The professional component of this thesis focuses on how deinstitutionalisation and the current public mental health system have affected individuals with schizophrenia. Chapter one discusses the process of deinstitutionalisation and the research that has examined the impact of this initiative. Chapter two concentrates on schizophrenia, specifically the symptoms, course, etiological theories and treatments of this illness. Four case studies are then provided in order to explore how deinstitutionalisation and the current mental health system have affected individuals with schizophrenia. The names and identifying characteristics of these clients and their families have been modified to ensure anonymity. Chapter three describes a 47 year old woman, AA, who was referred for a neuro-psychological assessment. Chapter four outlines the second case study, a 23 year old male, BB, who was referred for a psychological assessment regarding diagnosis and treatment recommendations. Chapter five describes the third case study, a 54 year old woman, CC, who was referred for therapy and consultation regarding future treatment recommendations. Chapter six discusses the fourth case study, a 21 year old male, DD, who was seen for crisis intervention and treated in the community. Each of these case studies outlines the background history, formulation and treatment approaches. These case reports are used to illustrate how deinstitutionalisation and the present public mental health system affect individuals with schizophrenia. Chapter seven provides an overall discussion and conclusion to these case studies.

No description available.

No description available.

The criminal justice and mental health systems increasingly overlap as persons with mental illness (PMI) are disproportionately present throughout components of the criminal justice system, a concern to mental health and criminal justice professionals alike. In response, various initiatives (aimed across components of the criminal justice system) have been developed and implemented as a means of combating this overrepresentation. The following research will focus on one specialized police-based initiative, the Crisis Intervention Team (CIT), which aims to train police how to recognize mental illness, de-escalate persons in crisis, and to seek treatment-based alternatives to arrest, when appropriate (Schwarzfeld, Reuland, & Plotkin, 2008). Alternatives to arrest consist of various community-based mental health services such as public hospitals (some of which are designated as emergency receiving facilities, or ERFs) or private clinics. While the components of CIT training likely influence officers in unique ways, research has yet to empirically examine how CIT influences police perception, behavior or the incidence of referrals to mental health treatment. As an initial step, this research assessed the attitudes police have regarding the hospital and mental health system within their district. Specifically, this research provides a basic understanding of how police regard their local hospitals and mental health facilities that are posited as available alternatives to arrest, and help identify the role CIT plays in shaping these attitudes. This study found almost no significant difference in the attitudes CIT-trained officers had towards district ERF and the local mental health system as compared to non-CIT officers. Only in one of the six departments studied was there a significant difference between the attitudes of CIT-officers and non-CIT officers; with the non-CIT officers actually having more positive attitudes about their local mental health system than CIT-officers. The six departments studied had nearly similar attitudes of their mental health resources, which would barely be considered passing on a standard grading scale. While officers in this study do not have very positive attitudes towards the ERF they use to transport PMI or their districts’ mental health system, these attitudes may in fact be more positive than many police departments without any specialized approach or initiative. The significance and policy implications of these attitudes are discussed at length, as these findings speak to the need for increased attention by both the mental health and criminal justice systems. Recommendations for future research, including expanding this study to rural departments or agencies with no connection to CIT, are also outlined.

The objective of this research is to review the degree of United States Army compliance in the implementation of evidence-based design practices within the Military Health System construction cycle. This research looks at the impact of the 2007 Assistant Secretary of Defense for Health Affairs memorandum directing the use of evidence-based design within the Military Healthcare System construction process. The memorandum impacted the military medical construction process that includes over 6.2 billion dollars in government programmed military medical construction covering 9.2 million beneficiaries. An analysis of federal construction documents, interviews, and an online survey was conducted with 85 government and civilian healthcare facility planners to measure general evidence-based design knowledge, direct knowledge of medical construction policy requirements, and the level to which the Military Health System Evidence-based Design Principles matrix has been implemented within four selected military medical construction projects. Results of the review of construction publications show minimal evidence of evidence-based design incorporation with key federal regulatory documents. The results of an online survey conducted during the research had a 65.8% response rate (39 government personnel, 17 civilian personnel). The survey showed that basic knowledge of evidence-based design was present, but revealed severe deficiencies in specific knowledge and application of construction policies. Review of selected medical facilities demonstrated non-standardized incorporation of evidence-based design features. This research concludes that evidence-based design has achieved minimal integration into the Military Health System general knowledge base and project execution. Achieving compliance with the 2007 directive memorandum requires that significant efforts be made in personnel training and reconciliation with federal military medical construction documents.

