Using a systems thinking approach to explore the complex relationships between schizophrenia and premature mortality.

BACKGROUND: People with schizophrenia have a higher risk of mortality compared to the general population, which has not improved over time. The majority of premature deaths are due to comorbid physical diseases, driven by interrelated factors operating at the individual level, through health systems and influenced by social determinants of health. A holistic understanding of this problem and the causal pathways linking these factors together is lacking. AIMS: This study aims to understand why the mortality gap between people with schizophrenia and the general population is not improving by developing a causal loop diagram (CLD), a systems thinking approach which enables empirical research and theoretical knowledge to be combined into a visual representation of causal relationships and feedback loops. METHOD: The CLD was constructed using published literature, including both quantitative and qualitative studies, to identify key variables and relationships, and refined through consultation with experts in the topic area. RESULTS: A total of 21 variables and 68 connections were included in the CLD, with 23 distinct feedback loops identified. Stigma and social support had the most connections, while unemployment was involved in the greatest number of feedback loops. Most feedback mechanisms served to reinforce behavioural risk factors, inadequate healthcare and social disadvantage. CONCLUSIONS: The CLD has created a holistic and dynamic understanding of the causal pathways driving the mortality gap between people with schizophrenia and the general population, providing insights into why it has persisted over time. One of the key findings was the critical role of social determinants in shaping health outcomes, highlighting the need for person-centred models of care and multisectoral government action.

"I am not a Good Woman?" Exploring the Views and Challenges of Nurses When Discussing HPV Testing and Associated Cervical Screening with Women in Iraq.

Introduction: Cervical cancer is mostly caused by high-risk Human papillomavirus HPV, with an estimation prevalence of HPV of 99.7% worldwide. The US Food and Drug Administration (FDA) approved an HPV test for primary cervical screening in 2014. An HPV-DNA test, which provides higher protection against invasive cervical carcinomas, is replacing the long-standing Pap smear as the primary method of cervical cancer screening. Objective: To explore nurses' experience and knowledge of HPV DNA testing and how screening impacts on women's health through increasing awareness and proposing actions for health education strategies. Method: A qualitative exploratory study was conducted on a purposeful sample of 25 qualified nurses, who were all employed in regional hospitals within a gynecological department in Kirkuk, Iraq. The nurses were interviewed with a semi-structured topic guide between November 2021 and February 2022. Responses were transcribed verbatim, translated into English and analysed using a content thematic analysis approach. Results: Four themes with associated sub-themes emerged following coding and peer review. Participants had lack of experience and fragmented knowledge of HPV DNA testing/screening. Culturally sensitive resources for patients and training for nurses was identified key requirements. Conclusions: Currently, there are no facilities for a HPV testing/screening services available in Iraq. The role of nurses undertaking HPV screening is not established and yet nurses represent the largest sector of health professionals. The dissemination of a collaborative HPV screening training programme to include clinical competence and knowledge for nurses and gynaecologists may improve knowledge, and could also be effective in improving patient awareness and engagement with cervical health.

The clinical implications of climate change for mental health.

Climate change affects mental health through multiple pathways, including direct and indirect impacts, physical health and awareness of the climate crisis. Climate change increases the magnitude and frequency of extreme events with little or no time for recovery. This Review aims to provide an overview of the current evidence to inform the mental health field's response to climate change. While further innovation is needed, promising approaches for health professionals are identified at the levels of interventions for individuals, community and system-wide responses, and advocacy and education. Health worker training is important, so we offer guidance on mental health assessment and clinical risks from climate change. We also outline strategies to enhance individual and community psychological resilience and promising approaches to working with people experiencing emerging climate-related disorders. Beyond clinical care, mental health professionals can lead on climate action and sustainability in health care and can research and educate on the health effects of climate change.

Excess mortality in severe mental disorders: A systematic review and meta-regression.

