Understanding the barriers to integrating maternal and mental health at primary health care in Vietnam

The prevalence of common perinatal mental disorders in Vietnam ranges from 16.9% to 39.9%, and substantial treatment gaps have been identified at all levels. This paper explores constraints to the integration of maternal and mental health services at the primary healthcare level and the implications for the health system's responsiveness to the needs and expectations of pregnant women with mental health conditions in Vietnam. As part of the RESPONSE project, a three-phased realist evaluation study, we present Phase One findings which employed systematic and scoping literature reviews, and qualitative data collection (focus groups and interviews) with key health system actors, in Bac Giang province, Vietnam, to understand the barriers to maternal mental healthcare provision, utilisation, and integration strategies. A four-level framing of the barriers to integrating perinatal mental health services in Vietnam was used in reporting findings, which comprised individual, socio-cultural, organisational, and structural levels. At the socio-cultural and structural levels, these barriers included: cultural beliefs about the holistic notion of physical and mental health, stigma towards mental health, biomedical approach to healthcare services, absence of comprehensive mental health policy, and a lack of mental health workforce. At the organisational level, there was absence of clinical guidelines on the integration of mental health in routine antenatal visits, a shortage of staff, and poor health facilities. Finally, at the provider level, a lack of knowledge and training on mental health was identified. The integration of mental health into routine antenatal visits at the primary care level has the potential help to reduce stigma towards mental health and improve health system responsiveness by providing services closer to the local level, offering prompt attention, better choice of services, and better communication while ensuring privacy and confidentiality of services. This can improve the demand for mental health services and help reduce the delay of care-seeking.

CONQUER Scleroderma: association of gastrointestinal tract symptoms in early disease with resource utilization

OBJECTIVES

SSc is associated with increased health-care resource utilization and economic burden. The Collaborative National Quality and Efficacy Registry (CONQUER) is a US-based collaborative that collects longitudinal follow-up data on SSc patients with <5 years of disease duration enrolled at scleroderma centres in the USA. The objective of this study was to investigate the relationship between gastrointestinal tract symptoms and self-reported resource utilization in CONQUER participants.

METHODS

CONQUER participants who had completed a baseline and 12-month Gastrointestinal Tract Questionnaire (GIT 2.0) and a Resource Utilization Questionnaire (RUQ) were included in this analysis. Patients were categorized by total GIT 2.0 severity: none-to-mild (0-0.49); moderate (0.50-1.00), and severe-to-very severe (1.01-3.00). Clinical features and medication exposures were examined in each of these categories. The 12-month RUQ responses were summarized by GIT 2.0 score categories at 12 months.

RESULTS

Among the 211 CONQUER participants who met the inclusion criteria, most (64%) had mild GIT symptoms, 26% had moderate symptoms, and 10% severe GIT symptoms at 12 months. The categorization of GIT total severity score by RUQ showed that more upper endoscopy procedures and inpatient hospitalization occurred in the CONQUER participants with severe GIT symptoms. These patients with severe GIT symptoms also reported the use of more adaptive equipment.

CONCLUSION

This report from the CONQUER cohort suggests that severe GIT symptoms result in more resource utilization. It is especially important to understand resource utilization in early disease cohorts when disease activity, rather than damage, primarily contributes to health-related costs of SSc.

What can one legitimately expect from a health system? A conceptual analysis and a proposal for research and action

In 2007, the WHO proposed the Building Blocks Framework and articulated 'responsiveness' as one of the four goals for health systems. While researchers have studied and measured health systems responsiveness since, several aspects of the concept remain unexamined, including, understanding the notion of 'legitimate expectations'-a notion central to the definition of responsiveness. We begin this analysis by providing a conceptual overview of how 'legitimacy' is understood in key social science disciplines. Drawing on insights from this overview, we examine how 'legitimacy' is understood in the literature on health systems responsiveness and reveal that there is currently little critical engagement with this notion of the 'legitimacy' of expectations. In response, we unpack the concept of 'legitimate' expectations and propose approaches and areas for reflection, research, and action. We conclude that contestation, and ongoing negotiation of entrenched health system processes and norms which establish citizens' 'legitimate' expectations of health systems, is needed-through processes that ensure equitable and wide participation. We also call on researchers, in their capacity as key health policy actors, to trigger and initiate processes and help create equitable spaces for citizens to participate in establishing 'legitimate' expectations of health systems.

