Building an empowerment program to improve the health of patients with severe mental disorders / Exemple de coconstruction d'un programme d'empowerment en faveur de la santé des personnes vivant avec des troubles psychiques

Introduction: Risk factors and cardiovascular diseases are overrepresented in people with severe and persistent mental disorders. A person diagnosed with schizophrenia or bipolar disorder is two to three times more likely to die of cardiovascular disease than the general population. Purpose of research: An empowerment program has been co-created to reduce these health inequalities. It is one part of the COPsyCAT project. The people-centered approach has been used. The participation of the patients, caregivers, and health professionals was decisive. Results: Stakeholders redefined the objectives of the program. The aim is to improve quality of life, rather than reducing cardiovascular risk. Existing tools -that have been evaluated for their usability - were selected to allow for self-directed patient orientation, so that the constraints between psychiatry and primary care could be circumvented. The program is based on the pooling of existing resources in a territory. The individual power of action and the organization of healthy offers are thus designed to reinforce each other. Conclusions: This article concretely describes the steps through to which the COPsyCAT empowerment program was designed, in co-construction by the researchers of the study, the users and user associations and healthcare professionals at based on their experiential knowledge. The feasibility of the program and the appropriation of tools in real situations will soon be evaluated. The measure of the program's effectiveness on cardiovascular risk will come in second time.

Introduction: Au sein de la population présentant des troubles psychiques sévères et persistants, on observe une surreprésentation des facteurs de risque et des pathologies cardiovasculaires. Une personne chez qui un diagnostic de schizophrénie ou de troubles bipolaires a été porté aurait deux à trois fois plus de risque de mourir d'une maladie cardiovasculaire que la population générale. But de l'étude: Dans le cadre du projet « Collaboration patient-soignant pour une meilleure prise en charge des troubles cardiovasculaires des patients souffrant de troubles psychiques au long cours ¼ (COPsyCAT), un programme d'empowerment a été coconstruit pour réduire ces inégalités de santé. La prise en compte de l'expérience et des besoins des patients, de leurs aidants et des professionnels de santé est au cœur de chacune des étapes méthodologiques suivies pour la création du programme. Résultats: Les parties prenantes ont défini le programme comme devant viser l'amélioration de la qualité de vie et non la réduction du risque cardiovasculaire. Des outils ont été sélectionnés selon leur maniabilité pour permettre l'orientation autogérée des patients, de telle sorte que les contraintes inhérentes aux cloisonnements entre psychiatrie et soins primaires soient contournées. Le programme se base sur la mutualisation des ressources existantes sur un territoire. Pouvoir d'agir individuel et construction de contexte favorable à la santé sont ainsi pensés pour se renforcer mutuellement et agir sur des leviers réformateurs. Conclusions: Cet article décrit concrètement les étapes grâce auxquelles le programme d'empowerment COPsyCAT a été conçu, en coconstruction par les chercheurs de l'étude, les usagers et associations d'usagers et les professionnels de santé à partir de leurs savoirs expérientiels. La faisabilité du programme et l'appropriation des outils en situation réelle va être prochainement évaluée. La mesure de l'efficacité du programme sur le risque cardiovasculaire viendra dans un second temps.

Psychiatric and primary care professionals' suggestions for reducing cardiovascular risks for psychiatric patients / Propositions des professionnels pour réduire le risque cardiovasculaire des patients psychiatriques

INTRODUCTION: Cardiovascular diseases represent one of the major causes of mortality in France and are the main cause of excess mortality in people suffering from long-term mental disorders (LTMD), apart from causes related to suicide. AIM OF THE STUDY: The aim of this article is to identify, from the point of view of primary care and psychiatric professionals, psychiatric users’ expectations and needs in order to help them improve their medical and paramedical management of cardiovascular risk (CVR). METHOD: This is a prospective, multi-centered qualitative study carried out in two phases: An exploratory phase, with individual interviews at the beginning of the study to enable the creation of ad hoc collective interview grids, followed by a proper qualitative study, which is in line with medical anthropology and the sociology of health systems. RESULTS: The 30 psychiatric professionals interviewed agreed on the need for better coordination with out-of-hospital care providers. Even if openness is advocated, there is a reminder of the specificities of psychiatry and the importance of taking these specificities into account in general. The 26 primary care professionals show a desire to learn more about psychiatric disorders, pathologies, and treatments in order to facilitate the management of these patients with specific needs. CONCLUSION: The cross-referencing of these results will allow to propose an appropriate intervention in order to induce convincing effects on the reduction of the CVR in people suffering from LTMD.

