Aim: The overall aim of this thesis was to illuminate experiences of relatives of persons with severe mental illness, and their need for support from formal care. Furthermore, to illuminate nursing support of relatives of persons with severe mental illness. Methods: A mixed methods design was used. In study I, data was collected with a questionnaire responded by 226 relatives and analysed with statistics. In study II, data was gathered with interviews with a strategic sample of 18 relatives, analysed with phenomenography. Study III gathered data from 216 relatives using open-ended questions in the questionnaire (I), analysed with qualitative content analysis. In study IV, data was collected by means of focus-group interviews with 4 groups of nurses, working in mental healthcare and analysed with phenomenography. Main findings: The relatives experienced that their lives were intertwined with the life of their severely mentally ill next of kin. The relatives experienced burden and a poor health, and there were associations between burden and health (I). The relatives had to balance between multiple concerns and make choices on behalf of others and themselves, constantly struggling between opposing feelings and between reflections (II). Relatives’ encounters with mental health personnel were mainly negative, although some had positive experiences. They strived for involvement in mental healthcare for the sake of their severely mentally ill next of kin, and wanted inclusion and support for their own sake, but mostly felt left alone with straining but inescapable responsibilities (III). The nurses conceived that their responsibility was first and foremost the patient and to develop an alliance with him or her. The nurses often felt they had to exclude relatives, but were sometimes able to support them (IV). Conclusions: Relatives’ lives are intertwined with the life of their severely mentally ill next of kin. Relatives’ overall demanding life situation means that the mental health services must involve relatives for the sake of the severely mentally ill person but also include them for their own sake. They need practical and emotional support. Guidelines must be designed to address relatives’ needs, and support must be adapted to the individual relative. / Hensikt: Avhandlingens overordnete hensikt var å belyse erfaringer med å være pårørende til personer med alvorlig psykisk lidelse, og deres behov for støtte fra helsevesenet. Videre å belyse støtte fra sykepleiere til pårørende til personer med alvorlig psykisk lidelse. Metode: Mixed methods design ble benyttet. I studie I ble data samlet med spørreskjema besvart av 226 pårørende, og analysert med statistikk. I studie II ble data samlet ved hjelp av intervju med et strategisk utvalg av 18 pårørende, analysert med fenomenografi. I studie III ble data samlet gjennom åpne spørsmål i et spørreskjema (I), besvart av 216 pårørende og analysert med kvalitativ innholdsanalyse. I studie IV ble data samlet ved hjelp av fokusgruppeintervju med 4 grupper sykepleiere fra psykisk helsevern, analysert med fenomenografi. Hovedfunn: Pårørende opplevde at deres liv var sammenvevd med livet til den som hadde en alvorlig psykisk lidelse. De pårørende opplevde byrde og dårlig helse, og det var sammenheng mellom byrde og helse (I). De pårørende måtte balansere en rekke hensyn, gjøre valg på vegne av andre og seg selv, og samtidig kjempe med motstridende følelser og motstridende tanker (II). Pårørendes erfaringer med møter med helsepersonell i psykisk helsevern var hovedsakelig negative, men noen hadde positive opplevelser. De strevde for å bli involvert i behandlingen for familiemedlemmet med den alvorlige psykiske lidelsen sin del, de ønsket å bli inkludert og motta støtte for egen del, men følte seg overlatt med strevsomt ansvar som de ikke kunne unnslippe (III). Sykepleierne anså at deres ansvar først og fremst var overfor pasienten, og å skape en allianse med vedkommende. Sykepleierne opplevde ofte at de måtte ekskludere pårørende, men var noen ganger i stand til å støtte dem (IV). Konklusjoner: Pårørendes liv er sammenvevd med livet til den som har en alvorlig psykisk lidelse. Pårørendes krevende livssituasjon innebærer at psykisk helsevern må involvere dem for den som har den alvorlige psykiske lidelsen, samt inkludere pårørende for deres egen del. De har behov for praktisk og emosjonell støtte. Retningslinjer må på plass for å ivareta pårørendes behov, og støtten må tilpasses den enkelte pårørende

