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.

Contribución de una estrategia de atención centrada en la persona con multimorbilidad al Modelo de Atención Integral de Salud Familiar y Comunitario en Chile / Contribution of a multimorbidity person-centered care strategy to the Comprehensive Family and Community Healthcare Model in Chile

BACKGROUND: The Multimorbidity Person-Centered Care Model allows to customize care according the needs of each person. AIM: To characterize the perception of health teams about the contribution of the Multimorbidity Person-Centered Care Model (MACEP) to the development of the key principles of the Comprehensive Family and Community Health Care Model (MAIS). MATERIAL AND METHODS: A qualitative collaborative study with 35 interviews and the participation of 67 professionals from the primary healthcare network. Content analysis using mixed code system with MAXQDA2020 program. RESULTS: The innovations and complex interventions that positively affect the development and implementation of the essential principles of MAIS were recognized by participants as a contribution of the central elements of MACEP. CONCLUSIONS: This contribution is an opportunity for the expeditious implementation of Family Health principles in the health network. Incorporating the vision of implementers and users, who are part of these changes, is essential. It is necessary to establish, project and evaluate innovations to identify, implement and promote learning at Health Services throughout the country.

Programa de Acción Mundial para Superar las Brechas en Salud Mental (mhGAP) en Chile: aprendizajes y desafíos para América Latina y el Caribe / Mental Health Global Action Programme (mhGAP) in Chile: Lessons Learned and Challenges for Latin America and the Caribbean / Programa de ação mundial para reduzir as lacunas em saúde mental (mhGAP) no Chile: aprendizados e desafios para América Latina e Caribe

RESUMEN Objetivos. Presentar la metodología de evaluación integral de la implementación del Programa de Acción Mundial para Superar las Brechas en Salud Mental (mhGAP) en Chile y exponer sus resultados. Métodos. Estudio evaluativo de corte transversal basado en una encuesta a referentes clave del programa, desplegados en los 29 servicios públicos de salud del país, y entrevistas individuales y grupos focales con actores clave y expertos. El foco de la evaluación estuvo en la relevancia e impacto del mhGAP en la prestación de servicios de salud mental y en la implementación del programa. Resultados. Los participantes evaluaron positivamente la implementación progresiva del mhGAP en Chile, en particular: 1) manifestaron contar con mejores herramientas de detección, diagnóstico y tratamiento de trastornos frecuentes, y estrategias eficientes de derivación; 2) calificaron todos los módulos como importantes; los más relevantes fueron autolesión/suicidio (x¯ = 4,77) y trastornos mentales y conductuales del niño y el adolescente (x¯ = 4,58); 3) evaluaron favorablemente las Jornadas Nacionales y sus réplicas y su contribución al éxito de la implementación del mhGAP; 4) coincidieron en la necesidad de incorporar nuevos actores, fortalecer algunos aspectos y ampliar la información sobre el programa. Conclusiones. La implementación del mhGAP en Chile constituye un caso emblemático de aprendizaje, apoyado por el desarrollo de la salud mental comunitaria y la salud familiar, entre otros factores. Lo logrado abre una oportunidad única para continuar avanzando en la implementación de este programa en el país y transmitir esta experiencia a otros contextos de América Latina y el Caribe.

ABSTRACT Objectives. Present the methodology for comprehensive evaluation of the implementation of the Mental Health Global Action Programme (mhGAP) in Chile and describe the program's results. Methods. Cross-sectional evaluative study based on a survey of key program informants deployed in 29 public health services in the country, as well as individual interviews and focus groups with key actors and experts. The evaluation was focused on the relevance and impact of mhGAP on the provision of mental health services and on the implementation of the program. Results. The participants gave a positive evaluation of the progressive implementation of mhGAP in Chile. In particular: 1) They reported having better tools for detecting, diagnosing, and treating common disorders, and efficient referral strategies; (2) They rated all modules as important, the most relevant being self-harm/suicide (x¯ = 4.77) and mental and behavioral disorders in children and adolescents (x¯ = 4.58); (3) They favorably assessed the National Mental Health Day training courses and the subsequent courses repeated at the local level, indicating that these courses contributed to successful implementation of mhGAP; (4) They agreed on the need to incorporate new actors, strengthen certain aspects, and expand information on the program. Conclusions. The implementation of mhGAP in Chile is an emblematic example of learning supported by the development of community mental health and family health, among other factors. These accomplishments offer a unique opportunity to continue advancing the implementation of this program in the country and to implement this experience in other contexts in Latin America and the Caribbean.