Introduction: Les maladies cardio-vasculaires représentent une des causes majeures de mortalité en France. Elles sont la cause principale de surmortalité des personnes souffrant de troubles psychiques au long cours (TPLC) en dehors des causes liées au suicide. But de l'étude: Cet article vise à identifier, selon le point de vue de professionnels de soins primaires et de la psychiatrie, leurs attentes et leurs besoins pour apporter aux usagers de la psychiatrie une meilleur prise en charge médicale et paramédicale du risque cardiovasculaire (RCV). Méthode: Il s'agit d'une étude qualitative prospective et multicentrique réalisée en deux temps : une phase exploratoire, par entretiens individuels en début d'étude afin de permettre la création des grilles d'entretiens collectifs ad hoc, suivie d'une étude qualitative proprement dite, qui s'inscrit dans la lignée de l'anthropologie médicale et de la sociologie des systèmes de santé. Résultats: Les 30 professionnels de la psychiatrie interrogés s'accordent sur la nécessité d'une meilleure coordination avec les soignants en extra hospitalier. Même si une ouverture est prônée, on observe un rappel des spécificités de la psychiatrie et l'importance d'une prise en compte générale de ces spécificités. Les 26 professionnels de soins primaires témoignent d'une volonté de mieux connaître les troubles, pathologies et traitements psychiatriques pour faciliter la prise en charge de ces patients à besoins spécifiques. Conclusion: Le croisement de ces résultats permettra de proposer une intervention appropriée en vue d'induire des effets probants sur la réduction du RCV chez les personnes souffrant de TPLC.

Reducing cardiovascular risk in people living with long-term psychiatric disorders / Réduire le risque cardiovasculaire chez les personnes vivant avec des troubles psychiques

INTRODUCTION: This qualitative study based on focus group study aims to identify experiences, expectations, and representations of people with long-term mental illness and their caregivers regarding cardiovascular disease and its risk factors. The aim of this work is to build a cardiovascular risk reduction program for people affected by long-term mental illness. RESULTS: Four major themes were identified in the corpus: (1) knowledge concerning physical health, (2) barriers to the implementation of better practices, (3) levers towards a healthier life and (4) expectations and needs for a better lifestyle. CONCLUSIONS: This work has provided us with concrete elements for the creation of a cardiovascular risk reduction program for people living with long-term mental illness. The challenges of this program will be to adapt to the needs and expectations of people living with long-term mental illness while facilitating the role of caregivers.

Introduction: Cette étude qualitative, basée sur des Focus Groups, vise à identifier les expériences, attentes et représentations des personnes ayant des troubles psychiques au long cours (TPLC) ainsi que des aidants concernant les maladies cardiovasculaires et leurs facteurs de risque. Le but de ce travail est de construire un programme de réduction du risque cardiovasculaire (CV), destiné aux personnes concernées par ces troubles. Résultats: Quatre thèmes majeurs ont été identifiés dans le corpus : (1) les connaissances et acquis concernant la santé physique, (2) les freins à la mise en place de meilleures pratiques, (3) les leviers vers une vie plus saine et (4) les attentes et besoins pour une meilleure hygiène de vie. Conclusions: Ce travail nous a fourni des éléments concrets pour la création d'un programme de réduction du risque CV pour les personnes vivant avec un TPLC. Les enjeux de ce programme seront de s'adapter aux besoins et aux attentes des personnes vivant avec un TPLC tout en facilitant le rôle des aidants.

