Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action

BACKGROUND

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare.

AIMS

We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion.

METHOD

We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes.

RESULTS

Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors.

CONCLUSIONS

We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

A quantitative analysis of human rights-related attitude changes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities following completion of the WHO QualityRights e-training in Ghana

BACKGROUND

Despite growing recognition of essential human rights, people with mental health conditions and psychosocial, intellectual, or cognitive disabilities' rights are known to be frequently violated in mental healthcare worldwide, with common use of coercive practices and limited recognition of people's right to exercise their legal capacity and make decisions for themselves on treatment and other issues affecting them. To tackle this issue, Ghana adopted the WHO QualityRights Initiative in 2019. This aims to introduce a right-based, person-centred recovery approach within the mental health care system, protecting and promoting the rights of people with mental health conditions, psychosocial, cognitive, and intellectual disabilities in the healthcare context and community.

METHODS

E-training (capacity-building) was provided in Ghana across a broad array of stakeholder groups including healthcare professionals, carers, and people with lived experience. The training covered legal capacity, coercion, community inclusion, recovery approach, service environment, and the negative attitudes commonly held by stakeholder groups; it was completed by 17,000 people in Ghana as of December 2021. We assessed the impact of the e-training on attitudes through comparing trainees' pre- and post-questionnaire responses on 17 items, each measured on a 5-point Likert scale (strongly disagree to strongly agree), such that higher scores indicated negative attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders. Analyses were conducted on two main groups: matched pairs (417 pairs of baseline and follow-up questionnaire responses matched to a high degree of certainty), and the unmatched group (4299 individual completed questionnaire responses).

RESULTS

We assessed the impact of the WHO QualityRights e-training on attitudes: training resulted in highly significant attitude changes towards alignment with human rights, with scores changing by approximately 40% between baseline and follow-up. In particular, attitude changes were seen in items representing treatment choice, legal capacity, and coercion. This change was not affected by age, gender, or background experience.

CONCLUSIONS

The QualityRights e-training programme is effective in changing people's (especially healthcare professionals') attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities: this is a step towards mental healthcare being more with human rights-based worldwide.

Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare

Background & objectives

Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation.

Methods

Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training.

Results

Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State.

Interpretation & conclusions

The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Evaluation of Serial Testing After Exposure to COVID-19 in Early Care and Education Facilities, Illinois, March-May 2022

OBJECTIVE

To understand SARS-CoV-2 transmission in early care and education (ECE) settings, we implemented a Test to Stay (TTS) strategy, which allowed children and staff who were close contacts to COVID-19 to remain in person if they agreed to test twice after exposure. We describe SARS-CoV-2 transmission, testing preferences, and the number of in-person days saved among participating ECE facilities.

METHODS

From March 21 through May 27, 2022, 32 ECE facilities in Illinois implemented TTS. Unvaccinated children and staff who were not up to date with COVID-19 vaccination could participate if exposed to COVID-19. Participants received 2 tests within 7 days after exposure and were given the option to test at home or at the ECE facility.

RESULTS

During the study period, 331 TTS participants were exposed to index cases (defined as people attending the ECE facility with a positive SARS-CoV-2 test result during the infectious period); 14 participants tested positive, resulting in a secondary attack rate of 4.2%. No tertiary cases (defined as a person with a positive SARS-CoV-2 test result within 10 days after exposure to a secondary case) occurred in the ECE facilities. Most participants (366 of 383; 95.6%) chose to test at home. Remaining in-person after an exposure to COVID-19 saved approximately 1915 in-person days among children and staff and approximately 1870 parent workdays.

CONCLUSION

SARS-CoV-2 transmission rates were low in ECE facilities during the study period. Serial testing after COVID-19 exposure among children and staff at ECE facilities is a valuable strategy to allow children to remain in person and parents to avoid missing workdays.

Attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders in Ghana: a World Health Organization study

BACKGROUND

There are currently major efforts underway in Ghana to address stigma and discrimination, and promote the human rights of those with mental health conditions, within mental health services and the community, working with the World Health Organization's QualityRights initiative. The present study aims to investigate attitudes towards people with lived experience of mental health conditions and psychosocial disabilities as rights holders.

METHODS

Stakeholders within the Ghanaian mental health system and community, including health professionals, policy makers, and persons with lived experience, completed the QualityRights pre-training questionnaire. The items examined attitudes towards coercion, legal capacity, service environment, and community inclusion. Additional analyses explored how far participant factors may link to attitudes.

