Co-locating public mental health services in communities: a realist evaluation

Background

Public mental health (PMH) services address social determinants of mental health, such as poverty, poor housing, and job insecurity. Austerity and welfare reform in the UK has led to cuts to social and welfare support, increasing poor mental health and widening inequalities, exacerbated by COVID-19. State health services lack capacity to tackle social issues that contribute to a large proportion of expressed mental health need. Co-locating PMH services within community spaces is a potential solution to increase early access and improve quality of services. Using a realist evaluation, we sought to develop the theory on how community co-location affects PMH outcomes, who this works best for, and how this is impacted by the context of delivery.

Methods

We collected data from service-users and service-providers at six case study sites across England, UK, using interviews (n = 62), four focus groups (n = 40) and two stakeholder workshops (n = 19).

Results

We identified four overarching theories. First, community providers do not operate under the same limits as state services allowing them the flexibility and time to build trust and ongoing relationships with service users. Second, the ethos and culture of services is to empower users to access help and be independent. Third, accessing support from a shared local space allows a coordinated and holistic response reducing barriers such as distance, cost, and anxiety. Four, as they are recreational services and spaces for access by all with no predefined/required level of need they are better at promoting wellbeing and primary prevention.

Conclusions

Community co-location of PMH services can strengthen the overall mental health system by widening reach to people vulnerable to poor mental health and enabling earlier intervention on associated social determinants. This has potential to reduce mental health inequalities and demand on the state health system.

Key messages

Community interventions for improving adult mental health: mapping local policy and practice in England

BACKGROUND

Public mental health (PMH) aims to improve wellbeing and prevent poor mental health at the population level. It is a global challenge and a UK priority area for action. Communities play an important role in the provision of PMH interventions. However, the evidence base concerning community-based PMH interventions is limited, meaning it is challenging to compare service provision to need. Without this, the efficient and equitable provision of services is hindered. Here, we sought to map the current range of community-based interventions for improving mental health and wellbeing currently provided in England to inform priority areas for policy and service intervention.

METHOD

We adopted an established mapping exercise methodology, comparing service provision with demographic and deprivation statistics. Five local authority areas of England were selected based on differing demographics, mental health needs and wider challenging circumstances (i.e. high deprivation). Community-based interventions were identified through: 1) desk-based research 2) established professional networks 3) chain-referral sampling of individuals involved in local mental health promotion and prevention and 4) peer researchers' insight. We included all community-based, non-clinical interventions aimed at adult residents operating between July 2019 and May 2020.

RESULTS

407 interventions were identified across the five areas addressing 16 risk/protective factors for PMH. Interventions for social isolation and loneliness were most prevalent, most commonly through social activities and/or befriending services. The most common subpopulations targeted were older adults and people from minority ethnic backgrounds. Interventions focusing on broader structural and environmental determinants were uncommon. There was some evidence of service provision being tailored to local need, though this was inconsistent, meaning some at-risk groups such as men or LGBTQ+ people from minority ethnic backgrounds were missed. Interventions were not consistently evaluated.

CONCLUSIONS

There was evidence of partial responsiveness to national and local prioritising. Provision was geared mainly towards addressing social and individual determinants of PMH, suggesting more integration is needed to engage wider service providers and policy-makers in PMH strategy and delivery at the community level. The lack of comprehensive evaluation of services to improve PMH needs to be urgently addressed to determine the extent of their effectiveness in communities they serve.

Community interventions improving mental health in minority ethnic adults in the UK: a scoping review

Background

Black, Asian and Minority Ethnic (BAME) groups in the UK are disproportionately affected by poor mental health. This scoping review sought to determine the effectiveness of community interventions designed to improve the metal health and wellbeing of adults from BAME groups in the UK.

Methods

We searched six electronic academic databases for studies published between 1990- 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the Template for Intervention description and replication (TIDieR) guide was used for data extraction and intervention descriptions. Quality was assessed using Cochrane Risk of Bias tools. Grey literature results were deemed beyond the scope of this review; numerous (>50) small scale community interventions were found without available outcomes data.

Results

Of 4,501 studies, seven met the inclusion criteria: four randomised control trials, one pre and post pilot study, one cross sectional study and one ethnographic study. Interventions included therapy-style sessions, peer-support groups, educational materials, gym access, and a family services programme. Common components included a focus on tackling social isolation, using lay health workers from within the community, signposting, and cultural adaptation. Only three studies reported a statistically significant positive outcome on mental health and six were appraised as having a high risk of bias. Knowledge gaps emerged around effective interventions for men, some BAME groups, and tackling the wider determinants of mental health.

Conclusions

There is a paucity of high-quality evidence on community interventions focussed on improving public mental health among BAME groups. Decision makers need scientific evidence to inform effective approaches to mitigating health disparities. Our next steps are to map promising community activities and interventions that are currently being provided to help identify emerging evidence.

Key messages

Evidence is limited and weak on community interventions that reduce mental health burden among minority ethnic people. Evaluation of promising interventions at scale can close the evidence gap.