Cette étude de cas vise à comparer le modèle de soins implanté sur le territoire d’un centre de santé et des services sociaux (CSSS) de la région de Montréal aux modèles de soins en étapes et à examiner l’influence de facteurs contextuels sur l’implantation de ce modèle. Au total, 13 cliniciens et gestionnaires travaillant à l’interface entre la première et la deuxième ligne ont participé à une entrevue semi-structurée. Les résultats montrent que le modèle de soins hiérarchisés implanté se compare en plusieurs points aux modèles de soins en étapes. Cependant, certains éléments de ces derniers sont à intégrer afin d’améliorer l’efficience et la qualité des soins, notamment l’introduction de critères d’évaluation objectifs et la spécification des interventions démontrées efficaces à privilégier. Aussi, plusieurs facteurs influençant l’implantation d’un modèle de soins hiérarchisés sont dégagés. Parmi ceux-ci, la présence de concertation et de lieux d’apprentissage représente un élément clé. Néanmoins, certains éléments sont à considérer pour favoriser sa réussite dont l’uniformisation des critères et des mécanismes de référence, la clarification des rôles du guichet d’accès en santé mentale et l’adhésion des omnipraticiens au modèle de soins hiérarchisés. En somme, l’utilisation des cadres de référence et d’analyse peut guider les gestionnaires sur les enjeux à considérer pour favoriser l’implantation d’un modèle de soins basé sur les données probantes, ce qui, à long terme, devrait améliorer l’efficience des services offerts et leur adéquation avec les besoins populationnels. / The purpose of the present study was to compare the care model of one Montreal local territory to the stepped-care model and to investigate factors influencing the implementation of this model. A qualitative case-study approach was employed involving 13 semi-structured interviews with services providers and managers from primary and specialist mental healthcare. Results showed that the hierarchical care model in place in this territory is compared in several points with the stepped-care model. However, some elements of these models have to be integrated to improve efficiency and quality of care, including the introduction of objective evaluation criteria and the specification of evidence-based interventions. Furthermore, some factors influenced the implementation of this hierarchical care model. Thus, the presence of collaborative working and learning strategies were identified to be a key condition. However, some elements must be considered to facilitate its success like the standardization of the referral criteria and process, the clarification of the mental health guichet d’accès (centralized access point) roles and the general practitioners' adherence to the care model. In conclusion, the use of the reference and analysis frames of this study may guide managers on issues to be considered to support the implementation of an evidence-based care model which may facilitate mental healthcare efficiency and its adequacy with the population needs.

Made available in DSpace on 2014-12-17T15:38:51Z (GMT). No. of bitstreams: 1 ShyrleyBG_DISSERT.pdf: 2114425 bytes, checksum: f08a567de42af6302c6b562315cbc90d (MD5) Previous issue date: 2011-04-08 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / Psychologists‟ insertion in mental healthcare ambulatory clinics occurred during the decade of 1980, in the context of the claims disseminated by sanitary and psychiatric reforms, of the formation of minimum mental healthcare teams and of the retraction of the private clinic. Historically, this migration had been accompanied by the importation of practices traditionally applied at the clinics. Furthermore, the lack of clear guidelines from the Health Ministery occasioned the opening of ambulatory clinics with diversified structures at each city. The objective of this dissertation was to study the practices of psychologists at mental healthcare ambulatory references at Aracaju-SE. Were interviewed psychologists of these services and managers of the municipal health secretary using a semi-structured interview guideline, in addition to the analysis of management reports. It was observed that the mental healthcare references had experienced substantial changes referred to its structures and operation, leading to a present framework of expansion and readjustment. It was realized that there is an effort by the psychologists to maintain individual and group assistance, using adjustments in the frequency of the sessions and in the focus of the activities. Besides the progresses, the relation with the psychiatrist still works basically through the medical record, blocking advances on joint discussions of the cases. Some advances toward the amplified clinic are notable, like the overcoming of the isolated usage of psychiatric diagnostic and the replacement of the line‟ criterion by the urgency one. Sheltering had become an interesting strategy on flux ordination, however the mismatch between offer and demand seems to be a matter which extrapolates the psychologists‟ sphere at the references. For this reason the narrow of the relation with family healthcare centers seems to be the major challenge to be faced by psychologists at mental healthcare ambulatory references / A inser??o do psic?logo nos ambulat?rios de sa?de mental ocorreu na d?cada de 1980, no contexto das reivindica??es propagadas pela reforma sanit?ria e psiqui?trica, da forma??o de equipes m?nimas de sa?de mental e da retra??o da cl?nica privada. Historicamente, essa migra??o foi acompanhada da importa??o de pr?ticas tradicionalmente aplicadas no consult?rio. Ademais, a falta de diretrizes claras por parte do Minist?rio da Sa?de ocasionou a abertura de ambulat?rios com estruturas diversificadas em cada munic?pio. O objetivo desta disserta??o foi estudar a atua??o do psic?logo nas Refer?ncias Ambulatoriais em Sa?de Mental de Aracaju-SE. Foram entrevistados psic?logos desses servi?os e gestores da secretaria municipal de sa?de a partir de roteiro semiestruturado, al?m da an?lise de relat?rios de gest?o. Observou-se que as Refer?ncias em Sa?de Mental sofreram transforma??es substanciais quanto ? sua estrutura e funcionamento, levando a um quadro atual de expans?o e de readequa??o. Percebeu-se um esfor?o por parte dos psic?logos em manter os atendimentos individuais e de grupo, a partir de ajustes na frequ?ncia nas sess?es e no foco das atividades. N?o obstante os progressos, a rela??o com o psiquiatra ainda se processa basicamente pelo prontu?rio, impedindo de avan?ar na discuss?o conjunta dos casos. S?o not?veis alguns avan?os em dire??o ? cl?nica ampliada, como a supera??o do uso do diagn?stico psiqui?trico de forma isolada e da substitui??o do crit?rio fila pelo de urg?ncia. O acolhimento tornou-se uma estrat?gia interessante de ordena??o do fluxo, por?m o descompasso entre oferta e demanda parece ser uma quest?o que extrapola o ?mbito dos psic?logos das refer?ncias. Por essa raz?o, o estreitamento da rela??o com as unidades de sa?de da fam?lia parece ser o maior desafio a ser enfrentado pelos psic?logos das Refer?ncias Ambulatoriais em Sa?de Mental

