Community-oriented System Research Articles

Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services

BackgroundItaly can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).MethodsA set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions.RESULTS31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments.ConclusionsHealthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.

Explore pre-hospital emergency challenges in the face of the COVID-19 pandemic: A quality content analysis in the Iranian context.

Backgroundpre-hospital emergency is a community-oriented system that responds to the medical needs of the injured or patients with acute and emergency illnesses outside of health care facilities until they are transferred to a medical center. This study aimed to explore pre-hospital emergency challenges in the face of the COVID-19 pandemic.Material and methodsThis study was conducted as a qualitative content analysis in Iran. Using the purposive sampling method, data were collected through in-depth individual interviews with 28 prehospital paramedic personnel from November 2020 to November 2021. Graneheim and Lundman's conventional content analysis methods were used to analyze the data and for the trustworthiness of the data, this study used Lincoln and Guba's recommendations.ResultsAfter multiple rounds of analyzing and summarizing the data and taking into consideration similarities and differences, four main categories and 10 subcategories were created based on the results of the data analysis and including (1) Culture and Community. (2) Service delivery (3) Human resources; (4) Medical supplies and equipment.ConclusionAccording to the findings of this study emergency medical system employees are suffering from a range of psychiatric problems as a result of a lack of equipment and job overload, which has a detrimental impact on the quality of pre-hospital emergency care. Therefore, emergency care senior management should develop comprehensive guidelines, provide more equipment and minimize professional challenges to improve the quality and safety of pre-hospital emergency care services.

Standard comparison of local mental health care systems in eight European countries

There is a need of more quantitative standardised data to compare local Mental Health Systems (MHSs) across international jurisdictions. Problems related to terminological variability and commensurability in the evaluation of services hamper like-with-like comparisons and hinder the development of work in this area. This study was aimed to provide standard assessment and comparison of MHS in selected local areas in Europe, contributing to a better understanding of MHS and related allocation of resources at local level and to lessen the scarcity in standard service comparison in Europe. This study is part of the Seventh Framework programme REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care in Europe) project. A total of eight study areas from European countries with different systems of care (Austria, England, Finland, France, Italy, Norway, Romania, Spain) were analysed using a standard open-access classification system (Description and Evaluation of Services for Long Term Care in Europe, DESDE-LTC). All publicly funded services universally accessible to adults (≥18 years) with a psychiatric disorder were coded. Care availability, diversity and capacity were compared across these eight local MHS. The comparison of MHS revealed more community-oriented delivery systems in the areas of England (Hampshire) and Southern European countries (Verona - Italy and Girona - Spain). Community-oriented systems with a higher proportion of hospital care were identified in Austria (Industrieviertel) and Scandinavian countries (Sør-Trøndelag in Norway and Helsinki-Uusimaa in Finland), while Loiret (France) was considered as a predominantly hospital-based system. The MHS in Suceava (Romania) was still in transition to community care. There is a significant variation in care availability and capacity across MHS of local areas in Europe. This information is relevant for understanding the process of implementation of community-oriented mental health care in local areas. Standard comparison of care provision in local areas is important for context analysis and policy planning.

Cumulative incidence of childhood autism: a total population study of better accuracy and precision

Most studies on the frequency of autism have had methodological problems. Most notable of these have been differences in diagnostic criteria between studies, degree of cases overlooked by the initial screening, and type of measurement. This study aimed to replicate the first report on childhood autism to address cumulative incidence as well as prevalence, as defined in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) Diagnostic Criteria for Research. Here, the same methodological accuracy (exactness of a measurement to the true value) as the first study was used, but population size was four times larger to achieve greater precision (reduction of random error). A community-oriented system of early detection and early intervention for developmental disorders was established in the northern part of Yokohama, Japan. The city's routine health checkup for 18-month-old children served as the initial mass screening, and all facilities that provided child care services aimed to detect all cases of childhood autism and refer them to the Yokohama Rehabilitation Center. Cumulative incidence up to age 5 years was calculated for childhood autism among a birth cohort from four successive years (1988 to 1991). Cumulative incidence of childhood autism was 27.2 per 10 000. Cumulative incidences by sex were 38.4 per 10 000 in males, and 15.5 per 10 000 in females. The male: female ratio was 2.5:1. The proportions of children with high-functioning autism who had Binet IQs of 70 and over and those with Binet IQs of 85 and over were 25.3% and 13.7% respectively. Data on cumulative incidence of childhood autism derived from this study are the first to be drawn from an accurate, as well as precise, screening methodology.

