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.

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.

Mental health stigma: what is being done to raise awareness and reduce stigma in South Africa?

OBJECTIVE

Stigma plays a major role in the persistent suffering, disability and economic loss associated with mental illnesses. There is an urgent need to find effective strategies to increase awareness about mental illnesses and reduce stigma and discrimination. This study surveys the existing anti-stigma programmes in South Africa.

METHOD

The World Health Organization's Assessment Instrument for Mental Health Systems Version 2.2 and semi-structured interviews were used to collect data on mental health education programmes in South Africa.

RESULTS

Numerous anti-stigma campaigns are in place in both government and non-government organizations across the country. All nine provinces have had public campaigns between 2000 and 2005, targeting various groups such as the general public, youth, different ethnic groups, health care professionals, teachers and politicians. Some schools are setting up education and prevention programmes and various forms of media and art are being utilized to educate and discourage stigma and discrimination. Mental health care users are increasingly getting involved through media and talks in a wide range of settings. Yet very few of such activities are systematically evaluated for the effectiveness and very few are being published in peer-review journals or in reports where experiences and lessons can be shared and potentially applied elsewhere.

CONCLUSION

A pool of evidence for anti-stigma and awareness-raising strategies currently exists that could potentially make a scientific contribution and inform policy in South Africa as well as in other countries.

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.

Meaningfulness as an epistemologic concept for explicating the researcher's constitutive part in phenomenologic research

In his philosophy, Husserl gave us the epistemologic concept of intentionality. In phenomenologic research, intentionality can be understood in a practical way as our connections to the phenomena that we are studying. When phenomenologic data are the transcripts of interviews, our connections can be seen during data analysis as we identify passages in transcripts that stand out as personally meaningful. Tracing back through our past experiences to the origins of that meaningfulness provides us with a picture of the preunderstanding, assumptions, and beliefs that contribute to our unique perception of the phenomena that we are studying. Concrete guidelines are given for initiating the process of discovering one's constitutive part in phenomenologic studies.

Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly

OBJECTIVES

To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes.

DESIGN

Retrospective chart review.

SETTING

ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon.

PARTICIPANTS

All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2).

MEASUREMENTS

POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life.

RESULTS

The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes.

CONCLUSIONS

POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

Encountering violence and aggression in mental health nursing: a phenomenological study of tacit caring knowledge

Violence is a growing psychosocial problem in the health care working environment. Literature shows that nurses are physically assaulted, threatened, and verbally abused more often than other professionals. However, some nurses are able to relate to clients in a way that produces positive resolution. This study explored the phenomenon of positive encounters with aggressive and violent clients. Guided by a phenomenological method, data were analyzed within a lifeworld perspective. The essential meaning of the phenomenon of caregivers' experiences of encountering violent clients is described as an "embodied moment," which is explicated by seven themes of meaning, "respecting one's fear and respecting the client," "touch," "dialogue," "situated knowledge," "stability," "mutual regard," and "pliability." The authors discuss the meaning of the outcome and propose both theory and praxis-oriented activities toward decreasing aggression and violence in health care.

Expanding self-awareness through exploration of meaningful experience

In a phenomenological investigation of nurses' meaningful experiences with patients, the author continued investigation of caregiver/patient interaction reported in two previous studies of confirmation and exclusion. Exploration of meaningful experience is presented as an avenue for greater self-awareness for the caregiver. Findings include description of study participants' lived meaningful experiences and the essential structures of experiencing meaningfulness. The lived meaningful experiences were characterized by intense emotion, implicit experiencing, and relating. The essential structures of experiencing meaningfulness were found to be a temporal process of reflecting and articulating the discovery of self and the function of meaningful experience as a template for both future and past experiences. Expanded self-understanding through exploration of meaningful experience is discussed for its significance in nursing practice and education.

A lifeworld paradigm for nursing research

This article is a companion to an earlier article entitled "Challenging a Reductionistic Paradigm as a Foundation for Nursing," which appeared in the December 1995 issue of the Journal of Holistic Nursing. The authors discuss how five concepts-encounter, openness, immediacy, uniqueness, and meaning-which constitute their philosophy for nursing practice, also comprise a foundation for human sciences research. In the first article, encounter was presented as the core concept for practice. In the present work, openness is the central idea in a lifeworld research paradigm, with encounter, immediacy, uniqueness, and meaning as supporting concepts. Openness is explicated with the notions of open-mindedness, open-heartedness, phenomenological questioning, and preunderstanding. A lifeworld paradigm for research is based on phenomenological philosophy and the understanding that the conduct of research is guided by the researcher's openness to the phenomena of the everyday world.