RESULTS

Overall, attitudes towards the rights of persons with lived experience were not well aligned with a human rights approach to mental health. Most people supported the use of coercive practices and often thought that health practitioners and family members were in the best position to make treatment decisions. Health/mental health professionals were less likely to endorse coercive measures compared to other groups.

CONCLUSION

This was the first in-depth study assessing attitudes towards persons with lived experience as rights holders in Ghana, and frequently attitudes did not comply with human rights standards, demonstrating a need for training initiatives to combat stigma and discrimination and promote human rights.

Human rights in mental healthcare; A review of current global situation

The relationship between mental health and human rights is complex and bidirectional. Global mental health movements have been emphasizing the promotion of human rights in mental health care in accordance with the UN Convention on the Rights of Persons with Disabilities and the WHO QualityRights Initiative. The main objective of this review is to have an overview of the current global situation of human rights in mental health services by performing a review of scientific literature. The literature search and elimination process yielded a total of 26 articles focussing on human rights-related reports and tools. Further assessment of these articles clearly shows that despite significant improvements in mental health service delivery in the past decade, there is still substantial reporting of the continuing prominence of stigmatizing attitudes, and human rights violations and abuses in mental health settings. The human rights perspective requires society, particularly policymakers, to actively promote necessary conditions for all individuals to fully realize their rights. We suggest developing a more comprehensive model in mental health that integrates human rights into existing services and approaches. A model that recognizes that all people with mental health conditions and psychosocial disabilities are rights holders.

A nationwide evaluation study of the quality of care and respect of human rights in mental health facilities in Ghana: results from the World Health Organization QualityRights initiative

Background

In 2012, Ghana ratified the United Nations Convention on the Rights of Persons with Disabilities and enacted a Mental Health Act to improve the quality of mental health care and stop human rights violations against people with mental health conditions. In line with these objectives, Ghanaian stakeholders collected data on the quality of mental health services and respect for human rights in psychiatric facilities to identify challenges and gather useful information for the development of plans aimed to improve the quality of the services offered. This study aimed to assess psychiatric facilities from different Ghanaian regions and provide evidence on the quality of care and respect of human rights in mental health services.

Methods

Assessments were conducted by independent visiting committees that collected data through observation, review of documentation, and interviews with service users, staff, and carers, and provided scores using the World Health Organization QualityRights Toolkit methodology.

Results

This study revealed significant key challenges in the implementation of the United Nations Convention on the Rights of Persons with Disabilities principles in Ghanaian psychiatric services. The rights to an adequate standard of living and enjoyment of the highest attainable standard of health were not fully promoted. Only initial steps had been taken to guarantee the right to exercise legal capacity and the right to personal liberty and security. Significant gaps in the promotion of the right to live independently and be included in the community were identified.

Conclusions

This study identifies shortcomings and critical areas that the Ghanaian government and facilities need to target for implementing a human rights-based approach in mental health and improve the quality of mental health care throughout the country.

Quality of care and respect of human rights in mental health services in four West African countries: collaboration between the mental health leadership and advocacy programme and the World Health Organization QualityRights initiative

BACKGROUND

Although recent reports suggest that service users in West African psychiatric facilities are exposed to poor quality of care and human rights violations, evidence is lacking on the extent and profile of specific deficits in the services provided to persons with mental health conditions.

AIMS

To evaluate the quality of care and respect of human rights in psychiatric facilities in four West African countries, The Gambia, Ghana, Liberia and Sierra Leone, using the World Health Organization QualityRights Toolkit.

METHOD

Trained research workers collected information through observation, review of records and interviews with service users, caregivers and staff. Independent panels of assessors used the information to assign scores to the criteria, standards and themes of the QualityRights Toolkit.

RESULTS

The study revealed significant gaps in these facilities. The rights to an adequate standard of living and to enjoyment of the highest attainable standard of health were poorly promoted. Adherence to the right to exercise legal capacity and the right to personal liberty and security was almost absent. Severe shortcomings in the promotion of the right to live independently and be included in the community were reported.

CONCLUSIONS

Inadequate appreciation of service users' rights, lack of basic approaches to protect them and the non-promotion of rights-based services in these facilities are major problems that need to be addressed. Although it recognises the resource constraints and need for more human and financial resources, the study also identifies critical areas and challenges that require significant changes at the facility level.