There has been an increase in empirical evidence indicating an association between governance and health systems, suggesting that better governed countries tend to have healthier populations with better performing health systems. This is an important finding, as it could point to structural public health interventions having a greater impact on health systems performance than individually targeted interventions. This doctoral thesis in public health (DrPH) from Brunel University is a compilation of three independent research projects undertaken under different settings, converging in the examination of the relationship between governance and health systems. The first project was a study conducted in the African region of the World Health Organization with the aim of understanding how and to what extent measures of governance are statistically correlated with performance of health systems as measured by a key health outcome: the under-five child mortality. The second project was a case study from a high income country in Europe during the period in which it went through an economic meltdown, the focus being a qualitative analysis of the extent to which the response to economic crisis influenced public health policy making and short term performance of the health system. The third project was a policy analysis carried out in an upper middle income country in Asia and the focus was to examine how the long history of health financing reform has influenced the performance of the health system. All research projects indicate an association between governance and health systems and the case studies provide empirical evidence of how health systems are affected by governance quality. The African study shows a statistically positive relationship between governance indicators and health outcomes, suggesting better governed countries to have lower child mortality. The European and the Asian cases suggest accountability, responsiveness, transparency and fair partnership to be important governance qualities for successful policy making and reforms. This evidence could be of use to current and future policy makers and others with the authority to configure and implement new public health policies. It indicates the importance of comprehensive analytical work prior to policy making with easy access to documents and fair participation with all stakeholders to increase the probability of reaching consensus oriented policy proposals followed by successful implementations. The main contribution of this thesis is to provide evidence through robust statistical/ qualitative analysis around the association between governance and health systems in countries at all income levels. The originality is located in the breadth (three different settings) as well as depth (three distinct, robust methods) of this kind of research. The congruence of findings regardless of study locations, the outcome measures used or types of methods applied have added to the growing evidence that there is a strong correlation between governance and health systems performance. This increased knowledge provides policy makers with additional evidence which can be applied to develop and improve governance with the aim of allocating public resources more efficiently and equitably. However, further research is required on governance and its link to health systems, inter alia how health equity is affected by selective partnership in the decision making processes and how political ideologies influence governance practices.

Did governments in different countries regulate common concerns about patient safety differently? If so how and why did they do this? This thesis undertakes a historical comparison of the regulation of patient safety in Britain and Canada between 1980 and 2005. These jurisdictions began the period with very similar regulatory frameworks, but by 2005 there were distinct differences in each jurisdiction‘s regulatory response to patient safety. Britain was very actively regulating all aspects of service provision within its health system in the name of patient safety, whereas Canada‘s regulatory direction showed adherence to the 1980s model with only scattered incremental developments. This thesis assesses the broader sociopolitical context and the structure of the health systems in each jurisdiction and concludes there are differences in the logics of these systems that established a foundation for future regulatory divergence. It is argued that between 1980 and 2005 there were two factors that influenced regulatory directionality in each jurisdiction: changing political norms associated with the development of neoliberalism and the New Public Management; and events or scandals associated with the provision of health services. The differing levels of penetration of both the changing political norms into governance cultures and of scandals into the public and political consciousness are critical to explaining regulatory differences between jurisdictions. The thesis concludes that what and how governments chose to regulate is a function of the perceived need for action and the dominant social and political norms within that society. Context is everything in the formulation of regulatory approaches to address pressing social problems.