RESUMO Objetivos. Apresentar a metodologia de avaliação completa da implementação do Programa de ação mundial para reduzir as lacunas em saúde mental (Mental Health GAP, mhGAP) no Chile e descrever seus resultados. Métodos. Estudo avaliativo transversal baseado em levantamento realizado com profissionais de referência do programa, distribuídos em 29 serviços de saúde da rede pública do país, e entrevistas individuais e grupos focais com as principais partes interessadas e especialistas. O enfoque da avaliação foi a relevância e o impacto do mhGAP na prestação de serviços de saúde mental e a implementação do programa. Resultados. Os participantes do estudo avaliaram positivamente a implementação progressiva do mhGAP no Chile. Em particular, 1) eles afirmaram possuir recursos melhores para detecção, diagnóstico e tratamento de transtornos frequentes e estratégias de encaminhamento eficientes; 2) classificaram todos os módulos como importantes, com destaque a autoagressão/suicídio (x¯ = 4,77) e transtornos mentais e de comportamento em crianças e adolescentes (x¯ = 4,58); 3) avaliaram de forma favorável a realização das Jornadas Nacionais de Saúde Mental e suas iterações em nível local contribuindo ao sucesso da implementação do mhGAP e 4) concordaram com a necessidade de atrair mais interessados, reforçar alguns aspectos e ampliar a divulgação do programa. Conclusões. A implementação do mhGAP no Chile é um caso emblemático de aprendizado apoiado no avanço da saúde mental comunitária e saúde da família, entre outros fatores. Esta conquista cria uma oportunidade única para continuar a expandir a implementação do programa no país e disseminar esta experiência a outros contextos na América Latina e Caribe.

Stigma towards people with mental disorders: perceptions of devaluation and discrimination in a sample of Chilean workers / Estigma hacia personas con trastornos mentales: percepciones de devaluación y discriminación en una muestra de trabajadores chilenos

Abstract Introduction Mental disorders represent one of the main causes of disease burden in the adult population. Negative public attitudes and behaviors toward people with mental disorders negatively affect the treatment, recovery, and social inclusion of those affected. Chile laks surveys on workers that address this issue. Objective To describe the perceptions of devaluation and discrimination towards people with mental disorders in a sample of Chilean workers. Method A cross-sectional study was carried out with 1 516 workers in the formal sector of four regions of Chile (Metropolitan Region [RM], Bío Bio [VIII], Valparaíso [V] and Coquimbo [IV]). The perception of discrimination and devaluation was explored through a modified version of the The perceived Devaluation-Discrimination Scale (PDD) comprising 15 questions. The relationship of each question with sociodemographic variables (age, sex, years of study, and region) and type of economic activity was assessed. Results The study found a high percentage of perceptions of devaluation and discrimination in most aspects considered, particularly those related to hiring a person who has been hospitalized due to a mental illness (85%), feeling sorry for people with severe mental illnesses (80%), and the unwillingness to marry a person with a mental illness (78%). Significant differences were observed in the opinions by sociodemographic variables and region of residence. Discussion and conclusion The perception of Chilean workers has high levels of stigma towards people living with mental disorders. It is necessary and urgent to develop effective anti-stigma public policies to promote a more inclusive, tolerant society.

