Examining the Role of Structural and Functional Social Network Characteristics in the Context of Chronic Pain: An Ego-centered Network Design.

The well-being and functioning of individuals with chronic pain (CP) vary significantly. Social factors, such as social integration, may help explain this differential impact. Specifically, structural (network size, density) as well as functional (perceived social support, conflict) social network characteristics may play a role. However, it is not yet clear whether and how these variables are associated with each other. Objectives were to examine 1) both social network characteristics in individuals with primary and secondary CP, 2) the association between structural network characteristics and mental distress and functioning/participation in daily life, and 3) whether the network's functionality mediated the association between structural network characteristics and mental distress, respectively, functioning/participation in daily life. Using an online ego-centered social network tool, cross-sectional data were collected from 303 individuals with CP (81.85% women). No significant differences between individuals with fibromyalgia versus secondary CP were found regarding network size and density. In contrast, ANCOVA models showed lower levels of perceived social support and higher levels of conflict in primary (vs secondary) CP. Structural equation models showed that 1) larger network size indirectly predicted lower mental distress via lower levels of conflict; 2) higher network density increased mental distress via the increase of conflict levels. Network size or density did not (in)directly predict functioning/participation in daily life. The findings highlight that the role of conflict, in addition to support, should not be underestimated as a mediator for mental well-being. Research on explanatory mechanisms for associations between the network's structure, functionality, and well-being is warranted. PERSPECTIVE: This paper presents results on associations between structural (network size, density) and functional (social support, conflict) social network characteristics and well-being in the context of CP by making use of an ego-centered network design. Results suggest an indirect association between structural network characteristics and individuals with CP their mental well-being.

Mechanism substitution in preventive innovations: Dissecting the reproduction of health inequalities in the United States.

In the last three decades, numerous studies in different countries have corroborated the main postulates of the Fundamental Cause Theory (FCT), providing evidence showing how health inequalities are reproduced as society increases its capacity to control disease and/or avoid its consequences through preventive innovations. However, documenting the reproductive logic proposed by the theory requires the development of a dynamic analytical approach to consider socioeconomic disparities in the incorporation of multiple preventive innovations over time, which could act as mediating mechanisms of the durable relationship between socioeconomic status and health/mortality. This study draws on data from different waves of the National Health Interview Survey and the National Health and Nutrition Examination Survey to analyze the diffusion processes of various innovations in the U.S. The results of the study show that educational inequalities emerge, are amplified, and are reduced by the continuous diffusion of preventive innovations, supporting the meta-hypothesis of substitution of mediating mechanisms according to the interconnections of FCT and Diffusion of Innovation Theory.

Trends in the use of benzodiazepine receptor agonists among working-age adults in Belgium from 2004 to 2018.

Introduction: The use of psychotropics, such as benzodiazepine receptor agonists (BzRAs), among working-age adults in Belgium has shown educational differences. However, it is unclear how work status plays a role in this relationship. Therefore, this research aims to investigate whether work status explains observed educational differences in BzRA use. In addition, considering medicalisation processes, where non-medical factors, such as work status, are increasingly associated with medical mental health care-seeking behavior, this research also aims to investigate whether work status explains observed educational differences in BzRA use, regardless of mental health status. Methods: Data are obtained from the Belgian Health Interview Survey (BHIS). Four successive waves are covered: 2004, 2008, 2013, and 2018. The weighted data represent a sample of 18,547 Belgian respondents aged 18 to 65 years old. Poisson regression models are used to analyze the research aims. Time evolutions are plotted using marginal means postestimation. Results: The average use of BzRAs shows a slight decline over the waves studied (2004 = 5.99, 2008 = 5.88, 2013 = 5.33, 2018 = 4.31). Educational and work status differences in BzRA use are observed, regardless of mental health status. Individuals with longer education report lower use compared to individuals with shorter education, and individuals who are unemployed, (pre-)retired, or sick or disabled report higher use compared to employed individuals. Furthermore, work status acts as a mediator, partially explaining educational differences in BzRA use, regardless of mental health status. Discussion: Work-related uncertainty leads to increased prescribing and medication use, regardless of mental health. Medicalisation and pharmaceuticalisation processes detach social problems from their social roots and treat them as personal failures. The marginalization of the social roots of unemployment, sick leave and involuntary (pre-)retirement has led to a personalization of responsibility. Negative feelings arising from such work statuses may cause isolated, non-specific symptoms for which medical treatment is sought.

