Viewpoint survey of mental health service users' experiences of discrimination in England 2008-2012

PURPOSE

Research suggests levels of discrimination among mental health service users in England are high, but fell over the course of the first phase of the Time to Change programme to reduce stigma and discrimination (2008-2011). The aim of this study was to determine changes in discrimination levels, both overall and by the area of life in which discrimination is experienced, since Time to Change began and over the first year of its second phase (2011-2012).

METHOD

Separate samples of mental health service users were interviewed annually from 2008 to 2012 using the Discrimination and Stigma Scale. In 2011 and 2012, social capital was also measured using the Resource Generator-UK.

RESULTS

Sample percentages of participants reporting the experience of discrimination in one or more life areas for years 2008-2012 were 91.4, 86.5, 86.2, 87.9 and 91.0 %, respectively. A multivariable logistic regression model was performed to test for significant differences by study year, weighted to match the study population and adjusted for employment status and diagnosis as potential confounding factors. The odds of reporting discrimination in one or more life areas were significantly lower as compared to 2008 for all subsequent years except for 2012 (0.76, 95 % CI 0.49-1.19). However, a weighted multiple regression model provided evidence of decreased mean overall discrimination in 2012 as compared to 2008 (mean decrease -7.57, 95 % CI -11.1 to -4.0, p < 0.001). The weighted mean number of social resources was 13.5 in 2012 as compared to 14.0 in 2011 (mean difference -0.60, 95 % CI -1.25 to 0.06).

CONCLUSIONS

While the overall level of discrimination across the life areas studied has fallen over 2008-2012, there is no evidence that more people using mental health services experience no discrimination. We suggest that the pattern suggesting a recent rise in discrimination following an earlier reduction may be linked to economic austerity. Further, the welfare benefits system has become an increasing source of discriminatory experience.

Integrating food poverty and minimum cost diet methods into a single framework: a case study using a Nepalese household expenditure survey

BACKGROUND

Current tools assessing affordability of nutritious diets are incomplete. "Food poverty" uses expenditure data to identify households unable to acquire a diet adequate in energy but does not consider other nutrients. The "minimum cost of a nutritious diet" method provides a threshold for purchasing a nutritious diet but must rely on other data to identify "nutrient-poor" households.

OBJECTIVE

Integrating both methods into a single framework using a common data source, we sought to jointly estimate the proportions of a population that are food and nutrient poor.

METHODS

Household expenditure data from the 2010/11 Nepal Living Standards Survey were used, focusing on representative samples of households from the mountain region (n = 401) and Kathmandu (n = 857). Food poverty thresholds were set at the cost for a low-income household to purchase a basket of foods providing adequate energy following the Cost of Basic Need method. Linear optimization was used to calculate a "nutrient poverty" threshold. Household expenditures were used to determine food and nutrient poverty rates.

RESULTS

The food and nutrient poverty thresholds were 13,294 and 18,628 rupees/person/year, respectively, in the mountain region and 14,610 and 22,945 rupees/ person/year, respectively, in Kathmandu. In the mountain region, 34% of households were both food and nutrient poor and 24% were just nutrient poor. In Kathmandu the percentages were 7% and 14%, respectively.

CONCLUSIONS

This approach, integrating two commonly used tools, provides a more nuanced interpretation of economic access to a nutritious diet and an opportunity to improve the design and targeting of nutrition and food security interventions.

Efficacy of a triage system to reduce length of hospital stay

BACKGROUND

Attempts have been made to improve the efficiency of in-patient acute care. A novel method has been the development of a 'triage system' in which patients are assessed on admission to develop plans for discharge or transfer to an in-patient ward.

AIMS

To compare a triage admission system with a traditional system.

METHOD

Length of stay and readmission data for all admissions in a 1-year period between the two systems were compared using the participating trust's anonymised records.

RESULTS

Despite reduced length of stay on the actual triage ward, the average length of stay was not reduced and the triage system did not lead to a greater number of readmissions. There was no significant difference in costs between the two systems.