Though mental health issues are prevalent in Black young adults, they underutilize mental healthcare services. This research examined the role of feature-based discrimination in mental healthcare (under)utilization. Study 1, a secondary analysis of the National Longitudinal Study of Adolescent to Adult Health, provided no evidence supporting a link between skin tone and mental healthcare utilization, when controlling for depression diagnosis. However, when controlling for depression symptoms, there was a trend such that Black young adults with darker, as opposed to lighter, skin tone utilized healthcare less. Study 2, an experimental study with 33 Black college students, showed 73% of the sample preferred a Black counselor. Additionally, they preferred counselors with darker skin, wider nose, and thicker lips, compared to counselors with lighter skin, narrower nose, and thinner lips. These findings suggest the importance of taking into account Afrocentric features and its social consequences when assessing health-related behaviors in Black Americans.

During the period 1967-1995, Swedish mental healthcare underwent a complete re-organisation, starting with county councils taking over responsibility for mental healthcare from the state. Asylums were then phased out and mental health care moved closer to patients. The Mental Health Reform of 1995 completed this decentralisation and put the emphasis on an independent and integrated life as a citizen in society and the idea of a dwelling of one’s own. This thesis describes and analyses spatial aspects of decentralised mental healthcare in Sweden, focusing on the decentralisation discourse regarding organisation, localisation, patient care and working methods behind decentralisation and its spatial performance. A case study of decentralised mental healthcare in Nacka, a Stockholm suburb, between 1958-1999 examines in particular the emerging decentralisation discourse 1958-1973, The Nacka Project 1974-1980 (one of the first examples of community care in Sweden), psychiatry in Nacka 1980-1994 and the official report Welfare and Freedom of Choice from 1995. The methods used include studies of documents, interviews, visual and architectural drawing analysis. The theoretical point of departure for the analysis is a post-structural heterogeneous concept of space where spatial materiality and discursiveness are looked upon as intertwined.    The result shows that the re-organisation of mental healthcare brought about a substantial spatial transformation. Normalisation of patients’ lives involved integration into society and support for independent living. The local environment was the main trope for the early stage of decentralised mental healthcare, but the notion of a dwelling of one’s own became the important trajectory to an independent life after 1995. The idea of the patient is challenged by the independence discourse, which could be said to contain an idea of the ‘non-patient’. Overall, it can be concluded that spatial organisations of the built environment are never value-free or neutral. They reflect, enable and constrain power relations in a society and material space can contribute to the power of one group at the expense of another. Furthermore, the results of the spatialities, or the meanings, cannot be predicted. It is therefore crucial to distinguish power in all its configurations and scales and to keep negotiations alive, especially within the field of mental healthcare, but also in the care sector as a whole and in other societal institutions where policies buildings and built environment interact with user practices. This kaleidoscopic perspective can be used for examining complexities in the past and present and for encouraging future potentialities in the process of making/enacting spatial relations. / QC 20120306