The use of a novel burn dressing out of bacterial nanocellulose compared to the French standard of care in paediatric 2nd degree burns - A retrospective analysis

PURPOSE

Paediatric burn care is a delicate discipline which benefits from special attention. Despite being highly effective, the current standard of care for second degree burns in the largest paediatric burn center in France - exposure to infrared light - involves long hospital stays, straining economic and professional resources, especially in times of a pandemic. The present study investigated this standard of care and compared it to the use of a bacterial nanocellulose dressing.

MATERIALS AND METHODS

A retrospective analysis of two groups has been performed: the control group assessed thirty consecutive children treated with the standard of care, and the intervention group assessed thirty consecutive children treated with the bacterial nanocellulose dressing. Parameters evaluated were: healed wounds, additional treatments, rate of infections, hospital length of stay, pain experience and overall satisfaction.

RESULTS

The two groups did not differ significantly in terms of age and TBSA. A significant reduction in hospital length of stay (p < .001) and pain experience (p < .001) could be observed. In terms of healed wounds, additional treatments and infections, the two groups were equally matched (p > .05) with satisfactory results in both groups. Tendencies towards better results could be seen in the intervention group.

CONCLUSION

The use of bacterial nanocellulose wound dressings is an important tool in the armamentarium of today's burn surgeons. Satisfying results were achieved, ameliorating burn care for children. Future studies are indicated to further support its value and assess the economic impact.

Disability and COVID-19: ensuring no one is left behind

The United Nations’ Sustainable Development Agenda calls for targeted attention to the needs and rights of the most vulnerable populations to ensure a life of dignity and human security for all. In this paper, we argue that persons with disabilities are in a disproportionately vulnerable situation in public health emergencies. By using the example of Coronavirus disease 2019 (Covid-19), we explain why that is and call for the systematic consideration of the needs and rights of persons with disabilities during the response to the outbreak and during the recovery phase. Otherwise, equity will continue to be merely an aspiration during this COVID-19 emergency - as it will in future health emergencies.

Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India

BACKGROUND

Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level.

AIMS

To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India.

METHOD

This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention.

RESULTS

Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15).

CONCLUSIONS

To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.

Implementing WHO-Quality Rights Project in Tunisia: Results of an Intervention at Razi Hospital

BACKGROUND

The aims were: 1) to measure the attitudes of learners (and future trainers) before and after a course on WHO-Quality Rights (QR); 2) to evaluate a psychiatric ward, by previously trained staff on QR, comparing it with a previous evaluation and discussing an improvement plan.

METHODS

1) Training sample: 19 subjects (8 males), 41.4±10.6 years, including jurists/lawyers, health professionals, and experts.The QR team developed the 26-item tool to assess the knowledge and attitudes of participants.2) Evaluation of quality of care and respect for human rights in the ward was carried out on 20 staff representatives, 20 family members and 20 users with QRToolkit.

RESULTS

1) Learning in QR has partially changed the knowledge and attitudes of trained people.2) The evaluation shows significant delays in the implementation of the rights advocated by the United Nations Convention on the Human Rights of Persons with Disabilities (CRPD). In Themes 1, 3, 4 and 5, the evaluation shows no differences compared to 2014, but in Theme 2, the level was lower than four years before.

CONCLUSION

The scarcity of resources due to the economic crisis that Tunisia is going through, cannot be considered the only cause of the delays highlighted. However, it is likely that in a context of uncertainty for the future, scarcity of resources and a decrease in staff (i.e., professionals dedicated to psychosocial intervention) may have demotivated the team towards recovery. The improvement in knowledge and attitudes of many staff members after the training may open future positive scenarios.

Conterminous United States land cover change patterns 2001-2016 from the 2016 National Land Cover Database

