Community-based Mental Healthcare: A Case Study in a Cross-border Region of Germany and the Netherlands.

BACKGROUND: Community-based mental healthcare (CBMH) aims at supplying psychiatric patients with rehabilitative care outside the hospital. The aim of this study was to compare the organization of CBMH in a cross-border region of Germany and the Netherlands. METHOD: Semi-structured interviews gave insight into characteristics of CBMH approaches applied in the German region of Aachen (IHP) and the Dutch Province of Limburg (FACT). We applied a Delphi technique to select a performance indicator (PI) set for CBMH, which served as a conceptual model to allow comparison. RESULTS: Both approaches are flexible, patient-centred and include the evaluation of quality. Both provide financial and administrative support for the access. CONCLUSION: CBMH approaches appear to be equally valid from several perspectives even if they revealed, at the same time, important differences related to scope, integration with non-CBMH care resources and geographic coverage. Secondarily, the study provides a contribution to the development of a PI set to compare and evaluate CBMH approaches.

Cross-Border Capacity Assessment in Dementia Care.

Within the Euregio Meuse-Rhine, cross-border cooperation in the healthcare sector has taken place on different occasions and at different levels. However, it still proving to be difficult to have an overview of the existing structures and activities of Euregio in specific healthcare fields, such as for instance, dementia care. The aim of this study is to examine to what extent cooperation in the Dutch province of Limburg in the field of dementia care can be considered Euregionally oriented. In order to create more cross-border transparency within the Euregional dementia care field, we conducted a capacity assessment analysis. Capacity assessment is the first step in the further development of healthcare capacities by mapping current as well as desired capacities. Although we related the model as applied in this study explicitly to dementia care in the Euregio Meuse-Rhine, the model could be applicable in other cross-border settings and/or healthcare fields as well. Despite the apparently well-functioning system of regional dementia care networks in the Dutch province of Limburg, none of the respondents declared to have structural contacts with similar organizations in the other (German and Belgian) parts of the Euregio. Moreover, many of our respondents argued that cross-border cooperation in the field of dementia care could be interesting in various ways, but at the same time there is currently no direct necessity to actively pursue such cooperation. Despite the absence of structural cross-border cooperation initiatives in the field of dementia care in the Euregio Meuse-Rhine, some suggestions can be made for the formulation of a potential capacity development response on the basis of the results of the capacity assessment as conducted in this study (showing gaps between current and desired capacities). Even if it is subsequently decided not to formulate a concrete capacity development response (for example due to the lack of a mutual objective need amongst organizations to engage in cross-border cooperation), a capacity assessment offers at the least a reflection on an organization's own performance as well as providing transparency between organizations. The main opportunities for the formulation of a capacity development response on a Euregional level in the field of dementia care are related to knowledge development and the creation of partnerships.

Shared decision making in the safety net: where do we go from here?

BACKGROUND: Shared decision making (SDM) is an interactive process between clinicians and patients in which both share information, deliberate together, and make clinical decisions. Clinics serving safety net patients face special challenges, including fewer resources and more challenging work environments. The use of SDM within safety net institutions has not been well studied. METHODS: We recruited a convenience sample of 15 safety net primary care clinicians (13 physicians, 2 nurse practitioners). Each answered a 9-item SDM questionnaire and participated in a semistructured interview. From the transcribed interviews and questionnaire data, we identified themes and suggestions for introducing SDM into a safety net environment. RESULTS: Clinicians reported only partially fulfilling the central components of SDM (sharing information, deliberating, and decision making). Most clinicians expressed interest in SDM by stating that they "selected a treatment option together" with patients (8 of 15 in strong or complete agreement), but only a minority (3 of 15) "thoroughly weighed the different treatment options" together with patients. Clinicians attributed this gap to many barriers, including time pressure, overwhelming visit content, patient preferences, and lack of available resources. All clinicians believed that lack of time made it difficult to practice SDM. CONCLUSIONS: To increase use of SDM in the safety net, efficient SDM interventions designed for this environment, team care, and patient engagement in SDM will need further development. Future studies should focus on adapting SDM to safety net settings and determine whether SDM can reduce health care disparities.

Toward best-practice post-disaster mental health promotion for children: Sri Lanka.

