Psychosocial health in adolescent unmarried motherhood in rural Uganda: Implications for community-based collaborative mental health education, and empowerment strategies in the prevention of depression and suicide.

Teenage pregnancy rates in Uganda are among the highest in sub-Saharan Africa. Child marriage is often the result of unmarried teenage pregnancy and is recognised by Uganda's government as a form of sexual violence and an outcome of inequality. However, unmarried motherhood incurs stigma and shame within traditionally living rural communities. Using co-produced Open Space and ethnographic methods, we examined the psychosocial impact of unmarried motherhood on girls and their communities, and explored problem-solving with key local stakeholders. Findings indicate that girls experience extreme stress, social exclusion and rejection by their families, and experience bereavement from school expulsion and the loss of their career aspirations. Depressive symptoms and suicidal behaviour are reportedly not uncommon among this population group. Community and family efforts to promote marriage for these mothers to avoid social stigma increased the mothers' feelings of depression, whereas mothers who became independent appeared to fare better psychologically. Community members and local stakeholders demonstrated a willingness to act locally to reduce the negative impacts of unmarried motherhood but lacked knowledge and support resources. Our findings indicate that mental health promotion for teenage mothers is likely to be better served through empowerment strategies rather than marriage and, in a context of poor mental health service access, there is a substantial role for community mobilisation and the promotion of self-help strategies to support teenage mothers. This study raises important points regarding different community understandings of depression and indicates collaboration between professionals and communities for a values-based approach.

Hyperacute stroke and the specialist nursing impact: exploring the cause and context of feelings of secondary traumatic stress - a qualitative inquiry.

Background: Secondary traumatic stress (STS) has been defined as the stress resulting from helping or wanting to help a traumatised or suffering person. The hyperacute nature of stroke specialist nurses' work places them at risk of developing STS. Aims: To explore the factors that are influential in stroke specialist nurses' experience of STS development within hyperacute practice. Methods: This study is qualitative with a narrative design. Data were collected from a purposive sample of stroke specialist nurses (20 female and 2 male) working in hyperacute services during the years 2016 and 2017. Data were analysed using Polkinghorne's approach. Results: This research identified four themes: exposure to acute suffering and death- young presentations; moral distress; interactions with relatives and problematic healthcare systems. Conclusion: The findings from this study suggest that stroke specialist nurses are exposed to multiple triggers which are commensurate with the potential for STS development. The findings contribute a new understanding of the emotional burden of hyperacute specialist stroke nursing that has implications for patient safety and satisfaction, services provision and staff well-being.

'I'm getting the balls to say no': Trajectories in long-term recovery from problem substance use.

This study uses individualisation theory to explore identity transition in substance misuse recovery. Identity narratives gained over 4 years from co-produced video/audio interview and video diary accounts were co-productively collected and analysed using framework analysis. Results indicate a trend towards individualistic and agentic identity as recovery trajectories progress over time. Within-case analysis demonstrates agentic growth for most participants, from early-stage gratitude and reliance on support groups to self-determination and independent decision-making. This early work exploring longer-term recovery adds to the current recovery and social identity discussion and provides evidence of identity growth in longer-term stages of recovery.

A hermeneutical study of professional accountability in nursing.

AIMS AND OBJECTIVES: This paper presents findings from a hermeneutical study which sought to explore how registered nurses experienced and perceived their professional accountability in clinical settings. BACKGROUND: Professional accountability encompasses the ideals and standards of nursing practice. Nurses are accountable for their actions under civil, criminal and contract law to their; employing organisation, their regulatory body and the patients for whom they care. DESIGN: This paper reports on a Heideggerian hermeneutical study involving seven registered nurses, working in clinical practice in the National Health Service in the United Kingdom. Methods The study adopted purposive sampling, collecting data by means of in-depth interviews. Data were analysed using the hermeneutic circle. COREQ checklist was used as a reporting guideline for this study. RESULTS: The findings suggest that professional accountability in nursing practice is a complex phenomenon, which can be compromised by many factors which are historically, socially or politically driven Participants experienced challenges through a lack of resources and poor managerial support, which compromised their ability to deliver high-quality patient care. However, collegiality strongly impacted upon resilience and positively influenced their well-being. RELEVANCE TO CLINICAL PRACTICE: Amid the challenges of the clinical workplace, a positive workplace culture with visible managerial support is a fundamental requirement in supporting professional accountability, development and retention of nurses. Findings highlight the view that leadership should be seen as a collective responsibility, which empowers staff to positively change the practice environment.

