Janice L. Cooper

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services

This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.

Adapting the Crisis Intervention Team (CIT) model of police-mental health collaboration in a low-income, post-conflict country: curriculum development in Liberia, West Africa.

OBJECTIVESnWe sought to develop a curriculum and collaboration model for law enforcement and mental health services in Liberia, West Africa.nnnMETHODSnIn 2013 we conducted key informant interviews with law enforcement officers, mental health clinicians, and mental health service users in Liberia, and facilitated a 3-day curriculum workshop.nnnRESULTSnMental health service users reported prior violent interactions with officers. Officers and clinicians identified incarceration and lack of treatment of mental health service users as key problems, and they jointly drafted a curriculum based upon the Crisis Intervention Team (CIT) model adapted for Liberia. Officers mental health knowledge improved from 64% to 82% on workshop assessments (t=5.52; P<.01). Clinicians attitudes improved (t=2.42; P=.03). Six months after the workshop, 69% of clinicians reported improved engagement with law enforcement. Since the Ebola outbreak, law enforcement and clinicians have collaboratively addressed diverse public health needs.nnnCONCLUSIONSnCollaborations between law enforcement and mental health clinicians can benefit multiple areas of public health, as demonstrated by partnerships to improve responses during the Ebola epidemic. Future research should evaluate training implementation and outcomes including stigma reduction, referrals, and use of force.

The Role of Fear-Related Behaviors in the 2013–2016 West Africa Ebola Virus Disease Outbreak

The 2013–2016 West Africa Ebola virus disease pandemic was the largest, longest, deadliest, and most geographically expansive outbreak in the 40-year interval since Ebola was first identified. Fear-related behaviors played an important role in shaping the outbreak. Fear-related behaviors are defined as “individual or collective behaviors and actions initiated in response to fear reactions that are triggered by a perceived threat or actual exposure to a potentially traumatizing event. FRBs modify the future risk of harm.” This review examines how fear-related behaviors were implicated in (1) accelerating the spread of Ebola, (2) impeding the utilization of life-saving Ebola treatment, (3) curtailing the availability of medical services for treatable conditions, (4) increasing the risks for new-onset psychological distress and psychiatric disorders, and (5) amplifying the downstream cascades of social problems. Fear-related behaviors are identified for each of these outcomes. Particularly notable are behaviors such as treating Ebola patients in home or private clinic settings, the “laying of hands” on Ebola-infected individuals to perform faith-based healing, observing hands-on funeral and burial customs, foregoing available life-saving treatment, and stigmatizing Ebola survivors and health professionals. Future directions include modeling the onset, operation, and perpetuation of fear-related behaviors and devising strategies to redirect behavioral responses to mass threats in a manner that reduces risks and promotes resilience.

Fear factor: The unseen perils of the Ebola outbreak

ABSTRACT As illustrated powerfully by the 2013–2016 Ebola outbreak in western Africa, infectious diseases create fear and psychological reactions. Frequently, fear transforms into action – or inaction – and manifests as “fear-related behaviors” capable of amplifying the spread of disease, impeding life-saving medical care for Ebola-infected persons and patients with other serious medical conditions, increasing psychological distress and disorder, and exacerbating social problems. And as the case of the US micro-outbreak shows, fear of an infectious-disease threat can spread explosively even when an epidemic has little chance of materializing. Authorities must take these realities into account if they hope to reduce the deadly effects of fear during future outbreaks.

Health system preparedness for integration of mental health services in rural Liberia

BackgroundThere are increasing efforts and attention focused on the delivery of mental health services in primary care in low resource settings (e.g., mental health Gap Action Programme, mhGAP). However, less attention is devoted to systematic approaches that identify and address barriers to the development and uptake of mental health services within primary care in low-resource settings. Our objective was to prepare for optimal uptake by identifying barriers in rural Liberia. The country’s need for mental health services is compounded by a 14-year history of political violence and the largest Ebola virus disease outbreak in history. Both events have immediate and lasting mental health effects.MethodsA mixed-methods approach was employed, consisting of qualitative interviews with 22 key informants and six focus group discussions. Additional qualitative data as well as quantitative data were collected through semi-structured assessments of 19 rural primary care health facilities. Data were collected from March 2013 to March 2014.ResultsPotential barriers to development and uptake of mental health services included lack of mental health knowledge among primary health care staff; high workload for primary health care workers precluding addition of mental health responsibilities; lack of mental health drugs; poor physical infrastructure of health facilities including lack of space for confidential consultation; poor communication support including lack of electricity and mobile phone networks that prevent referrals and phone consultation with supervisors; absence of transportation for patients to facilitate referrals; negative attitudes and stigma towards people with severe mental disorders and their family members; and stigma against mental health workers.ConclusionsTo develop and facilitate effective primary care mental health services in a post-conflict, low resource setting will require (1) addressing the knowledge and clinical skills gap in the primary care workforce; (2) improving physical infrastructure of health facilities at care delivery points; and (3) implementing concurrent interventions designed to improve attitudes towards people with mental illness, their family members and mental health care providers.

Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study

BackgroundAccess to mental health care services for patients with neuropsychiatric disorders remains low especially in post-conflict, low and middle income countries. Persons with mental health conditions and epilepsy take many different paths when they access formal and informal care for their conditions. This study conducted across three countries sought to provide preliminary data to inform program development on access to care. It thus sought to assess the different pathways persons with severe mental disorders and epilepsy take when accessing care. It also sought to identify the barriers to accessing care that patients face.MethodsSix in depth interviews, 27 focus group discussions and 77 key informants’ interviews were conducted on a purposively selected sample of health care workers, policy makers, service users and care takers in Uganda, Liberia and Nepal. Data collected along predetermined themes was analysed using Atlas ti software in Uganda and QSR Nvivo 10 in Liberia and NepalResultsIndividual’s beliefs guide the paths they take when accessing care. Unlike other studies done in this area, majority of the study participants reported the hospital as their main source of care. Whereas traditional healers lie last in the hierarchy in Liberia and Nepal, they come after the hospital as a care option in Uganda. Systemic barriers such as: lack of psychotropic medicines, inadequate mental health specialists and services and negative attitudes of health care workers, family related and community related barriers were reported.ConclusionAccess to mental health care services by persons living with severe mental disorders and epilepsy remains low in these three post conflict countries. The reasons contributing to it are multi-faceted ranging from systemic, familial, community and individual. It is imperative that policies and programming address: negative attitudes and stigma from health care workers and community, regular provision of medicines and other supplies, enhancement of health care workers skills. Ultimately reducing the accessibility gap will also require use of expert clients and families to strengthen the treatment coalition.

Fear-related behaviors in situations of mass threat

ABSTRACT This Disaster Health Briefing focuses on the work of an expanding team of researchers that is exploring the dynamics of fear-related behaviors in situations of mass threat. Fear-related behaviors are individual or collective behaviors and actions initiated in response to fear reactions that are triggered by a perceived threat or actual exposure to a potentially traumatizing event. Importantly, fear-related behaviors modulate the future risk of harm. Disaster case scenarios are presented to illustrate how fear-related behaviors operate when a potentially traumatic event threatens or endangers the physical and/or psychological health, wellbeing, and integrity of a population. Fear-related behaviors may exacerbate harm, leading to severe and sometimes deadly consequences as exemplified by the Ebola pandemic in West Africa. Alternatively, fear-related behaviors may be channeled in a constructive and life-saving manner to motivate protective behaviors that mitigate or prevent harm, depending upon the nature of the threat scenario that is confronting the population. The interaction between fear-related behaviors and a mass threat is related to the type, magnitude, and consequences of the population encounter with the threat or hazard. The expression of FRBs, ranging from risk exacerbation to risk reduction, is also influenced by such properties of the threat as predictability, familiarity, controllability, preventability, and intentionality.

In search of global governance for research in epidemics.

1632 www.thelancet.com Vol 390 October 7, 2017 The west African epidemic of Ebola virus disease in 2014–15 became a major tragedy because the global system under the International Health Regulations and the governance of research related to epidemics both failed to function as needed. Research started too late and yielded only one vaccine candidate with probable effectiveness. Today, the international framework for epidemic preparedness and response still does not include a role for research. Future crossnational epidemics and Public Health Emergencies of International Concern are likely to involve pathogens that have no proven effective vaccines or specific therapeutics. What can be done now to improve the prospects for scientific learning in the next epidemic? Concerned agencies have taken steps to better incorporate research into epidemic preparedness since the recent Ebola epidemic. These include the WHO R&D Blueprint with a priority list of diseases, consultations to establish a Global Coordination Mechanism for research and development to prevent and respond to epidemics, and an International Working Group on Financing Preparedness. These are welcome actions, but not sufficient because global health governance arrangements do not deliver what is needed. A key challenge is to create more inclusive arrangements that involve a broader range of actors with interests that cross or ignore state boundaries, so that collective action can be taken through agreed rules and institutions. For research related to epidemics, key actors include not only national governments, but also WHO, other multilateral organisations, humanitarian organ isations, philanthropic found ations, academic institutions, pharma ceutical and diagnostic companies, civil society organisations, and individual experts. These stakeholders were not well coordinated during the Ebola outbreak. They are connected in many formal and ad-hoc ways, yet have their own vested interests, ideologies, capabilities, mandates, and authorities. New governance models should be developed that account for these realities. A recent US National Academies of Sciences, Engineering, and Medicine committee report on clinical research in the Ebola epidemic includes recommendations to build workable governance and implementation arrangements for research during major epidemics— specifically for collaborative planning and coordination mechanisms between epidemics, and for rapid research response during an outbreak. Building on principles for the governance of evidence, there remain important issues to address. Clarification of goals with the full range of key stakeholders is essential. Broad agreement must be reached on the importance of collecting valid clinical data and integrating research into emergency preparedness and response. Agreement on other goals may be difficult but important for determining the scope of the epidemic research agenda; building capacity for disease surveillance and response and country-level management of scientific, ethical, and legal review of research; ensuring that the complete set of costs and benefits are shared fairly; and holding organisations accountable for research and epidemic preparedness and response actions. Concerned agencies also need to agree on working principles. For interepidemic prioritisation and planning activities, it is important to use consensus building and deliberative processes that demonstrate legitimacy, inclusiveness, authority, and public accountability. These attributes build trust and help to raise and distribute funding for governance and implementation activities. Agreement on goals and working principles provides a In search of global governance for research in epidemics

See my work: sustaining a data reporting practice by mental health clinicians in Liberia

Working with the Carter Center, we have developed and sustained software and training to enable data reporting at the patient level by mental health clinicians in Liberia. Over a four year time period, more than 140 clinicians have been trained in the use of the data reporting software, and more than 3000 valid reports have uploaded to the cloud. This participation has persisted despite significant technology challenges and little data feedback to clinicians. Because so many ICTD interventions fail, we were interested in the factors that contributed to sustaining the human and technology infrastructure to enable data reporting over this fairly long time period. We focus on motivations to participate and find support for positive motivations such as clinician pride. We find that being seen to do health work, not just doing the work, plays a critical role in motivation. We describe and critically analyze a novel approach to sustaining the technology, using student teams in a class. We assess project success through two lenses provided by the literature, first on characterization of project success and failure factors, and then on project champions.

Children's mental health policies in the United States: perspectives from advocates and state leaders

Previous research suggests a disconnect on both policy and practice between advocates and state leaders in child mental health.