There is a pressing need for low-cost intervention models to promote mental health among children in the wake of natural disasters. This article describes an evaluation of one such model: the Happy/Sad Letter Box (HSLB) Project, a mental health promotion intervention designed to minimize trauma in children, resulting from the Indian Ocean tsunami of 26 December 2004. The HSLB Project was implemented in 68 schools in Sri Lanka's Hambantota District from April 2005 forward. Methods included questionnaires (n = 203), interviews, and group consultation with schoolchildren, teachers, teacher counsellors, principals, educational zone directors and parents. The HSLB intervention was seen as relevant and non-stigmatized, cost-effective if implemented after initial recovery steps, anecdotally effective in identifying and helping resolve trauma, accommodating the full range of children's daily stressors and sustainable. Gender, children's age, school size and the level of the tsunami impact for response were found to correlate with response differences. Along four dimensions previously identified in the literature (ability to triage, matching of intervention timing and focus, ability to accommodate a range of stressors and context compatibility), the HSLB Project is a promising intervention model (1) for children; (2) at group-level; (3) relating to natural disasters. The Nairobi Call to Action [WHO (2009) Nairobi Call to Action for Closing the Implementation Gap in Health Promotion. Geneva: World Health Organization] emphasized the importance of mainstreaming health promotion into priority programme areas, specifically including mental health. The HSLB Project represents the integration of health promotion practice into disaster preparedness mental health infrastructure.

The ecological approach in health promotion programs: a decade later.

PURPOSE: Present a 10-year update of the ecologic model of health promotion published by Richard et al. in the American Journal of Health Promotion in 1996. APPROACH: We adapted and simplified the model by leaving out settings, focusing on levels, and incorporating interpersonal and individual levels and agents that are in control of environmental conditions. SETTING: Health care facilities, schools, workplaces, living environments, and public environments were represented in program descriptions. PARTICIPANTS: Forty-three program coordinators responsible for 47 programs were interviewed in the United States and The Netherlands. METHODS: A systematic interview protocol elicited general program descriptions and relevant aspects of the ecologic approach. Program aspects from written reports were coded by the authors into levels, interventions, targets, and strategies. RESULTS: The programs had 234 strategies and 276 targets, with a mean of 2.15 levels. Twenty-seven distinct intervention strategies were identified, with the most common being modification of an organization to which the at-risk individuals belong, followed by policy and community changes. CONCLUSION: Our data fit the ecologic model and our adaptations and indicate that over the past decade health promotion practice may have changed to include more multilevel programs. Systematic analysis of program strategies within and across environmental levels allows better understanding of the social ecology of health-related behavior and potential leverage points for change.

How to change environmental conditions for health

Since the Lalonde report, contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. They are also important for public-health because environments are the complex systems through which people are both empowered and exercise their empowerment. If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific envionmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article first presents one such analytical instrument. Then, building on examples relating to socio-economic health inequities, the analytical instrument is applied to reveal how it can add value to health professionals' effectiveness in planning intervention for more health-promoting environments.(AU)

How to change environmental conditions for health

Since the Lalonde report, contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. They are also important for public-health because environments are the complex systems through which people are both empowered and exercise their empowerment. If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific environmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article first presents one such analytical instrument. Then, building on examples relating to socio-economic health inequities, the analytical instrument is applied to reveal how it can add value to health professionals' effectiveness in planning interventions for more health-promoting environments.(AU)

How to change environmental conditions for health.

Since the Lalonde report, contemporary public-health theory has given steadily more attention to the role of environments in influencing health status. Environments, both social and physical, influence health directly or through complex interactions with behavior, genetics and health-care systems. They are also important for public-health because environments are the complex systems through which people are both empowered and exercise their empowerment. If public-health professionals are to play a significant role in influencing environments for health, they need analytical instruments that enable them to link specific environmental conditions with the actions necessary to improve them. These instruments must also enable public-health professionals to identify points of leverage for stimulating key actors to take the actions necessary to make environments more promoting of health. This article first presents one such analytical instrument. Then, building on examples relating to socio-economic health inequities, the analytical instrument is applied to reveal how it can add value to health professionals' effectiveness in planning interventions for more health-promoting environments.