Thrombus precursor protein (TpP): marker of thrombosis early in the pathogenesis of myocardial infarction

We have developed an enzyme-linked immunosorbent immunoassay for quantifying the immediate precursor proteins to intravascular thrombi. This thrombus precursor protein (TpP) assay identifies active thrombosis in several clinical conditions, including early myocardial infarction (MI). In a study of patients recruited for the GUSTO intervention study, MI patients had concentrations of TpP 4-20-fold that of controls; patients diagnosed without MI had concentrations similar to the control subjects. In a separate study of subjects presenting at the emergency room with chest pain, MI patients who presented early after the onset of chest pain had TpP concentrations significantly (P <0.01) higher than controls. Patients presenting late or diagnosed with other chest pain had concentrations within the reference range. The potential utility of the TpP assay as an aid for the diagnosis of thrombotic MI and other thrombotic conditions is described.

Thrombus precursor protein (TpP): marker of thrombosis early in the pathogenesis of myocardial infarction

We have developed an enzyme-linked immunosorbent immunoassay for quantifying the immediate precursor proteins to intravascular thrombi. This thrombus precursor protein (TpP) assay identifies active thrombosis in several clinical conditions, including early myocardial infarction (MI). In a study of patients recruited for the GUSTO intervention study, MI patients had concentrations of TpP 4-20-fold that of controls; patients diagnosed without MI had concentrations similar to the control subjects. In a separate study of subjects presenting at the emergency room with chest pain, MI patients who presented early after the onset of chest pain had TpP concentrations significantly (P &lt;0.01) higher than controls. Patients presenting late or diagnosed with other chest pain had concentrations within the reference range. The potential utility of the TpP assay as an aid for the diagnosis of thrombotic MI and other thrombotic conditions is described.

Challenging a reductionistic paradigm as a foundation for nursing

Historically, nursing practice has been grounded in the objective, analytic philosophy of the natural sciences. Over the past decades, caring--a humanistic concept--has been espoused as the essence of nursing. Paradoxically, practice based on the theme of caring remains aligned with the philosophy of the natural sciences and continues to use tools such as nursing process and nursing diagnosis, products of the natural sciences paradigm. The authors have outlined the foundation for a philosophy of caring. The encounter between caregiver and patient is the central aspect of this philosophy and is elaborated with the related concepts of openness, nonreductionism, immediacy, and meaning. In addition, holistic nursing practice requires attention by caregivers to their own self-awareness and the personal growth that is necessary for the demands of encountering patients. Practice based on such a philosophy maintains the primacy of the caregiver-patient relationship and permits the incorporation of analytic tools without depersonalizing effects.

Reenactment interviewing: a methodology for phenomenological research

Reenactment is proposed as an alternative interviewing strategy for phenomenological research. Three techniques borrowed from the psychodramatic method, warming up, scene-setting and soliloquy, are described as they were used in interviews with nurses participating in a study of caregiver/patient relationships. The rationale for and implementation of the techniques are discussed. Indications of successful reenactment during an interview are described and discussed. The data suggest that skillfully directed reenactment can generate intensely vivid recall of memories experiences and emotions, engendering rich descriptions of participants' lived experience and subsequently, produces significant dialogue between interviewer and participant. Parallels are drawn between phenomenological research/philosophy and the philosophy of action upon which psychodramatic techniques are based.

Combating the SOCIAL ISOLATION of Chronic Mental Illness

1. The diminished mental and emotional resources suffered by those with chronic mental illness (CMI) often lead to impoverished relationships that fail to produce satisfying connections with others. As a result, persons with CMI are frequently chronically lonely. 2. Moreno's sociometric principles and psychodramatic techniques for group therapy provide ways to increase interconnectedness with others by interrupting the self-reinforcing aspects of social isolation. 3. Role reversal, self-presentation, psychodramatic encounter, and sociometric exercises facilitate expanded emotional repertoire, let members know each other, provide relief from emotional distress, and produce information about the group needed to generate interaction.