The experience of abuse and mental health in the young Thai population A preliminary survey

OBJECTIVES

The aims of this study were to examine the prevalence of child abuse exposure among Thai people in a suburban community and to describe the association of abuse experiences with common mental disorders (CMD), alcohol use disorders and substance use.

METHODS

A population-based cross-sectional survey was conducted in Northern Bangkok on a representative sample of 202 young residents, aged 16-25 years.

RESULTS

Thirty eight percent of the respondents reported experiencing some form of abuse during childhood, with 5.8% having been subjected to sexual penetration, 11.7% having been physically abused and 31.8% emotionally abused. A graded relationship was found between the extent of exposure to abuse during childhood and mental problems. After controlling for potential confounders, CMD remained significantly associated with emotional abuse, and alcohol use disorders remained associated with sexual abuse. Strong but non-significant trends were present for associations between CMD and sexual abuse and all forms of abuse with substance use.

CONCLUSION

Child abuse experiences were common among the respondents. Childhood abuse, particularly sexual abuse, has a potentially devastating impact on adult mental health.

Social capital and mental illness: a systematic review

STUDY OBJECTIVE

The concept of social capital has influenced mental health policies of nations and international organisations despite its limited evidence base. This papers aims to systematically review quantitative studies examining the association between social capital and mental illness.

DESIGN AND SETTING

Twenty electronic databases and the reference sections of papers were searched to identify published studies. Authors of papers were contacted for unpublished work. Anonymised papers were reviewed by the authors of this paper. Papers with a validated mental illness outcome and an exposure variable agreed as measuring social capital were included. No limitations were put on date or language of publication.

MAIN RESULTS

Twenty one studies met the inclusion criteria for the review. Fourteen measured social capital at the individual level and seven at an ecological level. The former offered evidence for an inverse relation between cognitive social capital and common mental disorders. There was moderate evidence for an inverse relation between cognitive social capital and child mental illness, and combined measures of social capital and common mental disorders. The seven ecological studies were diverse in methodology, populations investigated, and mental illness outcomes, making them difficult to summarise.

CONCLUSIONS

Individual and ecological social capital may measure different aspects of the social environment. Current evidence is inadequate to inform the development of specific social capital interventions to combat mental illness.

Psychometric and cognitive validation of a social capital measurement tool in Peru and Vietnam

Social capital is a relatively new concept which has attracted significant attention in recent years. No consensus has yet been reached on how to measure social capital, resulting in a large number of different tools available. While psychometric validation methods such as factor analysis have been used by a few studies to assess the internal validity of some tools, these techniques rely on data already collected by the tool and are therefore not capable of eliciting what the questions are actually measuring. The Young Lives (YL) study includes quantitative measures of caregiver's social capital in four countries (Vietnam, Peru, Ethiopia, and India) using a short version of the Adapted Social Capital Assessment Tool (SASCAT). A range of different psychometric methods including factor analysis were used to evaluate the construct validity of SASCAT in Peru and Vietnam. In addition, qualitative cognitive interviews with 20 respondents from Peru and 24 respondents from Vietnam were conducted to explore what each question is actually measuring. We argue that psychometric validation techniques alone are not sufficient to adequately validate multi-faceted social capital tools for use in different cultural settings. Psychometric techniques show SASCAT to be a valid tool reflecting known constructs and displaying postulated links with other variables. However, results from the cognitive interviews present a more mixed picture with some questions being appropriately interpreted by respondents, and others displaying significant differences between what the researchers intended them to measure and what they actually do. Using evidence from a range of methods of assessing validity has enabled the modification of an existing instrument into a valid and low cost tool designed to measure social capital within larger surveys in Peru and Vietnam, with the potential for use in other developing countries following local piloting and cultural adaptation of the tool.

Common mental disorders in a young urban population in Colombia

BACKGROUND

There are few studies of mental ill health among young people in developing countries.

AIMS

To measure the prevalence of common mental disorders among low-income young people in the city of Cali, Colombia and to examine associations with violence and social capital.

METHOD

The Self-Reporting Questionnaire was administered to 1057 young people aged 15-25 years. Social capital, violence, alcoholism and socio-demographic variables were also measured.

RESULTS

We found 255 young people (24%) with common mental disorders. Being a woman, having limited education and experiencing high levels of violence were the main risk factors for common mental disorders. Social capital did not emerge as a risk factor.