The 2016 National Land Cover Database (NLCD) product suite (available on www.mrlc.gov), includes Landsat-based, 30 m resolution products over the conterminous (CONUS) United States (U.S.) for land cover, urban imperviousness, and tree, shrub, herbaceous and bare ground fractional percentages. The release of NLCD 2016 provides important new information on land change patterns across CONUS from 2001 to 2016. For land cover, seven epochs were concurrently generated for years 2001, 2004, 2006, 2008, 2011, 2013, and 2016. Products reveal that land cover change is significant across most land cover classes and time periods. The land cover product was validated using existing reference data from the legacy NLCD 2011 accuracy assessment, applied to the 2011 epoch of the NLCD 2016 product line. The legacy and new NLCD 2011 overall accuracies were 82% and 83%, respectively, (standard error (SE) was 0.5%), demonstrating a small but significant increase in overall accuracy. Between 2001 and 2016, the CONUS landscape experienced significant change, with almost 8% of the landscape having experienced a land cover change at least once during this period. Nearly 50% of that change involves forest, driven by change agents of harvest, fire, disease and pests that resulted in an overall forest decline, including increasing fragmentation and loss of interior forest. Agricultural change represented 15.9% of the change, with total agricultural spatial extent showing only a slight increase of 4778 km², however there was a substantial decline (7.94%) in pasture/hay during this time, transitioning mostly to cultivated crop. Water and wetland change comprised 15.2% of change and represent highly dynamic land cover classes from epoch to epoch, heavily influenced by precipitation. Grass and shrub change comprise 14.5% of the total change, with most change resulting from fire. Developed change was the most persistent and permanent land change increase adding almost 29,000 km² over 15 years (5.6% of total CONUS change), with southern states exhibiting expansion much faster than most of the northern states. Temporal rates of developed change increased in 2001-2006 at twice the rate of 2011-2016, reflecting a slowdown in CONUS economic activity. Future NLCD plans include increasing monitoring frequency, reducing latency time between satellite imaging and product delivery, improving accuracy and expanding the variety of products available in an integrated database.

Continuous pH monitoring in wounds using a composite indicator dressing - A feasibility study

PURPOSE

Modern burn care strives for new means to guarantee optimised wound healing. Several studies have shown a correlation between the pH value in a (burn) wound and successful wound healing. A multitude of devices to monitor pH is available, all requiring direct wound contact and removal of the dressing for pH monitoring. The aim of this feasibility study was to create a sterile and easy to handle method for pH monitoring while simultaneously using an advanced wound dressing.

MATERIALS AND METHODS

Dressing sheets of biotechnologically generated nanofibrillar cellulose (epicite^hydro) were chemically functionalised with the indicator dye GJM-534. pH-donors with increasing pH were subsequently applied to the created indicator dressing. To investigate temporal resolution and continuous monitoring we used circular pH-donors with different pH (7 and 10) and decreasing diameters that were placed on another dressing sheet. Clinically relevant spatial resolution was checked by a wound bed simulation with small areas (8 mm) of higher pH (10) on a field of lower pH (7) and vice versa.

RESULTS

The indicator dressing showed a gradual colouring from yellow to dark orange with increasing pH in steps of 0.3. After conversion of digital pictures to greyscale values, a sigmoidal distribution with a pK_a-value of 8.4 was obtained. A ring-like pattern with alternating colour change corresponding to the pH was observed in the continuous monitoring experiment and the wound bed simulation delivered excellent local resolution.

CONCLUSION

Since the pH of a (burn) wound can have a significant influence on wound healing, a pH indicator was successfully linked to an advanced, temporary, alloplastic wound dressing material. We were able to show the possibility of pH monitoring by the dressing itself. Additional testing, including studies with large case numbers for optimisation are necessary before clinical implementation.

Mental Health Policy Development and Implementation in Four African Countries

The purpose of the research programme introduced in this article is to provide new knowledge regarding comprehensive multisectoral approaches to breaking the negative cycle of poverty and mental ill-health. The programme undertakes an analysis of existing mental health policies in four African countries (Ghana, South Africa, Uganda, Zambia), and will carry out and evaluate interventions to assist in the development and implementation of mental health policies in those countries, over a five-year period. The four countries in which the programme is being conducted represent a variety of scenarios in mental health policy development and implementation.

Intravitreal bevacizumab (Avastin) versus triamcinolone (Volon A) for treatment of diabetic macular edema: one-year results

PURPOSE

The objective was to compare retinal morphology and function following intravitreal injections of bevacizumab (Avastin) or triamcinolone (Volon A) in patients with early diabetic macular edema (DME).

PATIENTS AND METHODS

The study was planned as a randomized, prospective, interventional clinical trial. A total of 30 diabetic patients with treatment-naïve, clinically significant macular edema were included in this study and randomized to two equal groups. One group initially received three injections of 2.5 mg bevacizumab in monthly intervals. The second group received a single injection of 8 mg triamcinolone, followed by two sham interventions. Functional and anatomic results were evaluated monthly using ETDRS vision charts and spectral-domain optical coherence tomography. According to the study protocol, retreatment after 3 months was dependent on functional and anatomic outcome in a PRN regimen.