This study addressed the use of benefit levers to develop a guide for an operational plan for spread of best practices in the health system of South Africa. Using the best evidence to inform practice is the cornerstone of quality patient care. Besides uptake and implementation, spreading best practices is crucial as this provides more patients with evidence-informed care and to improve practice and health (care) outcomes. However, spread of best practices is not always effectively done. An example includes Kangaroo Mother Care (KMC) as this best practice is translated for practice and implemented on a limited scale; spread to the whole system seems to be problematic. Various factors can be used to facilitate the spread of best practices. Edwards and Grinspun identified four benefit levers which create the tipping point towards successful adoption, implementation and spread of evidence: alignment, permeation plans, leadership for change, and supporting and reinforcing structures. However, little is known about these benefit levers and it remains unclear what the use of benefit levers for system-wide spread would entail, specifically for other contexts as the model (including the benefit levers) has never been operationalised (Edwards & Grinspun, 2011:19). The overall aim of this study entails therefore the development of a guide for an operational plan, formulating the use of benefit levers in the spread of best practices. To achieve this aim the following objectives for this study were set: 1. To explore and describe characteristics of benefit levers to facilitate spread of best practices. 2. To develop a guide for an operational plan to use benefit levers for the spread of best practices. This study was embedded in the postmodern paradigm, whereby the systems theory was used as a theoretical framework. The first objective was achieved by two steps. Firstly, an integrative literature review of concept clarification of the four benefit levers was done. Secondly, semi-structured individual interviews were conducted with key informants from a variety of levels of the health system involved in the spread of KMC in South Africa. Findings were used to achieve objective two. A draft guide for an operational plan was developed, based on the findings of the individual interviews. A logic model was used as format. This guide was refined by experts using the Delphi technique. The Delphi involved two rounds. From the feedback of the first round of the Delphi, a logic model which provides a graphic outlook of the guide, was suggested and refined in the second round, together with the guide. Further, after the Delphi, a template useable for practice was derived from the guide. The guide, logic model and template could help organisations or departments planning to spread best practices in a certain context (e.g. South Africa), to develop an operational plan, where these benefit levers are considered. This is crucial as currently best practices (such as Kangaroo Mother Care) are often not spread on a system-wide basis to improve practice. The guide will therefore be made accessible to health care workers and researchers in South Africa Finally, conclusions were drawn, the research was evaluated, limitations were identified and recommendations were formulated for nursing practice, education and research. Overall, it can be concluded that for effective spread of best practices the benefit levers alignment, permeation plans, leadership for change and supporting and reinforcing structures are required. Further, specifically regarding the objectives and steps of this study the following conclusions can be made: • Literature/studies about leadership for change and supporting and reinforcing structures was found, but regarding alignment and permeation plans, limited rigorous literature was found (Objective 1 – Step 1). • Key informants involved in the spread of a specific best practice (Kangaroo Mother Care) could see the value of benefit levers used for the spread of best practices in the South African health system (Objective 1 – Step 2). • Benefit levers were found useful for development of a guide for an operational plan to spread best practices. This guide will be made accessible to be used by healthcare organisations and departments in South Africa (Objective 2 – Steps 1 and 2). / Thesis (PhD (Nursing))--North-West University, Potchefstroom Campus, 2013