CONCLUSIONS

A large burden of mental ill health among young people was found; this requires urgent interventions and more research on the mechanisms which link mental health and violence.

Trends, priorities and policy directions in the control of vector-borne diseases in urban environments

The habitats available in urban environments tend to be rather lacking in diversity compared to those in the countryside, and relatively few species are able to exploit them. Those that can, however, often find themselves relatively well provided with food and places to live, and relatively free of competitors and predators. This applies not only to such well-known species as the house-sparrow, but also to most of the important mosquito vectors of human disease in urban areas. Human city dwellers thus tend to be exposed to a different spectrum of disease than their rural counterparts. This review describes how the physical and social changes associated with urbanization have altered the transmission of vector-borne disease. It concentrates on the important mosquito-borne infections: malaria, dengue and filariasis. Dengue virus vectors breed in relatively clean water in man-made containers, while urban filariasis vectors breed in highly polluted water, and these mosquitoes have now been spread by man's activities to almost every tropical city. With important exceptions, anopheline malaria vectors have not generally succeeded in adapting to urban life, but malaria can still be a problem where there are rural pockets in the middle of town. Each of these problems requires control using different technologies and timing. The following policy implications are stressed. The areas of responsibility between different sectors of the local services (health, water supply, sanitation), and between these and the public, need to be clearly defined. Due to the biological complexities of vector-borne disease, decentralized primary health care systems are generally incapable of ensuring that control efforts are adequately targeted in time and space. Community support is essential but specialized technical skills are also required.

Mental health and social capital in Cali, Colombia

Mental ill health forms an increasingly significant part of the burden of disease in developing countries. The growing interest in social risk factors for mental health coincides with the development of social capital research which may further inform the social model of mental health. The objective of the study reported here was to discover if there is an independent association between social capital and mental health when taking into account an array of demographic and violence variables. A total of 1168 youth (15-25 years) in a low income community in Cali, Colombia were surveyed. Mental health was measured by a 20 item self-report questionnaire. The instrument used to measure social capital covered structural and cognitive social capital. Twenty-four per cent of the sample were probable cases of mental ill health. Females had a prevalence rate three times higher than males. Using a model which considered demographic and social capital measures as potential risk factors for mental ill health, the significant risk factors emerged as being female, having limited schooling, working in the informal sector, being a migrant, and having low trust in people. The 'classic' poverty type variables (poor education and employment) were more important than social capital, as was the commonly dominant risk factor for mental ill health-being a woman. When violence factors were added to the model, the 'trust' factor fell out and the most important risk factors became (in descending order of importance): being female; no schooling/incomplete primary; and being a victim of violence. The dominance of poverty related factors, as opposed to social capital, prompts renewed attention to the explanatory mechanisms that link income inequality and poor mental health.

Measuring mental health in a cost-effective manner

Mental health has been found to contribute significantly to the global burden of disease. This has raised the profile of mental health in developing countries. Many countries still do not have mental health policies, nor do they incorporate mental health in their primary care package. Community mental health profiles are needed to inform policy. There is a demand for more studies of mental health and the inclusion of mental health measures in more general, comprehensive, population-based health surveys. This article reviews the use and performance of a World Health Organization-endorsed instrument known as the Self-Reporting Questionnaire 20 items (SRQ20). The paper concludes that the high face and criterion validity, ease of use and suitability for administration by lay workers support the use of the SRQ20 as a cost-effective instrument with which to measure community mental health.

The social distribution of explanations of health and illness among adolescents in São Paulo, Brazil

The present paper reports on a study, which investigated explanations of health and illness among adolescents from three socio-economic backgrounds in São Paulo, Brazil. Interviews and group discussions were used to elicit definitions of health and illness, explanations of illness causality and prevention and maintenance of health among 31 deprived adolescents with recent experience of living on the streets, 20 adolescents from poor families and 20 adolescents from privileged families. The findings showed that adolescents from different socio-economic conditions draw upon similar explanatory models to make sense of health and illness. There were also clear distinctions between the groups. Health and illness were presented as being dependent upon multiple factors such as resistance of the body and socio-economic status among privileged adolescents. In contrast, the explanations offered by deprived and poor adolescents for both health and illness rested on behaviour or exposure to environmental hazards. Moreover, drugs, sexually transmitted diseases and faith in God were prominent features of the accounts from deprived adolescents. The findings suggest a need for health professionals to be sensitive to people's perspectives of health and illness and their link to socio-economic conditions. To emphasize individuals' behaviour in the provision of health-related information among deprived adolescents might be counter productive and reinforce victim blaming.