Cumulative incidence of childhood autism: a total population study of better accuracy and precision

Most studies on the frequency of autism have had methodological problems. Most notable of these have been differences in diagnostic criteria between studies, degree of cases overlooked by the initial screening, and type of measurement. This study aimed to replicate the first report on childhood autism to address cumulative incidence as well as prevalence, as defined in the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) Diagnostic Criteria for Research. Here, the same methodological accuracy (exactness of a measurement to the true value) as the first study was used, but population size was four times larger to achieve greater precision (reduction of random error). A community-oriented system of early detection and early intervention for developmental disorders was established in the northern part of Yokohama, Japan. The city's routine health checkup for 18-month-old children served as the initial mass screening, and all facilities that provided child care services aimed to detect all cases of childhood autism and refer them to the Yokohama Rehabilitation Center. Cumulative incidence up to age 5 years was calculated for childhood autism among a birth cohort from four successive years (1988 to 1991). Cumulative incidence of childhood autism was 27.2 per 10000. Cumulative incidences by sex were 38.4 per 10000 in males, and 15.5 per 10000 in females. The male:female ratio was 2.5:1. The proportions of children with high-functioning autism who had Binet IQs of 70 and over and those with Binet IQs of 85 and over were 25.3% and 13.7% respectively. Data on cumulative incidence of childhood autism derived from this study are the first to be drawn from an accurate, as well as precise, screening methodology.

Developing Appropriate Community-Based Postgraduate Training in a Developing Country

The School of Medical Sciences, KNUST, established in 1975, indicated its educational orientation to a community-based and community-oriented system using the problem-based learning approach. Falling victim to the phenomenon of brain-drain, the School developed a postgraduate medical curriculum which takes into account the needs and demands of national governments and communities for quality specialist care and equitable distribution of existing health facilities. There is an innovative community-based fourth year for obstetrics and gynaecology, ophthalmology, otorhinolaryngology, paediatrics, surgery and medicine. After attainment of the Part I Examination, residents are sent to Ulm, Maastricht, Britain and the United States for clinical attachments for a period of 3 to 6 months before returning to sit for their Final Part II for the Fellowship of the West African College of Surgeons or Physicians (FWACS, FWACP). By ensuring that the Final Examinations take place after the elective attachment, none of the new breed of specialists so far produced has been lost to the Western world. The strengths and weaknesses of the programme are discussed.

Evaluating the closure or downsizing of psychiatric hospitals: social or clinical event?

The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalization have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalization, particularly as regards the downsizing/closure and role of psychiatric hospitals. I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalization is driven today by the same forces that were present at the outset of the movement. I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research. Lessons are drawn on how to fill certain vacant cells of the matrix.

I-Views: a community-oriented system for sharing streaming video on the Internet

Streaming media is pervasive on the Internet now and is continuing to grow rapidly. Most streaming media systems have adopted the model of broadcast. Unfortunately, the nature of the broadcast-like one-to-many communication model is not able to foster interaction and collaboration among people. In this paper we discuss a community-oriented communication model for sharing streaming video and introduce a prototype, I-Views. This is a system that permits individuals to use published, communally-owned media clips in order to author narratives by assembling clips, and to build communities of similar interests based on comparison of these narratives. By offering shared authorship, tools and virtual environments, I-Views demonstrates some potential directions for `sharable video.'

Community mental health systems generate new chronics: The study of a pure case

This study indicates that while a well-integrated comprehensive community mental health system (CMHS) can dramatically reduce the utilization of long-stay inpatient beds compared to more traditional care systems, it does not banish the appearance of “new chronic” patients from a catchment area. South Beach Psychiatric Center, the CMHS which is the focus of this study, is a state-operated program with a New York City location that provides all long-stay hospital beds and the major proportion of acute inpatient and community care for the 1.36 million people in its service delivery region. Compared to the patient population of traditional care systems, CMHS new chronic patients are younger, composed of more males, have a higher percentage of schizophrenia diagnoses, and show fewer signs of institutionalization. In addition, CMHS patients frequently exhibit dangerous behaviors. Major elements of CMHS operations contributing to these findings, particularly the small number of available long-stay beds, are reviewed. Recommendations are made for community-oriented system design.

Self-care in urban settings.

A variety of indicators favors the development of self-care systems for inner-city populations. This cannot be conceived as an isolated individual or a family enterprise. To be effective, self-care must be a community concept. This type of system requires (1) an information base; (2)an organized method of dissemination in a community; (3) support structures; and (4) an evaluation sybsystem. A community-oriented system would be an alternative and a complement to formal health services; individuals and families would manage common health problems, but would have ready access to formal services through community organizations. Links must also be provided between personal self-care and other forms of community development.