Resumen Introducción Los trastornos mentales representan una de las principales causas de carga de morbilidad en la población adulta. Las actitudes y conductas públicas negativas hacia las personas con trastornos mentales inciden negativamente en el tratamiento, la recuperación e inclusión social de las personas afectadas. Chile no cuenta con encuestas en trabajadores que aborden este tema. Objetivo Describir las percepciones de devaluación y discriminación hacia personas con trastornos mentales en una muestra de trabajadores chilenos. Método Se realizó un estudio transversal con 1 516 trabajadores del sector formal de cuatro regiones de Chile (Región Metropolitana [RM], de Bío Bio [VIII], de Valparaíso [V] y de Coquimbo [IV]). Se exploró la percepción de discriminación y devaluación por medio de una versión modificada de la Perceived Devaluation-Discrimination Scale (PDD) con 15 preguntas. Se analizó la relación de cada pregunta con variables sociodemográficas (edad, sexo, años de estudio y región) y tipo de actividad económica. Resultados Se detectó un alto porcentaje de percepción de devaluación y discriminación en la mayoría de los aspectos considerados, destacándose los relacionados con la contratación de una persona que ha sido hospitalizada por una enfermedad mental (85%), sentir pena por las personas con enfermedades mentales graves (80%) y el rechazo a casarse con una persona que tenga una enfermedad mental (78%). Se observaron diferencias significativas en las percepciones, según las variables sociodemográficas y las relativas a la región de residencia. Discusión y conclusión La percepción de los trabajadores en Chile muestra altos niveles de estigma social hacia personas con trastornos mentales. Es necesario y urgente desarrollar políticas públicas antiestigma efectivas, promoviendo al mismo tiempo una sociedad más inclusiva y tolerante.

Apoyo social percibido en pacientes con Hipertensión Arterial y Diabetes Mellitus tipo II en Atención Primaria y su relación con autopercepción de salud / Social support, self-rated health, treatment adherence and effectiveness in patients with type II diabetes and hypertension

Background: A high level of social support (SS) is associated with better health outcomes in many conditions, such as chronic diseases. Aim : To describe the level of SS in patients with Hypertension and type II Diabetes at Primary Health Care level in Chile and its association with self-rated health, adherence to treatment and better glycemic and blood pressure control. Material and Methods : SS was measured using a social support inventory previously validated in Chile. Self-Rated Health was assessed with a single non-comparative general question; adherence to medication was assessed using the four-item Morisky medication adherence scale. Blood glucose and blood pressure control were also assessed. A logistic regression was performed to estimate Prevalence Odds Ratio (POR) and Robust Poisson method to estimate the Prevalence Ratio (PR). Results : Eighty three percent of the 647 participants evaluated high for SS. There was a significant correlation between SS and Self-rated health (POR 2.32; 95% confidence intervals (CI) 1.19-11.23; PR 1.18; 95% CI 1.07-1.31). No statistically significant association was observed with medication adherence, glycemic or blood pressure control. Conclusions: High levels of SS were found. The association between self-rated health suggests that SS interventions targeting vulnerable subgroups would be worthwhile.

Estrategias innovadoras para el cuidado y el autocuidado de personas con enfermedades crónicas en América Latina / Innovative care and self-care strategies for people with chronic diseases in Latin America