Urban primary health care in Africa: a comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam

Since the 1980s, a number of health system interventions in Sub-Saharan Africa have targeted urban areas, reflecting increasing attention to the contextual contrasts between urban and rural health settings. This article compares attempts in two projects-in Zambia and Tanzania-to strengthen urban primary health care in the public sector and make it more inclusive in a dual sense: making quality services more accessible to the poor; and fostering community involvement in health care and health-related activity. The paper reveals that the projects have produced many similar outcomes (both positive and negative), despite differences in their managerial arrangements. After identifying issues that may need to be considered in other health initiatives, the discussion revisits the urban/rural dimension of health care in relation to three key aspects: the by-passing of primary services, community participation and inter-sectoral action.

The Dar Es Salaam Urban Health Project, Tanzania: a multi-dimensional evaluation

BACKGROUND

In the 1990s, as a response to rapid urbanization, there were a number of large, urban health initiatives in sub-Saharan Africa. Most tended to be comprehensive as opposed to selective in scope: they aimed at strengthening the health system as a whole, and placed emphasis on delivering improved services at the primary level, with increased community participation. A multi-dimensional approach is required to assess the achievements of such initiatives.

METHODS

In 2000 an external evaluation of the Swiss-funded Dar es Salaam Urban Health Project, Tanzania, used 50 key informant interviews, 90 health facility exit interviews, 90 community resident interviews and document analysis to assess achievements over a 10 year period. The study considered achievements in terms of capacity building, improving quality of care, community involvement, inter-sectoral action and sustainability.

RESULTS

Although the project achieved improvements in capacity building and in structural and technical quality of care, there were difficulties in generating inter-sectoral action and the concept of participation was limited. However, city-level 'ownership' of the activities was high, and, with the advent of sector-wide allocation of funds (SWAPs) in the health sector in Tanzania, the prospects for sustainability of the achievements made in the project appear to be good.

CONCLUSION

Both the multi-dimensional method of the evaluation and the findings can inform future urban health initiatives in sub-Saharan Africa and in other resource-constrained environments. The decentralization that occurred in Dar es Salaam and the general approach of the project provided a platform to test out various elements that are common to health sector reform across developing countries.

Maternal mobility across the rural-urban divide: empirical data from coastal Kenya

This paper describes the mobility patterns, rural-urban linkages and household structures for a low-income neighbourhood on the outskirts of Mombasa, Kenya's main port, and a rural settlement 60 kilometres away. Drawing on interviews with a sample of mothers resident in each location, it documents their perceptions of the advantages and disadvantages of rural and urban life, and shows the continuous interchange between the two areas. It also highlights how most rural to urban migrants are familiar with urban environments before moving and how, having moved, many maintain strong rural ties. The ways in which households are split across rural and urban areas is influenced by intra-household relations and by household efforts to balance the income-earning opportunities in town, the relatively low cost of living in rural areas and future family security. This produces dramatic differences between and among rural and urban mothers and suggests a need for policy makers and planners to recognize diversity and to build upon complex livelihood strategies that span the rural-urban divide.

Measuring social capital within health surveys: key issues

With growing recognition of the social determinants of health, social capital is an increasingly important concept in international health research. Although there is relatively little experience of measuring social capital, particularly in developing countries, there are now a number of studies that allow the identification of some key issues that need to be considered when measuring social capital. After summarizing definitions and the rise of interest in the link between social capital and health, measures used in key studies of social capital and health are presented. Some important issues are then considered: obtaining a sufficiently comprehensive measure which empirically captures the latest theoretical developments in the field (particularly the concepts of cognitive, structural, bonding and bridging social capital); moving from the individual to the ecological level; consideration of confounding factors, and validity and reliability.