[A practitioner's perspective of the latest lipid guidelines]. / Dernières recommandations européennes sur les dyslipidémies.

The latest ESC recommendations propose several interesting new concepts for the practitioner. The recommendations distinguish between the «apparently healthy¼ patient and the patient at specific cardiovascular risk (diabetes, renal failure, and familial hypercholesterolemia). New risk calculation tools are proposed (SCORE2 and SCORE2-OP). The proposed LDL-C targets are specific to each group, as a general rule, < 1.8 mmol/l for individuals at high risk and < 1.4 mmol/l for individuals at very high risk. Presence of risk modifiers, comorbidities and patient preferences modulates therapeutic approach which is usually based on optimizing lifestyle and statin medication when necessary.

Les dernières recommandations de l'European Society of Cardiology (ESC) introduisent plusieurs nouveaux concepts intéressants pour le praticien. Le patient «en bonne santé apparente¼ est différencié de celui à risque spécifique (diabète, insuffisance rénale et hypercholestérolémie familiale). De nouveaux outils de calcul du risque cardiovasculaire sont proposés (SCORE2 et SCORE2-OP). Les cibles de LDL-C proposées sont spécifiques à chaque groupe avec, en règle générale, une valeur < 1,8 mmol/l pour les patients à haut risque et < 1,4 mmol/l pour ceux à très haut risque. La présence de modificateurs de risque, les comorbidités et les préférences du patient modulent l'approche thérapeutique, qui repose habituellement sur le respect des règles hygiénodiététiques et, au besoin, l'administration d'une statine.

Results of a Qualitative Study Aimed at Building a Programme to Reduce Cardiovascular Risk in People with Severe Mental Illness.

People with severe mental illness (PSMI) have a shorter life expectancy and are more likely to have cardiovascular disease than the general population. Patients, carers, psychiatric professionals and primary care providers can all play a role in increasing PSMI physical health. The present qualitative exploratory study aimed to explore the views of these four populations as part of the multi-phase COPsyCAT project, whose objective is to build and test a cardiovascular risk prevention programme for PSMI. Overall, 107 people participated in the study's 16 focus groups, which were transcribed and analysed in a thematic analysis. With a view to building the health promotion programme, major themes identified in the corpus were translated into a list of needs as follows: communication, information, training and support. Results show that it is essential to improve communication between all the different stakeholders in mental health. The greatest challenge facing this programme will be to adapt it to the needs and expectations of PSMI while facilitating work between the various mental health stakeholders. Simple and inexpensive actions could be taken to improve the cardiovascular health of PSMI and will be experimented with during the programme's feasibility study which will start in September 2022.

"It depends how one understands it:" a qualitative study on differential uptake of oral cholera vaccine in three compounds in Lusaka, Zambia.

BACKGROUND: The Zambian Ministry of Health implemented a reactive one-dose Oral Cholera Vaccine (OCV) campaign in April 2016 in three Lusaka compounds, followed by a pre-emptive second-round in December. Understanding uptake of this first-ever two-dose OCV campaign is critical to design effective OCV campaigns and for delivery of oral vaccines in the country and the region. METHODS: We conducted 12 Focus Group Discussions (FGDs) with men and women who self-reported taking no OCV doses and six with those self-reporting taking both doses. Simple descriptive analysis was conducted on socio-demographic and cholera-related data collected using a short questionnaire. We analyzed transcribed FGDs using the framework of dose, gender and geographic location. RESULTS: No differences were found by gender and location. All participants thought cholera to be severe and the reactive OCV campaign as relevant if efficacious. Most reported not receiving information on OCV side-effects and duration of protection. Those who took both doses listed more risk factors (including 'wind') and felt personally susceptible to cholera and protected by OCV. Some described OCV side-effects, mostly diarrhoea, vomiting and dizziness, as the expulsion of causative agents. Those who did not take OCV felt protected by their good personal hygiene practices or, thought of themselves and OCV as powerless against the multiple causes of cholera including poor living conditions, water, wind, and curse. Most of those who did not take OCV feared side-effects reported by others. Some interpreted side-effects as 'western' malevolence. Though > 80% discussants reported not knowing duration of protection, some who did not vaccinate, suggested that rather than rely on OCV which could lose potency, collective action should be taken to change the physical and economic environment to prevent cholera. CONCLUSIONS: Due to incomplete information, individual decision-making was complex, rooted in theories of disease causation, perceived susceptibility, circulating narratives, colonial past, and observable outcomes of vaccination. To increase coverage, future OCV campaigns may benefit from better communication on eligibility and susceptibility, expected side effects, mechanism of action, and duration of protection. Governmental improvements in the physical and economic environment may increase confidence in OCV and other public health interventions among residents in Lusaka compounds.