Financial Loss and Depressive Symptoms in University Students During the First Wave of the COVID-19 Pandemic: Comparison Between 23 Countries.

Objectives: To assess the association between students' financial loss and depressive symptoms during the first wave of the coronavirus disease 2019 (COVID-19) pandemic and whether this association varied by countries having different levels of lockdown measures. Methods: This cross-sectional survey, conducted in spring 2020, included 91,871 students from 23 countries. Depressive symptoms were measured using the shortened Center for Epidemiological Studies Depression Scale and information on lockdowns retrieved from the COVID-19 government response tracker. The association between financial loss and depressive symptoms was investigated estimating prevalence ratios (PR) with multilevel Poisson models. Results: Some 13% of students suffered financial loss during the lockdown and 52% had a relatively high depression score, with large between-countries differences. Minimally and maximally adjusted models showed a 35% (PR = 1.35, 95% Confidence Interval (CI) = 1.29-1.42) and 31% (PR = 1.31, 95% CI = 1.26-1.37) higher prevalence of depressive symptoms in students who lost economic resources compared to students with stable economic resources. No substantial differences in the association were found across countries. Conclusion: Depressive symptoms were more frequent among students who suffered financial loss during the pandemic. Policy makers should consider this issue in the implementation of COVID-19 mitigating measures.

Revisiting the Effects of Organized Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis of Nationwide Data From 1997 to 2017.

This study revisits the effects of mammography screening programs on inequalities in breast screening uptake in Switzerland. The progressive introduction of regional mammography programs by 12 out of the 26 Swiss cantons (regions) since 1999 offers an opportunity to perform an ecological quasi-experimental study. We examine absolute income and marital status inequalities in mammography uptake, and whether the cantons' implementation of mammography programs moderate these inequalities, as previous research has devoted little attention to this. We use five waves of the Swiss Health Interview Survey covering the 1997-2017 period and comprising data on 14,267 women aged 50-70. Both up-to-date and ever-screening outcomes are analyzed with multilevel models which assess the mammography programs' within-canton effect. Findings show that higher income women and married women (compared to unmarried women) had significantly higher mammography uptake probabilities. Mammography programs did not moderate absolute income differences in up-to-date screening; however, they were associated with smaller absolute income differences in ever-screening uptake. Mammography programs related to higher screening uptake for married women, more than for unmarried women. In conclusion, we showed absolute income inequalities in mammography uptake which were not revealed by previous studies using relative inequality measures. Mammography programs may have contributed to reducing income inequalities in ever-screening, yet this was not observed for up-to-date screening. This study has implication for preventive health interventions-e.g., cancer screening promotion should pay attention to women's marital status since screening programs may widen the screening gap between married and unmarried women.

Cervical cancer screening programs and their context-dependent effect on inequalities in screening uptake: a dynamic interplay between public health policy and welfare state redistribution.

BACKGROUND: While organized and opportunistic cervical cancer screening (CCS) programs implemented across the European Union have increased participation rates, barriers to socioeconomically deprived women remain substantial, implying high levels of inequality in CCS uptake. AIM: This study assesses how the screening strategy (as a score based on the availability of organized population-based CCS programs), accessibility of the healthcare system (as an index of out-of-pocket expenditure as a proportion of total healthcare costs, public health expenditure as a percentage of total GDP, and general practitioner (GP) density per 10'000 inhabitants) and social protection (as a decommodification index), impact education- and income-based inequalities in CCS uptake. METHODS: A two-level design with 25-64-year-old women (N = 96'883), eligible for Pap smear screening, nested in 28 European countries, was used to analyze data from the European Health Interview Survey's second wave, using multilevel logistic regression modelling. RESULTS: Clear educational and income gradients in CCS uptake were found, which were smaller in countries with organized CCS programs, higher accessibility of the healthcare system and a higher level of decommodification. Furthermore, three-way interaction terms revealed that these gradients were smaller when organized CCS programs were implemented in countries with better accessibility of the healthcare system or a high level of decommodification. CONCLUSION: This study indicates that the combination of organized screening and high accessibility of the healthcare system or social protection is essential for having lower levels of inequality in CCS uptake. In such countries, the structural threshold for poorer and lower educated women to engage in CCS is lower. This may be explained by them having a better interaction with their GP, who may convince them of the screening test, lower out-of-pocket payments, and financial support to buffer against a disadvantageous position on the labor market.

Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries.

BACKGROUND: Little attention has been devoted to the role of macro-level determinants in preventive health inequalities, particularly in cancer screening participation. Research has evidenced inequalities in cancer screening uptake yet has mainly focused on the screening programmes' moderating role at the macro-level. To address this gap, this study examines how welfare provision and healthcare system features modify cancer screening uptake and inequalities across European countries. METHODS: Data from 99 715 (Pap smear) and 54 557 (mammography) women in 29 countries from the European Health Interview Survey (EHIS) 2014 wave and Swiss Health Interview Survey (SHIS) 2012 wave was analysed. We estimated multilevel logistic regression models, including cross-level interactions, to examine whether social protection expenditure in particular policy areas and healthcare system characteristics explained cross-country differences in Pap smear and mammography uptake and inequalities. RESULTS: Main findings revealed that GP gatekeeping systems were associated with reduced screening uptake likelihood in both Pap smear and mammography, and so were stronger primary care systems in Pap smear, while higher expenditures on old age and survivors were associated with increased mammography uptake. Cross-level interactions showed that in countries with higher expenditures on sickness/healthcare, disability, social exclusion and public health, and a higher number of GPs, educational inequalities in both Pap smear and mammography uptake were smaller, while higher out-of-pocket payments had the opposite effect of increasing inequalities. CONCLUSIONS: Overall, our results show that social protection policies and healthcare system features affect cancer screening participation. We conclude that institutional and policy arrangements interact with individuals' (educational) resources and, through the (re)distribution of valued goods and resources at the macro level, these arrangements may contribute to enhancing preventive healthcare use and mitigating screening uptake inequalities.

Perceived group discrimination based on one's gender and the gender gap in depression in Europe.

BACKGROUND: Gender discrimination is one of the most significant psychosocial stressors. This study examined whether the relationship between perceived group discrimination against one's gender (PGD) and the gender gap depression varied by societal levels of gender inequality. METHODS: The current study used data from three waves (2006, 2012 and 2014) of the European Social Survey and applied multilevel linear regression methods. We assessed depressive feelings through the eight-item version of the Centre for Epidemiological Studies Depression Scale. The sample contained 71,419 respondents living in 22 countries. RESULTS: While only a small percentage of people were confronted with PGD, this group consistently reported more depressive feelings. PGD had a similar effect on the mental health of men and women, except for men in more gender-egalitarian societies. When confronted with PGD, the latter group reported more depressive feelings in comparison to men in more gender unequal societies. CONCLUSIONS: Our research found a strong association between PGD and depression. In addition, this relationship varied by societal levels of gender equality. More pronounced gender equality strengthened this relationship in men. Research that ignores this social context might, therefore, be limited in terms of generalization.

Never and under cervical cancer screening in Switzerland and Belgium: trends and inequalities.

BACKGROUND: Research on inequalities in cervical cancer screening (CCS) participation has overlooked the distinction between 'never-' and 'under-screeners' while different socioeconomic and demographic determinants may underlie 'non-' and 'under-' screening participation. This study examines socioeconomic and demographic inequalities in never and under CCS participation. We compare cross-national prevalence and trends among these two groups in Switzerland and Belgium, two countries with similar opportunistic CCS strategy but different healthcare systems. METHODS: Data on 38,806 women aged 20-70 from the Swiss Health Interview Survey (1992-2012) and 19,019 women aged 25-64 from the Belgian Health Interview Survey (1997-2013), both population-based cross-sectional nationally representative surveys, was analysed. Weighted adjusted prevalence ratios were estimated with multivariate Poisson regressions. RESULTS: Over the studied period, never screening prevalence was about 15% in both Switzerland and Belgium and under screening prevalence about 14.0%. Socioeconomic gradients were found among both never- and under-screeners. Higher income women had lower never and under screening prevalence in Switzerland and a similar gradient in education was observed in Belgium. Importantly, distinct socioeconomic and demographic determinants were found to underlie never and under screening participation. Never screening was significantly higher among foreign nationals in both countries and this association was not observed in under screening. Never screening prevalence was lower among older age groups, while under screening increased with older age. Over time, age inequalities diminished among never- and under- screeners in Switzerland while educational inequalities increased among never-screeners in Belgium. CONCLUSION: Findings revealed that determinants of screening inequalities differed among never- and under-screeners and hence these should be addressed with different public health strategies. Crucially, socioeconomic and demographic inequalities were more pronounced among never-screeners who appeared to face more structural and persistent inequalities. Differences between the two countries should also be noted. The more liberal-type Swiss healthcare systems appeared to shape income-related screening inequalities, while education appeared to be a stronger determinant of never- and under-screening in Belgium.