The influence of user fees and patient demand on prescribers in rural Nepal

Irrational prescribing and over-prescription is a world-wide problem. Prescribers often cite patient demand as one of the main reasons why they over-prescribe, but the degree to which this is so is unknown. This article describes a study to test the hypothesis that patient demand causes over-prescription. The study occurred within the context of different kinds of nominal user fee for drugs in Nepal, where it was assumed that charging per drug item would deter patient demand, and hence over-prescription, as compared to charging per prescription. Focus group discussions with patients attending rural health facilities explored patient attitudes towards drugs. Patients and health workers were interviewed to gather quantitative data on (1) patient demand, and (2) health worker views of patient demand and their own prescribing habits, and comparing these with the drugs actually prescribed and dispensed to patients. Patients felt they needed more drugs than they were prescribed or dispensed, but stated that they would be happy to accept advice from prescribers for fewer drugs. In all areas of whatever fee type, there was no association between the number of drug items patients felt they needed pre-consultation and the number of drug items that they actually received as observed postconsultation. However, there was a significant association between the average number of drug items per patient that prescribers stated they usually prescribed and the actual number that were prescribed. It was concluded that patient demand was not affected by different kinds of user fee and did not directly influence prescribing behaviour.

Evaluation of medical rehabilitation in community based rehabilitation

Almost all governments and non-governmental organisations in developing countries use a community-based rehabilitation (CBR) approach to work with disabled people. Although disabled people's organisations reject the categorisation of disability in individual terms, 'medical rehabilitation' is still regarded as an important but time limited process within rehabilitation. The paper lists measures and methods used in a comprehensive evaluation, and presents a practical method to examine the quality of medical rehabilitation. The method was developed and applied in an evaluation of service needs and service provision for disabled people in low-income communities, for the Ministry of Welfare, Government of India. The method described is a tracer approach. It assesses quality in three aspects of medical rehabilitation: (i) Technical quality, based on application of minimum technical standards for each impairment. (ii) Interpersonal quality, by observation of service sessions and interviews with service users. (iii) Management (structural) quality, by comparing the rehabilitation goals of service users and service providers. The method differs from most others in that it is process oriented, as opposed to output oriented. The method meets the challenges of providing low-cost assessment of a difficult outcome measure (the quality of medical rehabilitation), within a complex process (CBR). It is anticipated that the tracer method will be useful to the objective evaluation of disability services throughout the developing world.

Healthy city projects in developing countries: the first evaluation

The 'healthy city' concept has only recently been adopted in developing countries. From 1995 to 1999, the World Health Organization (WHO), Geneva, supported healthy city projects (HCPs) in Cox's Bazar (Bangladesh), Dar es Salaam (Tanzania), Fayoum (Egypt), Managua (Nicaragua) and Quetta (Pakistan). The authors evaluated four of these projects, representing the first major evaluation of HCPs in developing countries. Methods used were stakeholder analysis, workshops, document analysis and interviews with 102 managers/implementers and 103 intended beneficiaries. Municipal health plan development (one of the main components of the healthy city strategy) in these cities was limited, which is a similar finding to evaluations of HCPs in Europe. The main activities selected by the projects were awareness raising and environmental improvements, particularly solid waste disposal. Two of the cities effectively used the 'settings' approach of the healthy city concept, whereby places such as markets and schools are targeted. The evaluation found that stakeholder involvement varied in relation to: (i) the level of knowledge of the project; (ii) the project office location; (iii) the project management structure; and (iv) type of activities (ranging from low stakeholder involvement in capital-intensive infrastructure projects, to high in some settings-type activities). There was evidence to suggest that understanding of environment-health links was increased across stakeholders. There was limited political commitment to the healthy city projects, perhaps due to the fact that most of the municipalities had not requested the projects. Consequently, the projects had little influence on written/expressed municipal policies. Some of the projects mobilized considerable resources, and most projects achieved effective intersectoral collaboration. WHO support enabled the project coordinators to network at national and international levels, and the capacity of these individuals (although not necessarily their institutions) was increased by the project. The average annual running cost of the projects was approximately 132,000 US dollars per city, which is close to the costs of the only other HCP for which a cost analysis has been undertaken, Bangkok (115,000 US dollars per year) Recommendations for these and other HCPs are provided.

The explanatory models of mental health amongst low-income women and health care practitioners in Lusaka, Zambia

There is currently much debate about the cultural construction and specificity of mental health. It is thus not surprising that explanatory models, which look at the meaning of illness for those suffering from it, have been widely used within the mental health field. This paper considers the significance of explanatory models and presents a study comparing the explanatory models of mental ill health used by urban women in low-income groups and local health care practitioners in ZAMBIA: To measure mental ill-health status, an instrument recommended by the World Health Organization was used - the Self Reporting Questionnaire, 20 items (SRQ 20). To obtain explanatory models, Kleinman's classic eight questions were adapted. The terms used by the practitioners to define and explain the mental health problems of women in low-income groups were 'stress and depression', with these two concepts being used interchangeably. In contrast, the phrase most frequently used by the women was 'problems of the mind'. The professionals regarded the experience of depression itself as a manifestation of ill health. For the women, however, only the physical symptoms were defined as ill health. There was a common agreement, however, that the women's socioeconomic situation as a major causal factor. Both groups identified the home environment as a key determinant, particularly the quality of marital relationships. Greater awareness of explanatory models may have beneficial effects on mental health policy and planning, both at national levels (where recognition of the true prevalence and burden of mental ill health should have an impact on public health policy) and at the level of local implementation (where training of health professionals to take patients' explanatory models into account might contribute towards the diagnosis of mental health problems).