Cette étude de cas vise à comparer le modèle de soins implanté sur le territoire d’un centre de santé et des services sociaux (CSSS) de la région de Montréal aux modèles de soins en étapes et à examiner l’influence de facteurs contextuels sur l’implantation de ce modèle. Au total, 13 cliniciens et gestionnaires travaillant à l’interface entre la première et la deuxième ligne ont participé à une entrevue semi-structurée. Les résultats montrent que le modèle de soins hiérarchisés implanté se compare en plusieurs points aux modèles de soins en étapes. Cependant, certains éléments de ces derniers sont à intégrer afin d’améliorer l’efficience et la qualité des soins, notamment l’introduction de critères d’évaluation objectifs et la spécification des interventions démontrées efficaces à privilégier. Aussi, plusieurs facteurs influençant l’implantation d’un modèle de soins hiérarchisés sont dégagés. Parmi ceux-ci, la présence de concertation et de lieux d’apprentissage représente un élément clé. Néanmoins, certains éléments sont à considérer pour favoriser sa réussite dont l’uniformisation des critères et des mécanismes de référence, la clarification des rôles du guichet d’accès en santé mentale et l’adhésion des omnipraticiens au modèle de soins hiérarchisés. En somme, l’utilisation des cadres de référence et d’analyse peut guider les gestionnaires sur les enjeux à considérer pour favoriser l’implantation d’un modèle de soins basé sur les données probantes, ce qui, à long terme, devrait améliorer l’efficience des services offerts et leur adéquation avec les besoins populationnels. / The purpose of the present study was to compare the care model of one Montreal local territory to the stepped-care model and to investigate factors influencing the implementation of this model. A qualitative case-study approach was employed involving 13 semi-structured interviews with services providers and managers from primary and specialist mental healthcare. Results showed that the hierarchical care model in place in this territory is compared in several points with the stepped-care model. However, some elements of these models have to be integrated to improve efficiency and quality of care, including the introduction of objective evaluation criteria and the specification of evidence-based interventions. Furthermore, some factors influenced the implementation of this hierarchical care model. Thus, the presence of collaborative working and learning strategies were identified to be a key condition. However, some elements must be considered to facilitate its success like the standardization of the referral criteria and process, the clarification of the mental health guichet d’accès (centralized access point) roles and the general practitioners' adherence to the care model. In conclusion, the use of the reference and analysis frames of this study may guide managers on issues to be considered to support the implementation of an evidence-based care model which may facilitate mental healthcare efficiency and its adequacy with the population needs.

Introduction: The study ‘Mental healthcare provision for adults with intellectual disability and a mental disorder’ (MEMENTA) is a cross-sectional epidemiological study carried out in three different regions of Germany. Its main aim is to assess the prevalence of mental disorders in adults with intellectual disability (ID) as well as quality of mental healthcare for this population. Methods and analysis: The target population are persons aged between 18 and 65 years with a mild or moderate ID. The study population will be recruited through service providers. A representative sample is realised by two-stage sampling. First, institutions providing services for people with ID (sheltered workshops) are selected in a stratified cluster sampling, with strata being (1) types of service-providing non-governmental organisations and (2) sizes of their sheltered workshops. Then persons working in selected sheltered workshops are selected by simple random sampling. An estimated number of 600 adults with ID will be included. Information will be obtained from the group leaders in the sheltered workshops, informal carers or staff members in sheltered housing institutions and the person with ID. Besides the main outcome parameter of psychiatric symptomatology and problem behaviour, other outcome parameters such as needs for care, quality of life, caregiver burden, health services utilisation and costs for care are assessed using well-established standardised instruments. If a comorbid mental disorder is diagnosed, quality of mental healthcare will be assessed with open questions to all interview partners and, in addition, problem-focused interviews with a small subgroup. Analyses will be carried out using quantitative and qualitative methods. Ethics and dissemination: Approval of all three local ethics committees was obtained. Research findings will add much needed empirical information in order to improve services provided to this vulnerable group of patients.