CONCLUSIONS

Based on our findings we cannot conclude that the triage system reduced length of stay, but we can conclude that it does not increase the number of readmissions as some have feared.

Discrimination against people with severe mental illness and their access to social capital: findings from the Viewpoint survey

Aims. Discrimination against people with severe mental illness is an international problem. It is associated with reduced social contact and hinders recovery. This paper aims to evaluate if experienced or anticipated discrimination is associated with social capital, a known correlate of mental health. Methods. Data from the annual viewpoint cross-sectional survey of people with severe mental illness (n = 1016) were analysed. Exploratory univariate analysis was used to identify correlates of social capital in the sample, which were then evaluated in linear regression models. Additional hypotheses were tested using t tests. Results. Experienced discrimination made a modest contribution to the explained variance of social capital. Experienced discrimination from friends and immediate family was associated with reduced access to social capital from these groups, but this was not found for wider family, neighbours or mental health staff. Experience of discrimination in finding or keeping a job was also associated with reduced access to social capital. Conclusions. Further longitudinal research is needed to determine how resources within people's networks can help to build resilience, which reduces the harmful effect of discrimination on mental health.

Stigma and discrimination against people with schizophrenia related to medical services

OBJECTIVE

To investigate whether people with schizophrenia experience discrimination when using health care services.

METHODS

A cross-sectional survey in 27 countries in centres affiliated to the INDIGO Research Network, using face-to-face interviews with 777 participants with schizophrenia (62% male and 38% female). We analysed the data related to health issues, including health care, disrespect of mental health staff, and also personal privacy, safety and security, starting a family, pregnancy and childbirth. Discrimination was measured by the Discrimination and Stigma Scale (DISC), which consists of 36 items comprising three sub-scales: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination.

RESULTS

More than 17% of patients experienced discrimination when treated for physical health care problems. More than 38% of participants felt disrespected by mental health staff, with higher ratings in the post-communist countries.

CONCLUSIONS

Mental health service providers have a key role in decreasing stigma in their provision of health care, and by doing more against stigmatizing and discriminating practices on the therapeutic and organizational level. This will require a change of attitudes and practices among mental and physical health care staff.

The influence of the WIC food package changes on the retail food environment in New Orleans

OBJECTIVE

To examine the effect of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package changes on availability of healthy foods in small stores.

DESIGN

Pre-post comparison group design with repeat in-store observations.

SETTING

New Orleans.

PARTICIPANTS

Small stores (n = 102; 77% of total) were visited in 2009. Of these, 91% were observed again in 2010, including both WIC (n = 27) and non-WIC (n = 66) stores.

INTERVENTION

The 2009 WIC food package changes to include healthier foods.

MAIN OUTCOME MEASURES

Change in store availability of fruits, vegetables, lower-fat milks, whole wheat bread, and brown rice. Change in number of varieties and shelf length of fruits and vegetables.

ANALYSIS

Difference-in-differences analysis using logit models for change in availability and regression models for change in number of varieties or shelf length.

RESULTS

The WIC stores were more likely to improve availability of lower-fat milks than non-WIC stores (adjusted odds ratio, 5.0, 95% confidence interval, 1.2-21.0). An even greater relative improvement was seen with whole grains. The WIC stores showed a relative increase in number of varieties of fresh fruits (0.9 ± 0.3; P < .01) and shelf length of vegetables (1.2 ± 0.4 meters; P < .01).

CONCLUSIONS AND IMPLICATIONS

Results suggest that WIC changes improved the availability of healthy foods in small stores in New Orleans. Similar changes throughout the country could have a significant impact on neighborhood food environments.

The relationship between metformin therapy and sleep quantity and quality in patients with Type 2 diabetes referred for potential sleep disorders

AIMS

Given that sleep disorders are known to be related to insulin resistance, and metformin has favourable effects on insulin resistance and on ventilatory drive, we sought to determine whether metformin therapy was related to sleep variables in a group of patients with Type 2 diabetes.