Maternal responses to childhood fevers: a comparison of rural and urban residents in coastal Kenya

Urbanization is an important demographic phenomenon in sub-Saharan Africa, and rural-urban migration remains a major contributor to urban growth. In a context of sustained economic recession, these demographic processes have been associated with a rise in urban poverty and ill health. Developments in health service provision need to reflect new needs arising from demographic and disease ecology change. In malaria-endemic coastal Kenya, we compared lifelong rural (n = 248) and urban resident (n = 284) Mijikenda mothers' responses to childhood fevers. Despite marked differences between the rural and urban study areas in demographic structure and physical access to biomedical services, rural and urban mothers' treatment-seeking patterns were similar: most mothers sought only biomedical treatment (88%). Shop-bought medicines were used first or only in 69% of the rural and urban fevers that were treated, and government or private clinics were contacted in 49%. A higher proportion of urban informal vendors stocked prescription-only drugs, and urban mothers more likely to contact a private than a government facility. We conclude that improving self-treatment has enormous potential to reduce morbidity and mortality in low-income urban areas, as has frequently been argued for rural areas. However, because of the underlying socio-economic, cultural and structural differences between rural and urban areas, rural approaches to tackle this may have to be modified in urban environments.

The referral process and urban health care in sub-Saharan Africa: the case of Lusaka, Zambia

Much of the current reform of urban health systems in sub-Saharan Africa focuses upon the referral system between different levels of care. It is often assumed that patients are by-passing primary facilities which leads to congestion at hospital outpatient departments. Zambia is well advanced in its health sector reform and this case study from the capital, Lusaka, explores the patterns of health seeking behaviour of the urban population, the reasons behind health care choices, the functioning of the referral system and the users' evaluations of the care received. Data were collected across three levels of the system: the community, local health centres and the main hospital (both in- and out-patients). Results showed those who by-passed health centres were doing so because they believed the hospital outpatient department to be cheaper and/or better supplied with drugs (not because they believed they would receive better technical care). Few users were given information about their diagnosis or reason for referral. The most striking result was the degree of unmet need for health services and the large number of individuals who were self-medicating due to lack of money rather than the minor nature of their illness. The current upgrading of urban health centres into 'reference centres' may provide a capacity for unmet need rather than decongesting the hospital outpatient department as originally intended.

Urbanization and mental health in Brazil: social and economic dimensions

While there have been attempts to examine urbanization and the quality of urban life as special risk factors in the generation of mental illness, the issue is controversial and remains largely unresolved. In this article particular consideration is given to the process of contemporary structural transformation in the Brazilian society leading to urbanization. Selected Brazilian studies of mental illness in urban areas are described. Economic displacement, or unemployment, emerges as the most significant risk factor for mental ill-health and is more important than, for example, rural to urban migration. Current studies are then criticized for focusing too much on the search for single risk factors instead of taking the social, structural context into account.

Private practitioners in the slums of Karachi: what quality of care do they offer?

Private health services have expanded in many developing countries over the last 10 yr. Qualified private practitioners provide basic health care for poorer groups in urban areas, although health care planners frequently criticize them for providing poor quality of care, charging high fees and failing to provide preventive health advice. In Karachi, a large city with more than 400 slums, private practitioners are important providers of care to the poor. This study assessed the nature and quality of care provided by 201 practitioners selected from four districts of the city. Vignettes of specific medical problems were used to assess their knowledge and their practice was measured by observing 658 doctor-patient contacts. The results show that knowledge was closer to accepted medical management than was their actual prescribing practice. On the other hand, their manners and interpersonal behaviour were good. Thus poor prescribing practice, which might equally stem from market influences as lack of knowledge, is the cause of low standards of care. In these circumstances, didactic in-service training to improve prescribing practice is unlikely to be successful.