The excess mortality observed in people with severe mental disorders (SMD) has not improved over time and is not captured in estimates of disease burden. This study aimed to improve upon previous analytic approaches to account for potential sources of heterogeneity in pooled mortality estimates. A systematic review of studies examining excess mortality in people with psychotic disorders and bipolar disorder was conducted. PubMed, EMBASE and PsycINFO were searched from January 1, 1980 to 31/12/20. Studies were eligible if they were longitudinal; the study population was diagnosed according to established criteria, not restricted to subgroups and the disorder was primary and not acute or transient; and mortality was reported in comparison to the general population or a control group without SMD. Meta-regression models were used to calculate pooled relative risks (RRs) of all-cause and cause-specific mortality adjusted for study- and population-level covariates. Risk of bias was assessed using an adaptation of the Newcastle-Ottawa scale. A total of 76 studies were included in the analyses. Covariates incorporated into the final models included age, sex, population type and mid-year. The adjusted RR for all-cause mortality in schizophrenia was 2.89 (95% CI 2.50 to 3.34) and 2.51 (95%CI 2.10 to 3.00) for bipolar disorder. There were larger RRs for broader categories of psychotic disorders. Mortality was elevated in each cause of death examined. Most of the heterogeneity between studies could not be accounted for. Future research should investigate underlying causal pathways and find ways to incorporate the excess mortality associated with SMD into global health estimates.

Global priorities for climate change and mental health research.

BACKGROUND: Compared with other health areas, the mental health impacts of climate change have received less research attention. The literature on climate change and mental health is growing rapidly but is characterised by several limitations and research gaps. In a field where the need for designing evidence-based adaptation strategies is urgent, and research gaps are vast, implementing a broad, all-encompassing research agenda will require some strategic focus. METHODS: We followed a structured approach to prioritise future climate change and mental health research. We consulted with experts working across mental health and climate change, both within and outside of research and working in high, middle, and low-income countries, to garner consensus about the future research priorities for mental health and climate change. Experts were identified based on whether they had published work on climate change and mental health, worked in governmental and non-governmental organisations on climate change and mental health, and from the professional networks of the authors who have been active in the mental health and climate change space. RESULTS: Twenty-two experts participated from across low- and middle-income countries (n = 4) and high-income countries (n = 18). Our process identified ten key priorities for progressing research on mental health and climate change. CONCLUSION: While climate change is considered the biggest threat to global mental health in the coming century, tackling this threat could be the most significant opportunity to shape our mental health for centuries to come because of health co-benefits of transitioning to more sustainable ways of living. Research on the impacts of climate change on mental health and mental health-related systems will assist decision-makers to develop robust evidence-based mitigation and adaptation policies and plans with the potential for broad benefits to society and the environment.

Global estimates of service coverage for severe mental disorders: findings from the WHO Mental Health Atlas 2017.

BACKGROUND: The study estimated service coverage for severe mental disorders (psychosis, bipolar disorder and moderate-severe depression), globally and regionally, using data collected from the Mental Health Atlas 2017. METHODS: Service coverage was defined as the proportion of people with a disorder contacting a mental health service among those estimated to have the disorder during a 12-month period. We drew upon 12-month service utilisation data from the Mental Health Atlas 2017. Expected prevalent cases of individual disorders were estimated using the disorder-specific prevalence rate estimates of the Global Burden of Disease Study 2016 and total population sizes. Methods for assessing the validity of country-reported service utilisation data were developed and applied. OUTCOMES: From 177 countries, 50 countries provided reliable service coverage estimates for psychosis, along with 56 countries for bipolar disorder, and 65 countries for depression. The mean service coverage for psychosis was lowest in low- [10.9% (95% confidence interval (CI) 3.3-30.4)] and lower middle-income countries [21.5% (95% CI 11.9-35.7)] and highest in high-income countries [59.5% (95% CI 42.9-74.1)]. Service coverage for bipolar disorder ranged between 3.1% (95% CI 0.8-11.5) and 10.4% (95% CI 6.7-15.8). Mean service coverage for moderate-severe depression ranged between 2.9% (95% CI 1.3-6.3) for low-income countries and 31.1% (95% CI 18.3-47.6) for high-income countries. INTERPRETATION: The reporting method utilised by the Mental Health Atlas appears to be reliable for psychosis but not for depression. This method of estimating service coverage provides progress in tracking an important indicator for mental health; however, it highlights that considerable work is needed to further develop global mental health information systems.