OBJETIVOS: Identificar estrategias innovadoras dirigidas a mejorar el cuidado y el autocuidado de los pacientes con enfermedades crónicas (EC) en América Latina y explorar el interés en crear una red latinoamericana de profesionales en ese campo. MÉTODOS: Estudio descriptivo exploratorio basado en una encuesta aplicada a expertos clave con reconocido liderazgo nacional o regional en la atención de pacientes con EC. El cuestionario de 25 preguntas recababa información sobre su experiencia en iniciativas de cuidado y autocuidado de pacientes con EC, la descripción de las iniciativas exitosas, la percepción de la capacidad de los países para innovar en este ámbito y el interés en participar en una red de profesionales latinoamericanos en ese campo, entre otras. Se realizó un análisis de contenidos para elaborar recomendaciones para la Región. RESULTADOS: Se obtuvo respuesta de 17 (37,8 por ciento) de los 45 expertos invitados; 82,4 por ciento afirmó conocer o participar en alguna iniciativa innovadora en el tema planteado. Existe un incipiente desarrollo de los tres tipos de estrategias innovadoras: cuidado por pares, cuidadores informales y telecuidado, esta última es la menos explorada. Hay un real interés en conformar una red latinoamericana para el desarrollo de estrategias innovadoras dirigidas al autocuidado de pacientes con EC. CONCLUSIONES: Las bases para una red de trabajo conjunto son promisorias y es prioritario fortalecer las competencias en esta área y desarrollar propuestas innovadoras para mejorar la atención de los pacientes con EC en la Región. Las medidas innovadoras deben ser complementarias y se deben ajustar al contexto específico de cada escenario.

OBJECTIVES: To identify innovative strategies for improved care and self-care of patients with chronic diseases (CD) in Latin America and to explore interest in creating a Latin American network of professionals in this field. METHODS: A descriptive study based on a survey of key experts with recognized national or regional leadership in CD patient care. The 25-question questionnaire sought information on their experiences with care and self-care initiatives for CD patients, descriptions of successful initiatives, the perceived ability of countries to innovate in this area, their interest in participating in a network of Latin American professionals in this field, and more. Content analysis was performed to develop recommendations for the Region. RESULTS: Responses were obtained from 17 (37.8 percent) of the 45 experts approached; 82.4 percent confirmed their knowledge of of involvement with an innovative initiative related to the subject. Initial development does exist in each of the three innovative strategy types: peer care, informal caregivers, and telenursing, the latter being the least explored. There is real interest in forming a Latin American network that focuses on development of innovative self-care strategies for CD patients. CONCLUSIONS: Support for a joint network is promising. Priorities are building skills in this area and developing innovative proposals for improved CD patient care in the Region. Innovative measures should be complementary and adapted to the specific context of each scenario.

Capital social y salud en América Latina y el Caribe: una revisión sistemática: [revisão] / Social capital and health in Latin America and the Caribbean: a systematic review: [revision]

OBJETIVO: Identificar la información validada disponible sobre la relación entre el capital so cial (CS) y la salud en América Latina y el Caribe (ALC). MÉTODOS: Se realizó una búsqueda sistemática de los trabajos publicados entre enero de 1990 y junio de 2007 en las bases de datos Medline, SciELO, LILACS y The Cochrane Library. Se analizaron todos los artículos de investigación y revisión publicados en revistas científicas, que evaluaran el CS y su relación con la salud en ALC. RESULTADOS: Se encontraron 15 artículos (11 de investigación original y 4 de revisión). Las áreas de salud exploradas por las investigaciones originales fueron: a) mortalidad y esperanza de vida, b) salud mental, c) traumas, d) estado nutricional y e) vacunación. Se analiza detalla damente la validez de estos trabajos, sus resultados y principales conclusiones. CONCLUSIONES: A pesar de las limitaciones propias del concepto de CS y de los estudios iden tificados, se puede afirmar que existe evidencia científica incipiente de la posible relación entre el CS y la salud en ALC. El CS podría desempeñar un papel protector en ciertas áreas sanita rias, como la prevención de traumas y la salud mental; no obstante, la relación entre el CS y la salud podría variar según los subtipos de CS y los contextos socioeconómicos y culturales es pecíficos. Resulta fundamental continuar desarrollando investigaciones en el ámbito de la epi demiología social, en las que se analice en profundidad la relación entre los determinantes so ciales y los aspectos específicos de la salud en el contexto de ALC.