Depression in women and men, cumulative disadvantage and gender inequality in 29 European countries.

Macro-sociological theories stress the contribution of gender inequality to this gender gap in depression, while cumulative advantage/disadvantage theory (CAD) reminds us that mental health inequalities accumulate over the life course. We explore the complementarity of both perspectives in a variety of European countries using data of the European Social Survey (2006 2012, 2014, N of countries = 29; N of men = 53,680 and N of women = 63,103) and using an 8-item version of the CES-D. Results confirm that the relevance of gender stratification for the mental health of women and men in Europe depends on age. The gender gap is nearly absent amongst adults in their twenties in the most gender equal countries, while an impressive gender gap is present amongst older adults in gender unequal countries, in accordance with CAD theory. These effects occur on top of the mental health consequences of taking up work and family roles at various life stages. The convergence of the results predicted by gender stratification and cumulative disadvantage theories strengthen the case for the link between gender, disadvantage and depression.

Cancer Screening Participation and Gender Stratification in Europe.

The current study examines whether the extent of macrolevel gender inequality affects the association between women's educational attainment and their participation in cervical and breast cancer screening and how this relationship is moderated by a country's cancer screening strategy (organized vs. opportunistic). A multilevel design with women (Ncervical = 99,794; Nbreast = 55,021) nested in 30 European countries was used to analyze data from the European Health Interview Survey (2013-2015). Results of multilevel logistic regression models demonstrate that higher macrolevel gender inequality is associated with (a) a lower overall likelihood that women have had a mammography and Pap smear and (b) a larger gap in participation between women with low and high levels of education, regardless of a country's screening strategy (i.e., no moderation by a country's screening strategy was found). We conclude that macrolevel gender stratification should not be neglected when designing cancer screening policy.

Cervical cancer (over)screening in Belgium and Switzerland: trends and social inequalities.

BACKGROUND: Cervical cancer screening (CCS) by means of Pap smears has led to a decrease in cervical cancer incidence and mortality. In the absence of organized programmes, CCS is opportunistic in Belgium and Switzerland. This might result in a high level of CCS overuse, as screening practices do not conform to the recommended 3-yearly screening interval and the target age-ranges (Belgium: 25-64, Switzerland: 20-70). This study aimed to assess trends in CCS uptake and overuse in Belgium and Switzerland and their social determinants, in the light of reimbursement initiatives, which were implemented in both countries. METHODS: Data from five waves of the Belgian Health Interview Survey (1997-2013) (N=11 141) and Swiss Health Interview Survey (1992-2012) (N=32 696) were used. We performed Poisson regressions to estimate adjusted prevalence ratios (APR), controlled for socio-economic and socio-demographic characteristics and health status. CCS overuse was operationalized as screening more than once every 3 years and screening above recommended age-range. RESULTS: CCS uptake remained relatively stable over time, with a mean coverage of 70.9% in Belgium and 73.1% in Switzerland. Educational and income gradients were found in both countries. Concerning CCS overuse, women above screening-eligible age showed consistently high screening rates, but screening within the past year declined significantly in both countries, matching the temporal implementation of the reimbursement initiatives. CONCLUSIONS: Although no increase in CCS coverage could be established, CCS has become more efficient in both countries as Pap smear overuse at the population level has declined after the implementation of reimbursement measures tackling CCS overuse.

Assessing Provider Bias in General Practitioners' Assessment and Referral of Depressive Patients with Different Migration Backgrounds: Methodological Insights on the Use of a Video-Vignette Study.

Although the prevalence of common mental health conditions such as depression and anxiety, is higher among people with a migration background, these groups are generally underrepresented in all forms of institutionalized mental health care. At the root of this striking discrepancy might be unequal referral by health care practitioners. In this article we describe the development of a quasi-experimental video vignette methodology to assess potential forms of unequal diagnosing, treatment and referral patterns, based on clients' migration background and asylum status. The presented methodology also allows to explore whether potential differences are related to provider bias, i.e. underlying attitudes and expectations held by general practitioners. Potential assets and drawbacks of this methodology are discussed in detail.