Poles apart: does the export of mental health expertise from the Global North to the Global South represent a neutral relocation of knowledge and practice?

The World Health Organization's Mental Health Action Plan 2013-2020 identifies actions for all member states to alleviate the global burden of mental ill health, including an obligation for mental healthcare to be delivered in a 'culturally appropriate' manner. In this article we argue that such a requirement is problematic, not least because such pronouncements remain framed by the normative prepositions of Western medical and psychological practice and their associated ethical, legal and institutional standpoints. As such, when striving to export Western mental health expertise, different paradigms for evidence will be necessary to deliver locally meaningful interventions to low and middle income countries. Our discussion highlights a number of philosophical concerns regarding methodologies for future research practice, including those relating to representation and exclusion in the guise of epistemic injury, presumptive methodologies arising from Western notions of selfhood, and related ethical issues.

An evaluation of the strengths and weaknesses of a register of newly diagnosed rheumatoid arthritis, 1986-2010.

OBJECTIVES: To evaluate the strengths and weaknesses of a register of management and outcomes of recently diagnosed RA, and allow comparisons between rheumatology centres on good clinical practice and guidelines. METHODS: A register of newly diagnosed RA was initiated in 1986 in nine different regions of England, later expanded to UK-wide membership in 2002. Standardized data collection includes disease activity, function, radiological damage, therapy, hospitalizations, major comorbidity and mortality. A centralized database generates individual reports and comparative data for each centre yearly. Aims have been compared with actual achievements and any changes over 25 years. RESULTS: Thirty rheumatology centres have recruited 2866 patients. Study outputs have included peer-reviewed scientific publications and contributions to the recent National Audit Office report on RA. Referral times into secondary care have changed little over 25 years, but time to initiation of drug therapies has decreased. Delays between publication of clinical trial evidence and management guidelines and their implementation in normal clinical practice are illustrated by relatively infrequent use of combination therapies at diagnosis. Consecutive case recruitment, centre participation and follow-up were reportedly compromised by local funding issues. Centre participants report a benefit from feedback of actual clinical practice compared with recommended standards of care. CONCLUSIONS: Most of the original objectives have been achieved. Cohort studies based predominantly in District General Hospitals provide unique insights into the natural history and impact of RA, its management, the translation of research findings into clinical practice and provide participating centres with important clinical governance and professional development opportunities.

Interstitial lung disease has a poor prognosis in rheumatoid arthritis: results from an inception cohort.

OBJECTIVES: Pulmonary complications of RA are well described. Although some are benign, interstitial lung disease (ILD) has a poor prognosis. Few RA inception cohorts have reported the natural history of ILD related to RA (RA-ILD). We examine its incidence, outcome and prognostic indicators. METHODS: Extra-articular features and comorbidity have been recorded yearly in a well-established inception cohort of RA with a 20-year follow-up. Standard clinical, laboratory and radiological measures of RA were recorded at baseline and yearly. Details of deaths were provided by a national central register. RESULTS: Out of 1460 patients, 52 developed RA-ILD, half either at baseline or within 3 years of onset. The annualized incidence was 4.1/1000 (95% CI 3.0, 5.4) and the 15-year cumulative incidence 62.9/1000 (95% CI 43.0, 91.7). Incidence of RA-ILD was associated with older age, raised baseline ESR and HAQ. Evidence to implicate any drug effect (e.g. MTX) was lacking. Of these patients, 39 died, attributed to RA-ILD in 28. Median survival following diagnosis of RA-ILD was 3 years. CONCLUSIONS: RA-ILD is an important and early feature of RA. It is related to disease activity and has a poor prognosis. Further studies are required to determine whether screening for pulmonary disease would identify these patients at an earlier stage.