OBJECTIVE: To identify validated information available on the relationship between social capital (SC) and health in Latin America and the Caribbean (LAC). METHODS: A systematic search for papers published from January 1990-June 2007 was conducted on the Medline, SciELO, LILACS, and the Cochrane Library databases. All of the research and review articles published by scientific journals that evaluated CS and its relationship to health in LAC were included in the analysis. RESULTS: Fifteen articles were found (11 original research and 4 reviews). The health topics examined by the research articles were: (a) mortality and life expectancy, (b) mental health, (c) injuries, (d) nutritional status, and (e) immunization. The validity of these works, the results, and the principal conclusions were analyzed in depth. CONCLUSIONS: Despite limitations inherent to the CS concept and the studies identified, it was confirmed that scientific evidence exists to support the possible association between CS and health in LAC. CS could play a protective role in certain health areas, such as injury prevention and mental health; not withstanding, the relationship between CS and health could vary according to CS subtype and socioeconomic context and culture. It is therefore imperative to continue social epidemiology research that thoroughly investigates the relationship between social determinants and specific aspects of health in LAC context.

Capital social y salud mental en comunidades urbanas de nivel socioeconómico bajo, en Santiago, Chile: Nuevas formas de entender la relación comunidad-salud / Social capital and mental health in low income urban communities in Santiago, Chile

Many studies suggest that social capital, defined as those intangible resources of a society or community (trust, participation and reciprocity), that might facilitate collective action, can be associated with positive health effects. Aim: To explore the relationship between social capital an the level of mental health, in urban communities of Santiago, Chile. Material and methods: In a qualitative-quantitative cross-sectional design, two low income neighborhoods in the municipality of Puente Alto were selected. Interviews to key agents and focus groups, as well as surveys (407) to adults from a representative random sample of households, were conducted, measuring social capital, using a locally devised questionnaire and mental health using the General Health Questionnaire (GHQ-12 instrument). A qualitative analysis based on the ®grounded theory¼ and a quantitative analysis through correlations and simple and logistic regression models were applied. Results: The quantitative analysis found an association between female gender, education and having a chronic disease, with low levels of mental health. At the same time, the trust component of social capital might be associated with a better mental health status. Qualitatively, all the components of social capital were identified as important for a better mental health. Conclusions: This study suggests the existence of a positive relationship between social capital and mental health. Developing trust in a community might be a useful tool to work in mental health at the community level.

Capital social y promoción de la salud en América Latina / Social capital and health promotion in Latin America

América Latina enfrenta problemáticas de desarrollo y salud comunes. La equidad y la superación de la pobreza son cruciales en la búsqueda de soluciones integrales y de alto impacto. El artículo analiza el concepto de capital social, su relación con salud, sus limitaciones y potencialidades, desde una perspectiva de desarrollo comunitario y promoción de salud en América Latina. También, se identifican desafíos prioritarios, como la medición y fortalecimiento del capital social. Se discute cómo y por qué el capital social pudiera ser crítico en una estrategia global de promoción de la salud, donde el empoderamiento y la participación comunitaria, el trabajo interdisciplinario e intersectorial permitirían avanzar en los objetivos de salud pública y en la concreción de un cambio social sustentable. Igualmente, se identifican algunas de las potenciales limitaciones del concepto de capital social en el contexto de promoción de la salud en América Latina.

Latin America faces common development and health problems and equity and overcoming poverty are crucial in the search for comprehensive and high impact solutions. The article analyzes the definition of social capital, its relationship with health, its limitations and potentialities from a perspective of community development and health promotion in Latin America. High-priority challenges are also identified as well as possible ways to better measure and to strengthen social capital. Particularly, it is discussed how and why social capital may be critical in a global health promotion strategy, where empowerment and community participation, interdisciplinary and intersectorial work would help to achieve Public Health aims and a sustainable positive change for the global development. Also, some potential limitations of the social capital concept in the context of health promotion in Latin America are identified.