ID has commonly occurred in community and special education sectors, with an emphasis on arranging supports for people with ID to develop component self-determination skills, like choice making, problem solving, and goal setting. From the perspective of organismic-dialectical theories, people develop and express self-determination through relationships and person-environment interactions at multiple system levels. Further research on the way family interactions and supports influence the self-determination of adults with ID is important. To address this need, this dissertation includes a qualitative study presented in two manuscripts and a quantitative study presented in one manuscript. The qualitative study explored processes and challenges in the family system during significant life transitions with an adult family member with ID. Families participated in semi-structured interviews and ethnographic observations of daily activities every three to four months for one year. Manuscript 1 concerns the influence of family processes on the self-determination of two young adults with ID as they attained adult roles in the community. Parents were observed to model goal setting, encourage choice making, and scaffold new skills, which helped the young adults with ID to experience autonomous motivation in their transitions. Parents reported feeling unsure of the best way to promote their adult child’s independence while ensuring his or her safety. They tried to resolve this dilemma with open and honest communication. Most interestingly, families collaborated in choice making to the extent that every family member perceived autonomy in transition planning and implementation. Manuscript 2 concerns the influence of transition processes and challenges on the quality of life and resilience of four families with an adult family member with ID. Although families reported different transition types, they progressed through similar transition stages. They invested in quality of life and self-determination as a foundation, considered future support needs, pre-planned and actively planned transitions, implemented transitions, adjusted to new roles and routines, and reflected upon their growth. Although all families experienced challenges during their transitions, two families entered a state of crisis when they did not receive mental health and residential supports. Findings highlight that transitions are lifelong processes in the family system, and risk and protective factors at multiple system levels affect resilience and self-determination. The quantitative study, presented in Manuscript 3, considers that the family system functions within broader socioecological environments that include formal services for adults with ID. Community participation supports provide opportunities to develop self-determination in recreational, educational, and vocational activities. In a cohort of families requesting community participation supports, the vast majority of parents endorsed the expectation that this service would improve choice-making outcomes for their adult child with ID. Preliminary results suggest that the gender and prior choice-making experience of the adult with ID may be associated with the odds of parents endorsing this expectation. The General Discussion integrates the primary findings from each manuscript within a conceptual framework informed by self-determination theory, family systems theory, and family resilience models. This dissertation has theoretical implications for the way the self-determination construct is understood and applied in research with families with a family member with ID. Further, this dissertation reveals practical implications for supporting families with a family member with ID during important life transitions.

Philosophiae Doctor - PhD (School of Public Health) / South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.

BACKGROUND: Women in Pakistan experience a high prevalence of depression; yet make negligible use of mental health services. Information about the barriers and facilitators to mental health services for women is scarce. The present study explored the barriers and facilitators in accessing mental health services and potential strategies to increase the access for women in Karachi. METHODS: A qualitative study was conducted with the help of 78 interviews. Women from primary care were screened for depression and thirty in-depth interviews were conducted with those who were not accessing mental health services. Twenty-nine interviews were conducted with women accessing mental health services for depression at mental health clinics. Nineteen key informant interviews were conducted with various stakeholders. Interviews were transcribed verbatim and coded for thematic analysis. RESULTS: Themes elicited were categorized into family and household, health services, and socio-cultural levels. At family and household level, lack of awareness, normalization of depression, lack of empowerment, burden of looking after children and threats of divorce discouraged women from seeking professional care. Stigma, discouragement to seek mental health care and religious interpretations of depression were reported as broader socio-cultural issues, driving many to visit faith healers instead. Gaps in medical education, general practitioners’ case overload, and poor quality of health care, gender bias, poor resource allocation and dearth of referral systems were highlighted as barriers at health services level. For facilitators themes of awareness, concern for children, the severity of the symptoms, family support, receiving a referral, affordability and organizational support were identified as factors that enabled women to access services. Both women and key-informants suggested that providing community-based interventions could be a viable option to increase the access. CONCLUSION: Study findings suggest that providing mental health services in communities, and reforming medical education through the training of health workers can improve access to mental health services for women. An intervention is proposed to provide mental health services through community based lady health workers in Karachi. This may provide more accessible, and potentially cost effective, mental health services to better address the mental health needs of the population. / 2018-12-08T00:00:00Z