A critical interpretive synthesis of migrants' experiences of the Australian health system

While the health of and healthcare use by migrants has received significant scholarly and policy attention in Australia, current debates highlight that a critical examination of the theoretical underpinnings of these inquiries and responses is needed. We conducted a systematic review and critical interpretive synthesis (CIS) to critically examine how the policy and scholarly literature conceptualises migrants' interactions with and experiences of the Australian health system. Guided by PRISMA, we searched for literature without imposing any limits. We also searched key State and Federal Government websites for relevant policy documents. Our initially broad inclusion criteria became refined as the CIS progressed. We prioritised the likely relevance and theoretical contribution of the papers to our inquiry over methodological quality. The CIS of 104 papers revealed that the Australian scholarly literature and policy documents consistently homogenise and reduce migrants according to an assumed, (1) cultural identity, (2) linguistic affiliation, and/or (3) broad geographic origin. Based on these three critiques and drawing on the theoretical literature, we propose a synthesising argument on how the Australian literature could better conceptualise migrants' experiences of the Australian health system. We contend that both research and policy should explicitly recognise and engage with the multifaceted and shifting ways that migrants define themselves, generally, and during their encounters with destination country health systems. Engagement with this notion is necessary for also understanding how aspects of migrants' identities are dynamically co-constructed during their interactions with the health system. These understandings have implications for improving the design and implementation of policies and programs directed at improving the responsiveness of Australia's health system to the needs and expectations of migrant communities specifically, and destination countries broadly.

Chronic activation of pDCs in autoimmunity is linked to dysregulated ER stress and metabolic responses

Plasmacytoid dendritic cells (pDCs) chronically produce type I interferon (IFN-I) in autoimmune diseases, including systemic sclerosis (SSc) and systemic lupus erythematosus (SLE). We report that the IRE1α-XBP1 branch of the unfolded protein response (UPR) inhibits IFN-α production by TLR7- or TLR9-activated pDCs. In SSc patients, UPR gene expression was reduced in pDCs, which inversely correlated with IFN-I-stimulated gene expression. CXCL4, a chemokine highly secreted in SSc patients, downregulated IRE1α-XBP1-controlled genes and promoted IFN-α production by pDCs. Mechanistically, IRE1α-XBP1 activation rewired glycolysis to serine biosynthesis by inducing phosphoglycerate dehydrogenase (PHGDH) expression. This process reduced pyruvate access to the tricarboxylic acid (TCA) cycle and blunted mitochondrial ATP generation, which are essential for pDC IFN-I responses. Notably, PHGDH expression was reduced in pDCs from patients with SSc and SLE, and pharmacological blockade of TCA cycle reactions inhibited IFN-I responses in pDCs from these patients. Hence, modulating the IRE1α-XBP1-PHGDH axis may represent a hitherto unexplored strategy for alleviating chronic pDC activation in autoimmune disorders.

Peoples' expectations of healthcare: A conceptual review and proposed analytical framework

Expectations shape how one experiences the healthcare one receives. In this paper we argue that the current conceptualisations of expectations within the healthcare literature have much to gain from the many recent and adjacent conceptual developments in other disciplines. The concept of expectations has been extensively studied across disciplines - we review the key texts on the subject in the business, management, social psychology, and sociology literatures to provide a conceptual overview and propose an integrative analytical framework for better understanding individuals' expectations in healthcare. We argue that peoples' expectations of a care encounter are usefully understood as being shaped by their social locations at particular points of time, which is at the intersection of multiple social structures and relations. Peoples' future expectations of care may also be influenced by the experiences of past and current care encounters, framed again by intersecting social structures and relations at that point in time. We demonstrate how an intersectional, translocational and relational analytical approach can allow researchers and practitioners to consider how peoples' social locations shape their expectations of care, not only within a given social environment, but at certain points in time and over time. We emphasise that, given the mobilities and mixing societies are experiencing globally, such an approach is particularly useful for understanding healthcare-related expectations and experiences of all.

Low dose computed tomography in suspected acute renal colic

AIM

To evaluate whether computed tomography (CT) of the renal tract in suspected renal colic using reduced exposure factors maintains diagnostic accuracy.

METHODS

Prospective multi-centre cohort study. Patients with suspected renal colic were examined using computed tomography (CT) of the renal tract followed by intravenous urography (IVU) in four different centres with five different CT systems.

RESULTS

Sixty-nine patients with suspected renal colic had CT of the renal tract followed by IVU. CT was performed with reduced exposure factors, giving a mean CT effective dose of 3.5 (range 2.8-4.5) mSv compared with 1.5 mSv for IVU. Ureteric calculi were detected in 43 patients: CT and IVU detected 40 (93%) ureteric calculi. CT identified other lesions causing symptoms in five patients and identified renal calculi in 24 patients. IVU identified renal calculi in six patients and made false positive diagnosis of renal calculi in seven patients. Mean examination time for CT was 5 minutes and for IVU was 80 minutes.

CONCLUSION

CT examination at reduced exposure factors maintains the diagnostic accuracy recorded in other series.