METHODS

We performed a retrospective, observational study of our centre's database for patients referred for potential sleep disorders and then compared metformin-treated patients with those not treated with the drug. All study patients had undergone the same standard polysomnographic procedure. A multivariate analysis was performed to establish whether or not there was an independent relationship between metformin use and sleep variables (after adjusting for age, gender, BMI, neck circumference, cumulated risk factors and insulin use).

RESULTS

We studied 387 patients (mean ± sd age: 58.4 ± 10.8 years), of whom 314 had been treated with metformin. Total sleep time and sleep efficiency were higher in metformin-treated patients than in patients not treated with metformin [total sleep time: 6 h 39 min vs. 6 h 3 min, respectively (P = 0.002); sleep efficiency: 77.9 ± 12.3 vs. 71.5 ± 17.2%, respectively (P = 0.003)]. These differences persisted after adjustment for covariates and were observed even although metformin users had a higher BMI than did non-users (median 37.5 vs. 34.8 kg/m(2) ; P = 0.045).

CONCLUSION

We showed that metformin therapy is associated with a longer sleep duration and better sleep efficiency. Randomized clinical trials are needed to confirm metformin's favourable effect on sleep quality and quantity.

Linking abuse and recovery through advocacy: an observational study

Aims. High numbers of psychiatric service users experience domestic violence, yet limited interventions exist for these victims. We piloted a domestic violence intervention for community mental health services to explore the feasibility of a future cluster randomized controlled trial. Methods. Quasi-experimental controlled design within five Community Mental Health Teams (three intervention and two control teams). The intervention comprised domestic violence training for clinicians' and referral to domestic violence advocacy for service users. Clinicians' (n = 29) domestic violence knowledge, attitudes and behaviours were assessed before and 6 months post-training. Service users' (n = 34) safety behaviours, unmet needs, quality of life and frequency/severity of abuse were examined at baseline and 3 months follow-up. Process evaluation data were also collected. Results. Clinicians receiving the intervention reported significant improvements in domestic violence knowledge, attitudes and behaviours at follow-up (p < 0.05). Service users receiving the intervention reported significant reductions in violence (p < 0.001) and unmet needs at follow-up (p < 0.05). Conclusions. Interventions comprising domestic violence training for clinicians and referral to domestic violence advocacy may improve responses of psychiatric services. Low rates of identification among teams not receiving training suggest that future trials using service user outcomes are unlikely to be feasible. Therefore, other methods of evaluation are needed.

Using theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization-wide implementation of two nursing-centric best-practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence-informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.

Car ownership and the association between fruit and vegetable availability and diet

OBJECTIVE

Nearly all research on the food environment and diet has not accounted for car ownership - a potential key modifying factor. This study examined the modifying effect of car ownership on the relationship between neighborhood fruit and vegetable availability and intake.

METHODS

Data on respondents' (n=760) fruit and vegetable intake, car ownership, and demographics came from the 2008 New Orleans Behavioral Risk Factor Surveillance System. Shelf space data on fresh, frozen, and canned fruits and vegetables were collected in 2008 from a random sample of New Orleans stores (n=114). Availability measures were constructed by summing the amount of fruit and vegetable shelf space in all stores within defined distances from respondent households. Regression analyses controlled for demographics and were run separately for respondents with and without a car.

RESULTS

Fruit and vegetable availability was positively associated with intake among non-car owners. An additional 100 m of shelf space within 2 km of a residence was predictive of a half-serving/day increase in fruit and vegetable intake. Availability was not associated with intake among car owners.

CONCLUSIONS

Future research and interventions to increase neighborhood healthy food options should consider car ownership rates in their target areas as an important modifying factor.

Experiences of discrimination among people using mental health services in England 2008-2011

BACKGROUND

Research suggests that levels of discrimination against people using mental health services are high; however, reports of these people's experiences are rare.

AIMS

To determine whether the Time to Change (TTC) programme target of 5% reduction in discrimination has been achieved.

METHOD

Separate samples of people using mental health services were interviewed annually from 2008 to 2011 using the Discrimination and Stigma Scale to record instances of discrimination.