"We don't have up to date knowledge about the disease" Practical challenges encountered in delivery of cervical cancer screening in Iraq.

This qualitative study aimed to explore the lived experience of medical doctors in delivering cervical cancer screening in a city in Iraq. METHODS: An applied grounded theory approach explored the reported experiences of doctors in the field. A purposive sample of 12 gynaecologists and one general practitioner (GP) working in two main hospitals participated: Semi-structured interviews took place from June to September 2015. Thematic coding of data was peer reviewed and included participant reading of transcripts and translations from Arabic to English. Theory generation involved synthesis of a prior literature review and interview findings. RESULTS: Gynaecologist and GP experiences showed overwhelming gaps in cervical cancer experience and screening. Iraqi women mainly presented for help with late-stage cancer. Practical barriers included cultural stigma, low priority for women's health needs, lack of knowledgeable leadership and perceived shortage of adequately trained staff. CONCLUSION: There is an urgent need for culturally appropriate cervical cancer prevention policies and strategies in Iraq, focused on evidence-based population-based cervical screening to identify and prevent advanced cervical cancer among women. Regional educational initiatives should be encouraged and primary healthcare systems supported to undertake screening.

Climate Change and Mental Health: A Scoping Review.

Climate change is negatively impacting the mental health of populations. This scoping review aims to assess the available literature related to climate change and mental health across the World Health Organisation's (WHO) five global research priorities for protecting human health from climate change. We conducted a scoping review to identify original research studies related to mental health and climate change using online academic databases. We assessed the quality of studies where appropriate assessment tools were available. We identified 120 original studies published between 2001 and 2020. Most studies were quantitative (n = 67), cross-sectional (n = 42), conducted in high-income countries (n = 87), and concerned with the first of the WHO global research priorities-assessing the mental health risks associated with climate change (n = 101). Several climate-related exposures, including heat, humidity, rainfall, drought, wildfires, and floods were associated with psychological distress, worsened mental health, and higher mortality among people with pre-existing mental health conditions, increased psychiatric hospitalisations, and heightened suicide rates. Few studies (n = 19) addressed the other four global research priorities of protecting health from climate change (effective interventions (n = 8); mitigation and adaptation (n = 7); improving decision-support (n = 3); and cost estimations (n = 1)). While climate change and mental health represents a rapidly growing area of research, it needs to accelerate and broaden in scope to respond with evidence-based mitigation and adaptation strategies.

Integrative review of cervical cancer screening in Western Asian and Middle Eastern Arab countries.

Population-based screening programs have resulted in minimizing mortality and morbidity from cervical cancer. The aim of this integrative review was to explore the factors influencing access of women from Western Asian and Middle Eastern Arab countries to cervical cancer screening. A systematic search for studies conducted in Arab countries in those regions, and published in English between January 2002 and January 2017, was undertaken. Thirteen papers were selected and subjected to quality appraisal. A three step analysis was used, which involved a summary of the evidence, analysis of both quantitative and qualitative data, and integration of the results in narrative form. Few population-based cervical cancer screening programs had been implemented in the relevant countries, with low knowledge of, and perceptions about, cervical screening among Arab women, the majority of whom are Muslim. Factors affecting the uptake of cervical cancer screening practices were the absence of organized, systematic programs, low screening knowledge among women, healthcare professionals' attitudes toward screening, pain and embarrassment, stigma, and sociocultural beliefs. Policy changes are urgently needed to promote population-based screening programs. Future research should address the promotion of culturally-sensitive strategies to enable better access of Arab Muslim women to cervical cancer screening.