The silver lining of greying: Ageing discourses and positioning of ageing persons in the field of social health insurance.

Contemporary ageing discourses and policies perceive being active as the key to a good later life and thereby focus on individual responsibility and self-care. Drawing on website articles and press releases of Belgian sickness fund agencies, this study analyses the ageing discourses and positioning of ageing persons of these organisations. A discourse analysis was performed using positioning theory to analyse how sickness fund agencies discursively construct the ageing process and position ageing persons, and to investigate how these positioning acts are related to sickness fund agencies' roles as social insurer, social movement, social entrepreneur and private insurer. Our results reveal three storylines on ageing; ageing as a medical problem, ageing as a new stage in life and ageing as a natural life process. These storylines are applied to construct ageing and position ageing persons in different ways. Depending on their role, sickness fund agencies take on a different position drawing on these different storylines. We also show how these storylines reproduce the moral framework on how to age well and thereby disempower ageing persons. Our results underline the importance of multidimensional perspectives on ageing.

Early predictors of impaired sleep: a study on life course socioeconomic conditions and sleeping problems in older adults.

Objectives: This study aimed to assess how childhood socioeconomic conditions are associated with sleeping problems in older adults and how this association may be mediated by socioeconomic conditions across the lives of individuals using a life course perspective. Since the life course opportunities differ systematically between men and women, attention was given to gender differences in the association.Methods: Data from 23,766 individuals aged over 50 years of the longitudinal Survey of Health, Ageing and Retirement in Europe (SHARE) were used. Logistic mixed-effect models were estimated to examine the associations between childhood socioeconomic conditions and the presence of sleeping problems.Results: For women, the analyses showed an association between childhood socioeconomic conditions and sleeping problems. For men, only current socioeconomic conditions were found to be relevant for sleep. The importance of childhood socioeconomic conditions for sleeping problems did not affect the evolution of sleeping problems over ageing.Conclusion: In this study no empirical support was found for processes of cumulative advantage/disadvantage or age-as-leveler. However, childhood does seem to be a critical period for the sleep of women, because the association with childhood socioeconomic conditions remains even when the circumstances later in life are considered. These findings, in particular the gender differences in the association, underline the importance of tracking life course patterns in the study of sleeping problems in older adults.

Do comprehensive school reforms impact the health of early school leavers? Results of a comparative difference-in-difference design.

In the current article, we examine whether and how reforms in tracking age affect educational inequalities in health among people between the ages of 25-75 years. Particular attention is paid to the health consequences for early school leavers. The study combines data from the European Social Survey (2002-2016) on 21 countries with country-cohort information on education policies. Moreover, a difference-in-difference design is used, which takes advantage of both the cross-national and cross-temporal variability in the implementation of comprehensive schooling reforms. The results reveal statistically significant, but very small effects of de-tracking policies on people's health. That is, comprehensive education leads to slight improvements in health among people who have attained upper secondary or tertiary education, but these improvements are achieved at the expense of the health of those with the lowest levels of education. Our study should encourage future research to further explore the institutional impact of educational systems on the health of individuals.

On the moderation of the relation between overeducation and depressive symptoms through labor market and macro-economic factors.

Empirical research has consistently shown that overeducation is positively associated with depressive symptoms. However, little is known about the cross-national variation of this association. This study investigates the issue by examining how macro-economic factors and labor-market policies moderate the link between two objective measures of overeducation (the realized-matches and job-analyst methods) and depressive symptoms. Analysis is based on individual-level data from the European Social Survey, Rounds 3, 6, and 7 (N = 51,054). Results from 20 countries, based on a sample of respondents between the ages of 20 and 65 years, indicate that higher unemployment rates are the primary factor strengthening the relationship between overeducation and depressive symptoms. The realized-matches method reveals one important exception for women. This exception is reported and discussed in light of the literature on gender discrimination. Our results provide no evidence that labor-market policies (unemployment benefits and employment-protection legislation) have any impact on the relationship under study.

The impact of regional screening policies on the diffusion of cancer screening participation in Belgium: time trends in educational inequalities in Flanders and Wallonia.