End-user acceptability study of the nanopatch™; a microarray patch (MAP) for child immunization in low and middle-income countries.

A promising new delivery technology, the microarray patch (MAPs) consists of an array of small solid-coated or dissolvable needles, up to one mm in length, that administers a dry formulation of a vaccine or pharmaceutical. This study is not a real-life evaluation study but determines the anticipated acceptability of the Nanopatch™, a solid microarray patch device, in Benin, Nepal and Vietnam for vaccine delivery, and identifies factors that could improve the acceptability of the technology to increase measles immunization coverage. This study combined several evaluation methods, including simulation of vaccine administration on children and in-depth interviews with key stakeholders, healthcare workers, community health volunteers, caretakers, and community representatives. A total of 314 people participated in the study. The overall rate of total acceptability of the patch for child immunization was 92.7%. General opinions were very positive, providing clinical studies confirm that MAP administration is demonstrated to be painless, safe and effective for infectious disease prevention. The study participants were asked to consider the best strategy to introduce such vaccine delivery innovation. Firstly, delivery by skilled healthcare workers at the healthcare facilities will be preferred to establish the technology. Following this, administration by selected volunteers and outreach delivery may be possible, though under the supervision of skilled healthcare workers. This study's protocol received approval from the World Health Organization (WHO) Ethical Research Committee (ERC0002813) and the national IRB in Benin, Nepal and Vietnam.

Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka, Zambia.

INTRODUCTION: Heterogeneous coverage threatens to compromise the effectiveness of immunization programs in Zambia. Demand-creation initiatives are needed to address this; however, there is incomplete understanding of why vaccine coverage is suboptimal. We investigated overarching perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements in Lusaka, Zambia. METHODS: Nested within a cholera vaccination uptake study, we sought to understand overarching perceptions on vaccines' hesitancy in three informal settlements in Lusaka, Zambia. We conducted 48 focus group discussions with a convenience sample of laypersons, lay healthcare workers, neighbourhood health committee members and vaccinators. RESULTS: Both laypersons and community-based health actors reported high vaccine acceptance though several sources of hesitancy were reported. Traditional remedies, alcohol use and religious beliefs emerged as drivers of vaccine hesitancy, likely reinforced by a background of distrust towards western medicine. Also mentioned were previous adverse events, fear of injections and low perceived need for immunization. Limited understanding of how vaccines work and overlapping local terms for vaccine and other medical concepts created confusion and inaccurate views and expectations. Some reported refusing injections to avoid pain and perceived risk of infection. Discussants emphasised the importance of education and preferred mobile immunization campaigns, with weekend to reach those with poor access and delivered by a combination of professional and volunteer workers. CONCLUSIONS: Vaccine hesitancy in Zambia is underpinned by many factors including personal experiences with vaccinations, alternative belief models, limited knowledge, deep misunderstanding about how vaccines work, and barriers to access. To overcome these, community-driven models that incorporate factual communication by professionals and operate outside of traditional hours, may help. Better research to understand community preferences for vaccine uptake could inform interventions to improve immunization coverage in Zambia.

Innovative vaccine delivery strategies in response to a cholera outbreak in the challenging context of Lake Chilwa. A rapid qualitative assessment.