RESULTS

Ninety-one per cent of participants reported one or more experiences of discrimination in 2008 compared with 88% in 2011 (z = -1.9, P = 0.05). The median negative discrimination score was 40% in 2008 and 28% in 2011 (Kruskal-Wallis χ(2) = 83.4, P<0.001).

CONCLUSIONS

The proportion of participants experiencing no discrimination increased significantly over the course of TTC but by less than the initial target. The overall median discrimination score fell by 11.5%. Data from 2010 and 2011 suggest that these gains may be hard to maintain during economic austerity.

A comparison of the expression of the malignant phenotype in two androgen-independent human prostate cancer cell lines after orthotopic implantation in nude mice

Expression of some features of the malignant phenotype were compared in the DU145 and PC-3M human prostate cancer cell lines after their intraprostatic growth in nude mice. At necropsy, 27/74 (36%) mice injected with DU145 cells and 41/75 (55%) injected with PC-3M cells had either invasive macroscopic tumors, or microscopic intraprostatic tumor cell nests (p = 0.02). Para-aortic lymph node metastases had occurred in 19% of the DU145 cell, and 44% of the PC-3M cell tumor-bearing animals (p = 0.033). Immunohistochemical staining showed high mutant p53 and vascular endothelial growth factor (VEGF) expression by DU145 cells; PC-3M cells did not express detectable p53, and had relatively low VEGF immunohistochemical reactivity. Assays by ELISA established a statistically significant difference in VEGF levels between the cell lines (p < 0.001). Urokinase-like plasminogen activator (uPA) levels, determined by ELISA, were ten-fold higher in the PC-3M cell tumors, as were matrix metalloproteinase-9 (MMP-9) activities assessed by zymography. These findings of high expression of uPA and MMP-9, two key proteolytic enzymes in the invasive/metastatic process, by PC-3M cell prostatic tumors are consistent with their aggressive behavior; the low VEGF levels compared with those in the poorly metastatic DU145 cell tumors suggest that other angiogenic factors may be critical for prostate cancer cell progression in this model.

Giant right atrial thrombus in hepatocellular carcinoma: real-time characterization by cardiac magnetic resonance and real time three-dimensional echocardiography

Hepatocellular carcinoma (HCC) with extension to the right atrium is an uncommon form of cardiac involvement. We report a case of a 67-year-old man admitted to our Department for the incidental findings of a mass in the right atrium. Physical examination revealed leg edema, distention of external jugular vein and ascites. The anamnestic collection revealed HCC occurred on post-alcoholic liver cirrhosis 3 years earlier. Transthoracic echocardiography revealed a dilated RA containing a mass, with superficial apposition of a thrombotic material. Bi-dimensional echocardiography is the most commonly used noninvasive tool for evaluating intracardiac masses. Although MRI is considered the gold standard, real-time three-dimensional echocardiography has the capability to obtain the entire volume reconstruction of an intracardiac mass, even with an irregular shape. Moreover, it permits an hemodynamic evaluation of the potential obstructive effects visualized from different angles and planes.<br />

Cardiovascular risk factors and physical activity behavior among elementary school personnel: baseline results from the ACTION! worksite wellness program

BACKGROUND

Although the prevalence of obesity is increasing during adulthood, there have been few assessments of obesity, cardiovascular risk factors, and levels of physical activity among adult elementary school staff.

METHODS

Data were collected from 745 African-American and White female school personnel in a suburban school district in southeastern Louisiana as part of the baseline assessment before implementation of a program to improve eating and physical activity behaviors. Anthropometry, blood pressure, serum lipids and lipoproteins, and glucose were measured using established protocols. Physical activity was assessed by accelerometry.

RESULTS

For both White and Black females, 30% were overweight (body mass index [BMI]) ≥25 kg/m(2) but <30 kg/m(2) ). Whereas 37% of White females were obese (BMI ≥ 30 kg/m(2) ), 61% of the Black females were obese. There was a positive association between BMI and other cardiovascular risk factors except for high-density lipoprotein cholesterol, where the association was negative. The mean number of minutes of daily moderate-to-vigorous physical activity was <1 minute per day and was lower for overweight and obese women than for normal weight women.