This study addressed the use of benefit levers to develop a guide for an operational plan for spread of best practices in the health system of South Africa. Using the best evidence to inform practice is the cornerstone of quality patient care. Besides uptake and implementation, spreading best practices is crucial as this provides more patients with evidence-informed care and to improve practice and health (care) outcomes. However, spread of best practices is not always effectively done. An example includes Kangaroo Mother Care (KMC) as this best practice is translated for practice and implemented on a limited scale; spread to the whole system seems to be problematic. Various factors can be used to facilitate the spread of best practices. Edwards and Grinspun identified four benefit levers which create the tipping point towards successful adoption, implementation and spread of evidence: alignment, permeation plans, leadership for change, and supporting and reinforcing structures. However, little is known about these benefit levers and it remains unclear what the use of benefit levers for system-wide spread would entail, specifically for other contexts as the model (including the benefit levers) has never been operationalised (Edwards & Grinspun, 2011:19). The overall aim of this study entails therefore the development of a guide for an operational plan, formulating the use of benefit levers in the spread of best practices. To achieve this aim the following objectives for this study were set: 1. To explore and describe characteristics of benefit levers to facilitate spread of best practices. 2. To develop a guide for an operational plan to use benefit levers for the spread of best practices. This study was embedded in the postmodern paradigm, whereby the systems theory was used as a theoretical framework. The first objective was achieved by two steps. Firstly, an integrative literature review of concept clarification of the four benefit levers was done. Secondly, semi-structured individual interviews were conducted with key informants from a variety of levels of the health system involved in the spread of KMC in South Africa. Findings were used to achieve objective two. A draft guide for an operational plan was developed, based on the findings of the individual interviews. A logic model was used as format. This guide was refined by experts using the Delphi technique. The Delphi involved two rounds. From the feedback of the first round of the Delphi, a logic model which provides a graphic outlook of the guide, was suggested and refined in the second round, together with the guide. Further, after the Delphi, a template useable for practice was derived from the guide. The guide, logic model and template could help organisations or departments planning to spread best practices in a certain context (e.g. South Africa), to develop an operational plan, where these benefit levers are considered. This is crucial as currently best practices (such as Kangaroo Mother Care) are often not spread on a system-wide basis to improve practice. The guide will therefore be made accessible to health care workers and researchers in South Africa Finally, conclusions were drawn, the research was evaluated, limitations were identified and recommendations were formulated for nursing practice, education and research. Overall, it can be concluded that for effective spread of best practices the benefit levers alignment, permeation plans, leadership for change and supporting and reinforcing structures are required. Further, specifically regarding the objectives and steps of this study the following conclusions can be made: • Literature/studies about leadership for change and supporting and reinforcing structures was found, but regarding alignment and permeation plans, limited rigorous literature was found (Objective 1 – Step 1). • Key informants involved in the spread of a specific best practice (Kangaroo Mother Care) could see the value of benefit levers used for the spread of best practices in the South African health system (Objective 1 – Step 2). • Benefit levers were found useful for development of a guide for an operational plan to spread best practices. This guide will be made accessible to be used by healthcare organisations and departments in South Africa (Objective 2 – Steps 1 and 2). / Thesis (PhD (Nursing))--North-West University, Potchefstroom Campus, 2013

The criminal justice and mental health systems increasingly overlap as persons with mental illness (PMI) are disproportionately present throughout components of the criminal justice system, a concern to mental health and criminal justice professionals alike. In response, various initiatives (aimed across components of the criminal justice system) have been developed and implemented as a means of combating this overrepresentation. The following research will focus on one specialized police-based initiative, the Crisis Intervention Team (CIT), which aims to train police how to recognize mental illness, de-escalate persons in crisis, and to seek treatment-based alternatives to arrest, when appropriate (Schwarzfeld, Reuland, & Plotkin, 2008). Alternatives to arrest consist of various community-based mental health services such as public hospitals (some of which are designated as emergency receiving facilities, or ERFs) or private clinics. While the components of CIT training likely influence officers in unique ways, research has yet to empirically examine how CIT influences police perception, behavior or the incidence of referrals to mental health treatment. As an initial step, this research assessed the attitudes police have regarding the hospital and mental health system within their district. Specifically, this research provides a basic understanding of how police regard their local hospitals and mental health facilities that are posited as available alternatives to arrest, and help identify the role CIT plays in shaping these attitudes. This study found almost no significant difference in the attitudes CIT-trained officers had towards district ERF and the local mental health system as compared to non-CIT officers. Only in one of the six departments studied was there a significant difference between the attitudes of CIT-officers and non-CIT officers; with the non-CIT officers actually having more positive attitudes about their local mental health system than CIT-officers. The six departments studied had nearly similar attitudes of their mental health resources, which would barely be considered passing on a standard grading scale. While officers in this study do not have very positive attitudes towards the ERF they use to transport PMI or their districts’ mental health system, these attitudes may in fact be more positive than many police departments without any specialized approach or initiative. The significance and policy implications of these attitudes are discussed at length, as these findings speak to the need for increased attention by both the mental health and criminal justice systems. Recommendations for future research, including expanding this study to rural departments or agencies with no connection to CIT, are also outlined.