Au Canada et ailleurs dans le monde, le système judiciaire occupe une place de plus en plus importante dans la prise en charge des personnes vivant avec un trouble mental grave. Le rôle du système judiciaire comme levier d'accès aux soins est particulièrement évident dans le cas des personnes déclarées non criminellement responsables pour cause de troubles mentaux (NCR). La vaste majorité des personnes déclarées non criminellement responsables pour cause de troubles mentaux (NCRTM), formant la clientèle principale des services psycho-légaux, était déjà connue des services de santé mentale. Cela questionne la présente capacité du réseau à répondre aux comportements perturbateurs et fait ressortir la possibilité de prévenir le potentiel passage à l’acte et la trajectoire judiciaire subséquence. La présente thèse de doctorat utilise des données administratives provenant des secteurs de la santé, de la justice et de la sécurité publique pour plus de 1 000 personnes qui ont reçu un verdict de non-responsabilité criminelle au Québec. Ces données sont complétées par des entrevues qualitatives avec des parties prenantes. Ensemble, l’analyse de ce corpus de données permettent de mettre en lumière les barrières à l'accès aux soins et les interruptions de services que subissent, dans leur parcours de soins, les personnes atteintes de troubles mentaux sévères et ayant des comportements perçus comme perturbateurs ou dangereux qui les rendent susceptibles d’être judiciarisés. Le premier article décrit les tendances d’utilisation de services de santé et des réclamations de médicaments sur ordonnances dans l’année précédant une infraction qui a entraîné un verdict de NRCTM. Les résultats indiquent que – bien que des résultats antérieurs montrent que plus de 70 % des personnes NCRTM avaient déjà été en contact avec des services pour des raisons de santé mentale – moins de la moitié des personnes déclarées NCRTM avaient bénéficié d’une réelle prise en charge médicale avant l’incident. Les résultats montrent également qu’une personne sur cinq avait commis l’infraction moins d'une semaine après le contact de santé mentale le plus récent. Parmi celles qui avaient au moins une prescription pour un antipsychotique, près de la moitié ne prenaient pas d’antipsychotique au moment de l’infraction. Le deuxième article identifie les facteurs individuels et contextuels facilitants et ceux faisant obstacles à l’accès aux services de santé mentale dans la période avant le délit. Les considérations géographiques jouent un grand rôle dans la possibilité d’accéder et de recevoir les services de santé mentale spécialisés – au-delà des facteurs individuels liés aux besoins. De plus, vivre avec des proches diminue de moitié la probabilité d’aller chercher des services de santé mentale et diminue l’intensité de l’utilisation de services de santé mentale spécialisés, même en tenant compte et ajustant les modèles pour les besoins. Finalement, le troisième article repose sur l’analyse d’entretiens individuels et de groupes d’entretiens focalisés avec 16 personnes ayant de l’expérience vécue (pairs aidants, proches aidants), des praticiens et des administrateurs. Les résultats mettent en évidence comment les expériences passées de stigmatisation, de traumatisme, d'inefficacité et de discrimination au sein d'un système hospitalo-centrique influencent la capacité des utilisateurs de services et des proches aidants à chercher et à s'engager dans les soins. Les mécanismes d'accès existants en période crise, tels que l'intervention policière et les services d'urgence, sont des options inacceptables pour les utilisateurs de services et leurs aidants familiaux et sont donc souvent considérés comme des derniers recours. Par conséquent, les utilisateurs de services entrent dans le système de santé avec des besoins complexes qui sont difficiles à traiter avec les connaissances cliniques actuelles et qui résultent bien souvent en des mesures coercitives plutôt qu’axées sur le rétablissement. Les résultats peuvent être interprétés à la lumière de la stigmatisation structurelle, qui fait référence aux politiques et pratiques institutionnelles qui ont un impact négatif sur les opportunités des personnes atteintes de maladies mentales. Dans le cas présent, la stigmatisation structurelle réduit l'accès aux soins en raison d'une allocation de ressources inadéquate, d'un manque de collaboration intersectorielle et d'intégration des soins, d'attitudes et de pratiques négatives des praticiens de la santé, et d'une surutilisation d'approches coercitives. Nous proposons des stratégies pour réduire les barrières à l’accès liées au système et aux prestataires de soins. / In Canada and elsewhere, the justice system is playing an increasingly important role in the care of individuals with severe mental illness. The role of the justice system as a lever for accessing care is particularly evident in the case of individuals found not criminally responsible on account of mental disorder (NCR). The vast majority of individuals found NCR, who make up the majority of forensic mental health service users, were already known to mental health services. This raises questions about the current capacity of the mental health system to respond to disruptive behaviors and highlights the potential for preventing future justice involvement. This doctoral thesis uses administrative data from the health, justice, and public security sectors for over 1,000 individuals who received a verdict of NCR in Québec. These data are complemented by qualitative interviews with stakeholders. Together, the analysis of this data corpus highlights the barriers to accessing care and service interruptions that individuals with severe mental illness and behaviors perceived as disruptive or dangerous encounter in their care pathway, leading to the risk of judicial involvement. The first article describes trajectories in health services use and prescription drug claims in the year preceding an offense that led to a NCR verdict. The results indicate that, although previous research has shown that over 70% of NCR individuals had already been in contact with mental health services, less than half of NCR individuals had received no consistent care prior to the offense. The results also show that one in five individuals committed the offense less than a week after their most recent mental health contact. Among those who had at least one prescription for an antipsychotic, nearly half were not taking an antipsychotic at the time of the offense. The second article identifies individual and contextual factors that facilitate or hinder access to mental health services in the period prior to the offense. Geographic considerations play a major role in the possibility of accessing and receiving specialized mental health services, beyond individual factors related to needs. Additionally, living with family members decreases the likelihood of seeking mental health services by half and decreases the intensity of specialized mental health service use, even after adjusting for models based on needs. Finally, the third article is based on the analysis of individual interviews and focus groups with 16 individuals with lived experience (peer support workers, family caregivers), practitioners, and administrators. The results highlight how past experiences of stigma, trauma, inefficiency, and discrimination within a hospital-centric system influence the ability of service users and family caregivers to seek and engage with care. Existing access mechanisms during crisis periods, such as police intervention and emergency services, are unacceptable options for service users and their family caregivers and are often considered as a last resort. As a result, service users enter the healthcare system with complex needs that are difficult to address with current clinical knowledge and often result in coercive measures rather than recovery-oriented care. The results can be interpreted in light of structural stigma, which refers to institutional policies and practices that negatively impact the opportunities of people with mental illness. In this case, structural stigma reduces access to care through inadequate allocation of resources, lack of intersectoral collaboration and care integration, negative attitudes and practices of healthcare practitioners, and overreliance on coercive approaches. We propose strategies to reduce system-level and provider-level barriers to access.