CONCLUSIONS

School personnel in the study have adverse cardiovascular risk factors, including high rates of obesity and very low levels of physical activity. Because these individuals are often called upon to promote health for children, they are an important target population for wellness interventions.

Understanding policy enactment: the New Orleans Fresh Food Retailer Initiative

BACKGROUND

Healthy-food financing initiatives have been endorsed as a way to improve food access, but relatively little research exists on understanding the formulation of such policies.

PURPOSE

This paper investigates the development of the New Orleans Fresh Food Retailer Initiative (FFRI) to highlight factors that enabled and impeded its enactment.

METHODS

In 2010 and 2011, semistructured interviews were conducted with 22 key informants with firsthand experience of this case, including representatives from the private sector, nonprofit organizations, and government. A participant-observer approach was used to synthesize these observations with archived written materials and the authors' own observations.

RESULTS

Historical disparities in food access in New Orleans were exacerbated by Hurricane Katrina, which also generated neighborhood activism and a pressing need to rebuild the city. A Food Policy Advisory Committee (FPAC) was formed from diverse groups. This paper describes the evolution of FPAC, its deliberations and report to the City Council, and actions to promote a financing initiative, as well as delays encountered in the process.

CONCLUSIONS

Enactment of the FFRI was facilitated by a window of opportunity that opened in the storm's aftermath, broad-based stakeholder buy-in, the existence of political champions, and policy-relevant information that was simple and convincing. Impediments to success included the constant turnover of city staff, a skeptical state bureaucracy, and the many competing priorities in New Orleans. This study highlights the importance of having a clear policy objective to address a well-defined and illustrated problem, key advocates in diverse organizations, and broad-based support for its implementation.

Small retailer perspectives of the 2009 Women, Infants and Children Program food package changes

OBJECTIVE

To understand vendor perspectives regarding changes made in 2009 to the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) food package.

METHODS

Fifty-two in-depth, qualitative interviews with owners or managers of small stores in 8 urban areas across 7 states conducted 6-12 months after the changes.

RESULTS

Store owners experienced implementation challenges, but felt the changes increased the number of customers, sales, and profits.

CONCLUSION

This research provides vendor perspectives on the 2009 WIC policy changes and may enhance policy implementation directed at increasing healthy food availability, particularly in urban communities.

Views of the Therapeutic Environment (VOTE): stakeholder involvement in measuring staff perceptions of acute in-patient care

BACKGROUND

The impact of staff perceptions of daily work pressures on burnout requires further exploration because both issues may be adversely affecting the quality of staff interactions with service users.

OBJECTIVES

To use a model of 'stakeholder involvement' to develop and test a self-report instrument capturing nursing staff perceptions of the daily pressures of working in acute in-patient mental health wards.

DESIGN

Measure development followed a participatory methodology, followed by psychometric testing of the new measure of the daily pressures of working on an acute ward (VOTE).

SETTINGS

Acute in-patient wards in an inner London mental health trust.

PARTICIPANTS

All nursing staff from acute in-patient settings are eligible for this study. In total 376 staff (qualified nurses and healthcare assistants) were involved at the various stages of measure development and testing.

METHODS

Focus groups of nursing staff met to discuss their perceptions of acute wards. A twenty item measure was generated through thematic analysis of these data and staff feedback. Reliability and validity were tested and the effects of demographic characteristics on VOTE, and VOTE on burnout were examined.

RESULTS

Staff found VOTE easy to understand and complete. Test-retest reliability and the internal consistency of the measure and subscales were good. A test of criterion validity showed that staff with negative perceptions of the daily pressures of the working on an acute ward also had negative perceptions of job satisfaction and high levels of burnout. Regression modelling showed that VOTE had a significant effect on burnout.

CONCLUSIONS

VOTE is a concise measure which combines aspects of care provision as well as the organisational and professional stressors of acute ward working. VOTE can be used to further explore how staff perceptions of the daily pressures of acute ward working affect the quality of care delivered.