A reactive campaign using two doses of Shanchol Oral Cholera Vaccine (OCV) was implemented in 2016 in the Lake Chilwa Region (Malawi) targeting fish dependent communities. Three strategies for the second vaccine dose delivery (including delivery by a community leader and self-administration) were used to facilitate vaccine access. This assessment collected vaccine perceptions and opinions about the OCV campaign of 313 study participants, including: fishermen, fish traders, farmers, community leaders, and one health and one NGO officer. Socio-demographic surveys were conducted, In Depth Interviews and Focus Group Discussions were conducted before and during the campaign. Some fishermen perceived the traditional delivery strategy as reliable but less practical. Delivery by traditional leaders was acceptable for some participants while others worried about traditional leaders not being trained to deliver vaccines or beneficiaries taking doses on their own. A slight majority of beneficiaries considered the self-administration strategy practical while some beneficiaries worried about storing vials outside of the cold chain or losing vials. During the campaign, a majority of participants preferred receiving oral vaccines instead of injections given ease of intake and lack of pain. OCV was perceived as efficacious and safe. However, a lack of information on how sero-protection may be delayed and the degree of sero-protection led to loss of trust in vaccine potency among some participants who witnessed cholera cases among vaccinated individuals. OCV campaign implementation requires accompanying communication on protective levels, less than 100% vaccine efficacy, delays in onset of sero-protection, and out of cold chain storage.

A rapid qualitative assessment of oral cholera vaccine anticipated acceptability in a context of resistance towards cholera intervention in Nampula, Mozambique.

INTRODUCTION: While planning an immunization campaign in settings where public health interventions are subject to politically motivated resistance, designing context-based social mobilization strategies is critical to ensure community acceptability. In preparation for an Oral Cholera Vaccine campaign implemented in Nampula, Mozambique, in November 2016, we assessed potential barriers and levers for vaccine acceptability. METHODS: Questionnaires, in-depth interviews, and focus group discussions, as well as observations, were conducted before the campaign. The participants included central and district level government informants (national immunization program, logistics officers, public health directors, and others), community leaders and representatives, and community members. RESULTS: During previous well chlorination interventions, some government representatives and health agents were attacked, because they were believed to be responsible for spreading cholera instead of purifying the wells. Politically motivated resistance to cholera interventions resurfaced when an OCV campaign was considered. Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumors related to vaccine safety, and negative experiences following routine childhood immunization. Despite major suspicions associated with the OCV campaign, respondents' perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy. DISCUSSION: Potential hesitancy towards the OCV campaign is grounded in global insecurity, social disequilibrium, and perceived institutional negligence, which reinforces a representation of estrangement from the central government, triggering suspicions on its intentions in implementing the OCV campaign. Recommendations include a strong involvement of community leaders, which is important for successful social mobilization; representatives of different political parties should be equally involved in social mobilization efforts, before and during campaigns; and public health officials should promote other planned interventions to mitigate the lack of trust associated with perceived institutional negligence. Successful past initiatives include public intake of purified water or newly introduced medication by social mobilizers, teachers or credible leaders.

Costing analysis and anthropological assessment of the vaccine supply chain system redesign in the Comé District (Benin).

OBJECTIVE: At the end of 2013, a pilot experiment was carried out in Comé health zone (HZ) in an attempt to optimize the vaccine supply chain. Four commune vaccine storage facilities were replaced by one central HZ facility. This study evaluated the incremental financial needs for the establishment of the new system; compared the economic cost of the supply chain in the Comé HZ before and after the system redesign; and analyzed the changes induced by the pilot project in immunization logistics management. METHOD: The purposive sampling method was used to draw a sample from 37 health facilities in the zone for costing evaluation. Data on inputs and prices were collected retrospectively for 2013 and 2014. The analysis used an ingredient-based approach. In addition, 44 semi-structured interviews with health workers for anthropological analysis were completed in 2014. RESULTS: The incremental financial costs amounted to US$55,148, including US$50,605 for upfront capital investment and US$4543 for ongoing recurrent costs. Annual economic cost per dose administered (including all vaccines distributed through the Expanded Program on Immunization (EPI)) in the Comé HZ increased from US$0.09 before system redesign to US$0.15 after implementation, mainly due to a high initial investment and the operational cost of HZ mobile warehouse. Interviews with health workers suggested that the redesigned system was associated with improvements in motivation and professional awareness due to training, supportive supervision, and improved work conditions. CONCLUSIONS: The system redesign involved a considerable investment at HZ level. Benefits were found in the reduction of transportation costs to health posts (HP) and commune health center (CHC) levels, and the strengthening of health workers professional skills at all levels in Comé. The redesigned system contributed to a decrease in funding needs at HP and CHC levels. The benefits of the investment need to be examined after the introduction of new vaccines and after a longer period.