RESULTS

Baseline best corrected visual acuity (BCVA) was 0.30 logMAR and central retinal subfield thickness (CSRT) was 505 μm in the bevacizumab group and 0.32 logMAR and 490 μm CSRT in the triamcinolone group. After 3 months, BCVA improved to 0.23 logMAR (bevacizumab) and 358 μm CRST and 0.26 logMAR (triamcinolone) and 308 μm CSRT. After 12 months, BCVA further recovered in the bevacizumab group (0.18 logMAR) but slightly decreased in the triamcinolone group (0.36 logMAR).

CONCLUSION

Intravitreal bevacizumab and triamcinolone are both equally effective in reducing CSRT in early DME. After 6 months, rehabilitation of vision was comparable in both treatment arms, whereas at the final follow-up at month 12, BCVA was superior in the bevacizumab than in the triamcinolone sample. This may be related to cataract development following steroid treatment, as well as to substance-specific mechanisms within the angiogenic versus the inflammatory cascade.

United States women and pornography through four decades: exposure, attitudes, behaviors, individual differences

Responding to a call for research on pornography and women's sexuality made by Weinberg, Williams, Kleiner, and Irizarry (2010), this study assessed pornography consumption, predictors, and correlates using nationally representative data gathered from U.S. women between 1973 and 2010 (N = 18,225). Women who were younger, less religious, and non-White were more likely to consume pornography. Women who consumed pornography had more positive attitudes toward extramarital sex, adult premarital sex, and teenage sex. Women who consumed pornography also had more sexual partners in the prior year, prior 5 years, and were more likely to have engaged in extramarital sex and paid sex. Consistent with Wright's (2011a) acquisition, activation, application model of mass media sexual socialization and the theorizing of Linz and Malamuth (1993), liberal-conservative ideology moderated the association between pornography exposure and sexual behavior. Specifically, the positive association between pornography exposure and women's recent sexual behavior was strongest for the most liberal women and weakest for the most conservative women. Cultural commentators and some academics argue that technological advances have resulted in a steady increase in the percentage of individuals who consume pornography. Little support was found for this assertion among U.S. women.

Pornography Consumption and Opposition to Affirmative Action for Women

Despite the persistence of wage gaps and other indicators of discrimination, many Americans oppose affirmative action for women. Our study investigated a potential source of social influence that has often been hypothesized to reduce compassion and sympathy for women: pornography. National panel data were employed. Data were gathered in 2006, 2008, and 2010 from 190 adults ranging in age from 19 to 88 at baseline. Pornography viewing was indexed via reported consumption of pornographic movies. Attitudes toward affirmative action were indexed via opposition to hiring and promotion practices that favor women. Contrary to a selective-exposure perspective on media use, prior opposition to affirmative action did not predict subsequent pornography viewing. Consistent with a social learning perspective on media effects, prior pornography viewing predicted subsequent opposition to affirmative action even after controlling for prior affirmative action attitudes and a number of other potential confounds. Gender did not moderate this association. Practically, these results suggest that pornography may be a social influence that undermines support for affirmative action programs for women. Theoretically, these results align with the perspective that sexual media activate abstract scripts for social behavior which may be applied to judgments that extend beyond the specific interaction patterns depicted.

Effects of antioxidants on glutathione levels and clinical recovery from the malnutrition syndrome kwashiorkor – a pilot study

Kwashiorkor is a severe edematous form of malnutrition with high prevalence and lethality in many African countries, and repeatedly has been reported to be associated with oxidative stress. The therapy of kwashiorkor is still ineffective. In this pilot study, we tested the hypothesis that oral application of thiol-containing antioxidants increases glutathione status and is beneficial for the clinical recovery of kwashiorkor patients. The longitudinal clinical intervention study was carried out at St Joseph's Hospital, Jirapa, Ghana. Children with severe kwashiorkor were randomly assigned to either a standard treatment (ST) receiving a therapeutic protocol based on the recommendations of the WHO or to one of three study groups receiving in addition 2 x 600 mg reduced glutathione or 2 x 50 mg alpha-lipoic acid or 2 x 100 mg N-acetylcysteine per day. Patients were followed up clinically and biochemically for 20 days and compared with 37 healthy controls. Both glutathione and alpha-lipoic acid supplementation had positive effects on survival. Also, the blood glutathione concentrations correlated positively with survival rates. Furthermore, the initial skin lesions, glutathione and total protein concentrations were found to be strong predictors of survival. The data strongly suggest that a therapy restoring the antioxidative capacity by applying cysteine equivalents in the form of glutathione and/or alpha-lipoic acid is beneficial for biochemical and clinical recovery of kwashiorkor patients.

Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis

This report reviews the evidence for the types of human rights violations experienced by people with mental and psychosocial disabilities in low-income and middle-income countries as well as strategies to prevent these violations and promote human rights in line with the UN Convention on the Rights of Persons with Disabilities (CRPD). The article draws on the views, expertise, and experience of 51 people with mental and psychosocial disabilities from 18 low-income and middle-income countries as well as a review of English language literature including from UN publications, non-governmental organisation reports, press reports, and the academic literature.

Evaluation of the PC-1 K121Q and G2906C variants as independent risk factors for ischaemic stroke

Overexpression of plasma cell membrane glycoprotein-1 (PC-1) inhibits insulin receptor tyrosine kinase activity and thus favours insulin resistance and atherosclerotic vascular disease. Recent findings indicate that the minor variant K121Q in the PC-1 gene confers an increased risk for early myocardial infarction independent of other established risk factors. We hypothesized that genetic variants in PC-1 may also influence the risk for cerebrovascular disease.

AIM

Therefore, we assessed the association of the PC-1 K121Q variant in the coding region and a polymorphism (G2906C) in the 3' untranslated region of the PC-1 gene with the risk of stroke.

PATIENTS

We analyzed 1014 patients with a history of ischaemic stroke from the Vienna stroke registry and 1001 control individuals without vascular disease.

RESULTS, CONCLUSION

Genotype frequencies of both genetic variants were similar in patients and controls in the total study population. By multivariate analysis, no interactions were observed between the PC-1 genotype and established vascular risk factors. However, the PC-1 2906C allele was significantly more frequent in patients who suffered from stroke before the age of 40 years. In these patients the risk for ischaemic stroke was increased four-fold.

An assessment of mental health policy in Ghana, South Africa, Uganda and Zambia

BACKGROUND

Approximately half of the countries in the African Region had a mental health policy by 2005, but little is known about quality of mental health policies in Africa and globally. This paper reports the results of an assessment of the mental health policies of Ghana, South Africa, Uganda and Zambia.

METHODS

The WHO Mental Health Policy Checklist was used to evaluate the most current mental health policy in each country. Assessments were completed and reviewed by a specially constituted national committee as well as an independent WHO team. Results of each country evaluation were discussed until consensus was reached.

RESULTS

All four policies received a high level mandate. Each policy addressed community-based services, the integration of mental health into general health care, promotion of mental health and rehabilitation. Prevention was addressed in the South African and Ugandan policies only. Use of evidence for policy development varied considerably. Consultations were mainly held with the mental health sector. Only the Zambian policy presented a clear vision, while three of four countries spelt out values and principles, the need to establish a coordinating body for mental health, and to protect the human rights of people with mental health problems. None included all the basic elements of a policy, nor specified sources and levels of funding for implementation. Deinstitutionalisation and the provision of essential psychotropic medicines were insufficiently addressed. Advocacy, empowerment of users and families and intersectoral collaboration were inadequately addressed. Only Uganda sufficiently outlined a mental health information system, research and evaluation, while only Ghana comprehensively addressed human resources and training requirements. No country had an accompanying strategic mental health plan to allow the development and implementation of concrete strategies and activities.

CONCLUSIONS

Six gaps which could impact on the policies' effect on countries' mental health systems were: lack of internal consistency of structure and content of policies, superficiality of key international concepts, lack of evidence on which to base policy directions, inadequate political support, poor integration of mental health policies within the overall national policy and legislative framework, and lack of financial specificity. Three strategies to address these concerns emerged, namely strengthening capacity of key stakeholders in public (mental) health and policy development, creation of a culture of inclusive and dynamic policy development, and coordinated action to optimize use of available resources.