The study investigated the possibility of developing a monitoring and evaluation tool to capacitate the South African Department of Home Affairs towards the sustainability of its mobile unit project. As South Africa has a history of gross discrepancies in the appropriation of services by the citizenry, a fleet of 117 mobile trucks was deployed as part of the 2004 Turnaround Strategy. The chosen structural-functionalist theoretical vantage point informed a quantitative baseline survey in which the views of thirty eight respondents in six provinces and across various ranks were gauged. The majority expressed positive views about the sustainability of the mobile units beyond project phase. They expressed confidence in the goals, relevance and realistic nature of the mobile units. In the SWOT analysis, the respondents expressed more strengths and opportunities than weaknesses and threats. These findings form the baseline for the development of the intended M&E framework. / M.A. (Sociology)

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The study investigated the possibility of developing a monitoring and evaluation tool to capacitate the South African Department of Home Affairs towards the sustainability of its mobile unit project. As South Africa has a history of gross discrepancies in the appropriation of services by the citizenry, a fleet of 117 mobile trucks was deployed as part of the 2004 Turnaround Strategy. The chosen structural-functionalist theoretical vantage point informed a quantitative baseline survey in which the views of thirty eight respondents in six provinces and across various ranks were gauged. The majority expressed positive views about the sustainability of the mobile units beyond project phase. They expressed confidence in the goals, relevance and realistic nature of the mobile units. In the SWOT analysis, the respondents expressed more strengths and opportunities than weaknesses and threats. These findings form the baseline for the development of the intended M&E framework. / Sociology / M.A. (Sociology)