BACKGROUND: We investigate whether the extent of educational inequalities in the use of Pap smears (cervical cancer screening) and mammograms (breast cancer screening) in Belgium has changed over time in accordance with the pattern predicted by diffusion of innovation theory, as well as how the regional cancer screening policies of Flanders and Wallonia influence this pattern. METHODS: Data were obtained from five successive cross-sectional waves (1997-2001-2004-2008-2013) of the Belgian Health Interview Survey. Final sample sizes consisted of 8988 women aged 25-64 years for cervical cancer screening and 4194 women aged 50-69 years for breast cancer screening. We calculated absolute and relative measures of inequality, more specifically, the slope index of inequality (SII) and the relative index of inequality (RII), and their development over time. RESULTS: In both Flanders and Wallonia, mammogram use increased greatly between 1997 and 2013, while Pap smear use has remained quite stable over time. Educational inequalities in cervical-cancer screening have been largely persistent over time in both regions. In contrast, educational inequalities in breast cancer screening fluctuated more between 1997 and 2013. Between 1997 and 2001, when the breast cancer screening programme was implemented in Flanders, RII reduced significantly by 45%. Inequality measures did not change significantly in Wallonia, where it is known that most women are screened opportunistically outside the programme. CONCLUSIONS: By focussing on Belgium, this study demonstrates that regional variations in the support of a national screening programme can result in regional variations in the pattern of diffusion for cancer screening, as well as to the development of inequalities in cancer screening participation. Moreover, the findings demonstrate that high visibility and awareness of the screening programme, as was more the case in Flanders than it was in Wallonia, are required in order to reduce or eliminate educational inequalities in cancer screening participation over time. General practitioners and gynaecologists can play a decisive role in this regard.

Effect of childhood socioeconomic conditions on cancer onset in later life: an ambidirectional cohort study.

OBJECTIVES: Living in low socioeconomic conditions during childhood is associated with poor health outcomes in later life. Whether this link also applies to cancer is unclear. We examined whether childhood socioeconomic conditions (CSCs) are associated with cancer risk in later life and whether this effect remained after adjusting for adulthood socioeconomic conditions (ASCs). METHODS: Data for 26,431 individuals ≥ 50 years old included in SHARE were analysed. CSCs were constructed by using indicators of living conditions at age 10. ASC indicators were education, main occupation, and household income. Gender-stratified associations of CSCs with cancer onset (overall and by site) were assessed by Cox regression. RESULTS: In total, 2852 individuals were diagnosed with cancer. For both men and women, risk of overall cancer was increased for advantaged CSCs and remained so after adjusting for ASCs (hazard ratio = 1.36, 95% CI 1.10, 1.63, and 1.70, 95% CI 1.41, 2.07). CONCLUSIONS: Advantaged CSCs are associated with an increased risk of overall cancer at older age, but results vary by cancer sites and sex. Participation in cancer screening or exposure to risk factors may differ by social conditions.

State and non-state mental health service collaboration in a South African district: a mixed methods study.

The Life Esidimeni tragedy in South Africa showed that, despite significant global gains in recognizing the salience of integrated public mental health care during the past decade, crucial gaps remain. State and non-state mental health service collaboration is a recognized strategy to increase access to care and optimal use of community resources, but little evidence exist about how it unfolds in low- to middle-income countries. South Africa's Mental Health Policy Framework and Strategic Plan 2013-20 (MHPF) underlines the importance of collaborative public mental health care, though it is unclear how and to what extent this happens. The aim of the study was to explore the extent and nature of state and non-state mental health service collaboration in the Mangaung Metropolitan District, Free State, South Africa. The research involved an equal status, sequential mixed methods design, comprised of social network analysis (SNA) and semi-structured interviews. SNA-structured interviews were conducted with collaborating state and non-state mental health service providers. Semi-structured interviews were conducted with collaborating partners and key stake holders. Descriptive network analyses of the SNA data were performed with Gephi, and thematic analysis of the semi-structured interview data were performed in NVivo. SNA results suggested a fragmented, hospital centric network, with low average density and clustering, and high authority and influence of a specialist psychiatric hospital. Several different types of collaborative interactions emerged, of which housing and treatment adherence a key point of collaboration. Proportional interactions between state and non-state services were low. Qualitative data expanded on these findings, highlighting the range of available mental health services, and pointed to power dynamics as an important consideration in the mental health service network. The fostering of a well-integrated system of care as proposed in the MHPF requires inter-institutional arrangements that include both clinical and social facets of care, and improvements in local governance.