Philosophiae Doctor - PhD / A review of the literature has shown that there is a lack of mental health information on which to base planning of mental health services and decisions concerning programme development for mental health services. Several studies have indicated that the use of an evidence-based health information system (HIS) reduces inappropriate clinical practices and promotes the quality of health care services. This study was aimed at developing a framework for a district-based mental health information management system, utilising the experiences of health care providers and caregivers about a district mental health information system (DMHIS). Activity Theory was used as the philosophical foundation of the information system for the study. A qualitative approach was employed using semi-structured individual interviews, Focus Group Discussions (FGDs), systematic review and document analysis. The intervention research design and development model of Rothman and Thomas (1994) was used to guide the study, which was conducted in the Cape Town Metropole area of the Western Cape. A purposive, convenient sampling method was employed to select study participants. Ethical clearance for the study was obtained from the University of the Western Cape, and permission to use the health facilities from the Department of Health. The data collection process involved 62 individual interview participants, from mental health nurses to district health managers, health information clerks, and patient caregivers/families and persons with stable mental conditions. Thirteen caregivers took part in the FGDs. Document review was conducted at three community mental health centres. The data were analysed manually using content analysis. Core findings of the interviews were lack of standardized information collection tools and contents for mental health, information infrastructure, capacity building, and resources. Information processing in terms of collection, compiling, analysing, feedback, access and sharing information were the major problems. Results from document analysis identified inconsistencies and inaccuracies of information recording and processing, which in turn affected the quality of information for decision making. Results from the systematic review identified five functional elements: organizational structure; information infrastructure; capacity building; inputs, process, output and feedback; and community and stakeholders’ participation in the design and implementation of a mental health information system (MHIS). The study has contributed a framework for a DMHIS based on the findings of the empirical and systematic review. It is recommended that there is a need to establish a HIS committee at district health facility level for effective implementation of the framework and quality information processing. There is a need to ensure that staffs have adequate knowledge and skills required for effective implementation of an information system. It is recommended that higher education institutions include a course on HISs in their curriculum. It is suggested that the South African Mental Health Policy be reviewed to include an MHIS and ensure involvement of the community and stakeholders in this system as well as adequate budget allocation.

Introduction: The study ‘Mental healthcare provision for adults with intellectual disability and a mental disorder’ (MEMENTA) is a cross-sectional epidemiological study carried out in three different regions of Germany. Its main aim is to assess the prevalence of mental disorders in adults with intellectual disability (ID) as well as quality of mental healthcare for this population. Methods and analysis: The target population are persons aged between 18 and 65 years with a mild or moderate ID. The study population will be recruited through service providers. A representative sample is realised by two-stage sampling. First, institutions providing services for people with ID (sheltered workshops) are selected in a stratified cluster sampling, with strata being (1) types of service-providing non-governmental organisations and (2) sizes of their sheltered workshops. Then persons working in selected sheltered workshops are selected by simple random sampling. An estimated number of 600 adults with ID will be included. Information will be obtained from the group leaders in the sheltered workshops, informal carers or staff members in sheltered housing institutions and the person with ID. Besides the main outcome parameter of psychiatric symptomatology and problem behaviour, other outcome parameters such as needs for care, quality of life, caregiver burden, health services utilisation and costs for care are assessed using well-established standardised instruments. If a comorbid mental disorder is diagnosed, quality of mental healthcare will be assessed with open questions to all interview partners and, in addition, problem-focused interviews with a small subgroup. Analyses will be carried out using quantitative and qualitative methods. Ethics and dissemination: Approval of all three local ethics committees was obtained. Research findings will add much needed empirical information in order to improve services provided to this vulnerable group of patients.

This study explores the challenges that unaccompanied minors face in accessing healthcare, especially mental health services, in Sweden. It uses a qualitative approach with five partici-pants aged 18–25, who were previously unaccompanied minors. Through interviews, the study identifies themes and patterns related to the theoretical framework, incorporating the KASAM theory and transcultural psychiatry, which emphasize self-reflection and cultural factors. The results reveal difficulties such as fear of impacting the asylum process, language barriers, anda lack of knowledge within the healthcare system. The study aims to contribute to understanding and improvements within the healthcare system. Limitations include a focus on Swedish conditions and the age group of 18–25. Suggestions for future research involve exploring wait times for psychiatric care and effectively communicating knowledge about mental health to these children to identify areas for improvement in healthcare. Overall, the study underscores the need to overcome barriers, customize healthcare to individual needs, and enhance understanding of this vulnerable group.