Anopheles parensis contributes to residual malaria transmission in South Africa

BACKGROUND

Understanding the contribution of outdoor-resting Anopheles mosquitoes to residual malaria transmission is important in terms of scaling up vector control towards malaria elimination in South Africa. The aim of this project was to assess the potential role of Anopheles parensis and other Anopheles species in residual malaria transmission, using sentinel surveillance sites in the uMkhanyakude District of northern KwaZulu-Natal Province.

METHODS

Monthly vector surveillance was conducted at the sentinel sites from January 2017 to May 2018. Outdoor-placed clay pot resting traps were used to collect male and female adult Anopheles mosquitoes. All Anopheles gambiae complex and Anopheles funestus group specimens collected were identified to species and all females were screened for Plasmodium falciparum circumsporozoite protein (CSP) by enzyme-linked immunosorbent assay (ELISA). Samples showing infectivity for P. falciparum were further verified by a nested PCR and subsequent DNA sequence analysis.

RESULTS

From a sample of 491 anophelines, Anopheles arabiensis (n = 228) and An. parensis (n = 194) were the most abundant. Other species collected included Anopheles merus (n =11), Anopheles quadriannulatus (n = 10), Anopheles leesoni (n = 29), Anopheles rivulorum (n =18), and Anopheles vaneedeni (n =1). Of the 317 female specimens screened for P. falciparum CSP, one Anopheles arabiensis and one An. parensis showed positive by ELISA and Plasmodium nested PCR. For the An. parensis specimen, confirmation of its species identity was based on sequence analysis of the ITS2 region, and the presence of P. falciparum DNA was further confirmed by sequence analysis.

CONCLUSIONS

Anopheles parensis is a potential vector of malaria in South Africa although its contribution to transmission is likely to be minimal at best owing to its strong zoophilic tendency. By contrast, An. arabiensis is a major vector that is primarily responsible for the bulk of residual malaria transmission in South Africa. As all recently collected sporozoite-positive Anopheles mosquitoes were found in outdoor-placed resting traps, it is necessary to introduce interventions that can be used to control outdoor-resting vector populations while maintaining the efficacy of South Africa's indoor house spraying operations.

The management of ischaemic and periampuation pain

This article describes the development and pilot application of a management tool designed to support healthcare practitioners in the management of ischaemic and periamputation pain. The ischaemic management periamputation care (IMPAC) guidelines have been piloted in the authors' clinical area and early results suggest that there are positive benefits accruing to patients and ward staff.

Clinical nurse specialists in acute pain management

Specialist practitioner and ward-based nursing roles should complement each other. Clinical nurse specialists have an important educational role in helping nurses to assess their own practice. Specialist services to manage acute pain should provide an integrated service to prevent the fragmentation of care.

A follow-up study of adults with learning disabilities and epilepsy

A programme to review the drug treatment of 215 adults with epilepsy and learning disabilities occurred in Leicestershire between 1982 and 1985. In 1997, a Leicestershire-wide study of epilepsy suffered by adults with learning disabilities was undertaken. The study sought information about many aspects of the epilepsy including the prescribing of medicines. One hundred and thirty-eight adults were common to both studies. A greater proportion was suffering active epilepsy in 1997 than in 1985. The deterioration in seizure control occurred despite an increase in polypharmacy, the introduction of new antiepileptic drugs and in some cases increases in dosage.

Epilepsy in adults with learning disabilities

Epilepsy is a common problem of adults with learning disabilities. Despite the high prevalence there have been few studies of the epilepsy suffered by adults with learning disabilities. The findings of a Leicestershire study are that multiple seizure types are a common presentation, and that for many (75%) the seizures remain refractory to treatment. Those who suffer tonic-clonic seizures are most likely to achieve remission, whereas for those with simple or complex partial seizures the prognosis is poor. For a significant proportion, status epilepticus, emergency admission to hospital and injuries occur on a regular basis.

Cystic fibrosis in adult life: a study of coping patterns

Despite comparable degrees of physical disability, some patients with cystic fibrosis (CF) cope more successfully than others with the difficulties of competitive adult life. This study found substantial differences between a coping and non-coping sample of adult CF patients. Non-copers had twice as many hospital admissions as copers over a year, even though their ventilatory function was better. The non-coping sample compared unfavourably with the copers in four main spheres of psychosocial functioning--their vocational records; level of family support; awareness of anomalies in sexual function; and knowledge about CF.

"Satellite" haemodialysis

Thirty of the 39 patients treated at the Blacktown Dialysis Centre, the first "satellite" dialysis centre in the greater metropolitan Sydney, had been referred from four Sydney renal units for long-term dialysis therapy. The move save approximately 150 kilometres in travelling and eight hours time each week for each of these patients. The cost of running the unit was approximately $10,000 per patient per year in the first year--no greater than that of home dialysis, and less than that of dialysis in a teaching hospital. The advantages of establishing satellite dialysis centre, the method of operation, and the results of the first year of operation of the Blacktown Dialysis Centre are described.