A new era in mental health care in vanuatu

Inequity in health-care delivery for those with mental illness is widespread throughout low- and middle-income countries. In the Pacific Island countries there are many barriers to addressing the growing mental health burden. In an effort to address this problem, the WHO is coordinating the Pacific Islands Mental Health Network involving 18 countries in the Pacific region with the financial support of New Zealand Aid (NZAid). JB and DP have developed and presented mental health training to health professionals, community leaders, and social service personnel in an environment in Vanuatu that is very different from that of their usual Australian-based general practices. They discuss evidence for their work, an outline of the programme, some difficulties working across different cultures, and the enthusiasm with which the training has been greeted. Vanuatu is now well on its way to addressing the inequity of access to mental health care with a culturally appropriate and self-sustaining mental health workforce.

Framework and methodology for evaluating mental health policy and plans

The importance of monitoring and evaluation for mental health service planning and delivery is indubitable. Notwithstanding, monitoring and evaluation of mental health policy and plans has received only limited attention. This paper presents an approach developed by the World Health Organization for monitoring mental health policy and plans that can be adapted and utilized for evaluation and monitoring of policy and plans in most other health spheres as well. Four critical areas are outlined i.e., evaluation of the policy document and the plan derived from it; monitoring the implementation of the strategic plan; evaluation of the implementation of the plan; and evaluation of whether the objectives of the policy have been achieved. Overcoming difficulties in objective assessment of policy documents and plans is discussed and two WHO checklists for evaluating the process, content and operational aspects of policies and plans are introduced together with a five step guidance process for conducting policy and plan evaluations.

Effect of P6 acustimulation on post-operative nausea and vomiting in patients undergoing a laparoscopic cholecystectomy

BACKGROUND

Non-pharmacologic techniques such as electrical acustimulation may mitigate post-operative nausea and vomiting (PONV). The primary purpose of this study was to investigate the effectiveness of acustimulation on attenuating PONV. Moreover, we tested whether a pre- or a post-induction application of acustimulation results in differences in PONV reduction.

METHODS

In this prospective, double-blind, randomized, controlled trial, we studied 200 patients undergoing a laparoscopic cholecystectomy during propofol (induction) fentanyl/isoflurane/atracurium (maintenance) anaesthesia. In the acustimulation group (n=101), subdivided into groups with pre-induction (n=57) and post-induction (n=44) acustimulation, an active ReliefBand device was placed at the P6 acupoint. In the sham group (n=99), also subdivided into pre-induction (n=55) or post-induction (n=44) groups, an inactive device was applied instead. The ReliefBand remained in place for 24 h after surgery. Nausea and vomiting/retching were recorded at 2, 6, and 24 h post-operatively.

RESULTS

The incidence of early nausea (up to 2 h) was significantly lower in the acustimulation than in the sham group (29% vs. 42%; P=0.043). No significant effect could be detected for retching/vomiting. Moreover, acustimulation showed no effect on PONV after 6 and 24 h. Risk factor analysis (female gender, non-smoker, history of PONV/motion sickness, and post-operative morphine usage) revealed a relative reduction in risk of 40% for nausea (P=0.021) and 55% for retching/vomiting (P=0.048) in patients with three or four risk factors present. The timing of (pre- vs. post-induction) acustimulation had no significant effect on PONV reduction.

CONCLUSION

Acustimulation at the P6 acupoint reduces early nausea, but not vomiting, after laparoscopic cholecystectomy, irrespective of its pre- or post-induction application.

Improving the quality of mental health care

OBJECTIVE

To develop international guidance for improving the quality of mental health care in low- and middle-income countries.

DESIGN

A panel developed recommendations based on a comprehensive literature review, consultation with over 100 experts from 46 countries and an analysis of international best practices. Recommendations A 5-pronged approach to improving the quality of mental health care is recommended. Quality improvement requires the alignment of policy and legislation with the attainment of good quality mental health outcomes. Key partners must be brought into the quality improvement process. Funding can be an important tool for promoting good quality but needs to be correctly aligned to meet policy objectives and to promote evidence-based interventions. Accreditation procedures and quality standards need to be carefully developed and resources allocated for their implementation. Finally, quality improvement must be brought into routine service management and delivery.

CONCLUSIONS

Through a systematic approach to quality improvement, it is possible to ensure that the best possible interventions are provided within the constraints of each country and that the rights and well-being of people with mental disorders is optimally promoted. Quality improvement is not a luxury but an integral part of ensuring that the best possible services are provided to all who need them.