Professional changes induced by a redesigned immunization supply chain in the Comé Health Zone, Benin.

At the end of 2013, the Government of Benin and Agence de Médecine Préventive (AMP) launched a demonstration project in Comé Health Zone (HZ) to optimize the vaccine supply chain. A key part of the demonstration project was the creation of an "informed push model" of vaccine distribution supported by a new logistician position at the health zone (district) level. At the conclusion of the demonstration project in 2015, the authors conducted an anthropological study consisting of semi-structured interviews with 62 participants to assess how the new model changed the professional identities, roles, responsibilities, and practices of personnel involved in vaccine management during and just after the demonstration project end in Comé HZ. The study found that health workers considered the logistician as a key player in enabling them to perform their public health mission, notably by improving knowledge and practices in vaccine management, providing supportive supervision, and improving the availability of vaccines and other supplies so that immunization sessions could occur more reliably and professionally within the communities they served. The demonstration project was widely accepted among study participants. The study was approved by the Cotonou Ethics Committee (CER-ISBA No. 56 dated 09/04/2015).

Acceptability and Feasibility of Delivering Pentavalent Vaccines in a Compact, Prefilled, Autodisable Device in Vietnam and Senegal.

BACKGROUND: Prefilled syringes are the standard in developed countries but logistic and financial barriers prevent their widespread use in developing countries. The current study evaluated use of a compact, prefilled, autodisable device (CPAD) to deliver pentavalent vaccine by field actors in Senegal and Vietnam. METHODS: We conducted a logistic, programmatic, and anthropological study that included a) interviews of immunization staff at different health system levels and parents attending immunization sessions; b) observation of immunization sessions including CPAD use on oranges; and c) document review. RESULTS: Respondents perceived that the CPAD would improve safety by being non-reusable and preventing needle and vaccine exposure during preparation. Preparation was considered simple and may reduce immunization time for staff and caretakers. CPAD impact on cold storage requirements depended on the current pentavalent vaccine being used; in both countries, CPAD would reduce the weight and volume of materials and safety boxes thereby potentially improving outreach strategies and waste disposal. CPAD also would reduce stock outages by bundling vaccine and syringes and reduce wastage by using a non-breakable plastic presentation. Respondents also cited potential challenges including ability to distinguish between CPAD and other pharmaceuticals delivered via a similar mechanism (such as contraceptives), safety, and concerns related to design and ease of administration (such as activation, ease of delivery, and needle diameter and length). CONCLUSIONS: Compared to current pentavalent vaccine presentations in Vietnam and Senegal, CPAD technology will address some of the main barriers to vaccination, such as supply chain issues and safety concerns among health workers and families. Most of the challenges we identified can be addressed with health worker training, minor design modifications, and health messaging targeting parents and communities. Potentially the largest remaining barrier is the marginal increase in pentavalent cost--if any--from CPAD use, which we did not assess in our study.

A systematic literature review of missed opportunities for immunization in low- and middle-income countries.

BACKGROUND: Missed opportunities for immunization (MOIs) may contribute to low coverage in diverse settings, including developing countries. METHODS: We conducted a systematic literature review on MOIs among children and women of childbearing age from 1991 to the present in low- and middle-income countries. We searched multiple databases and the references of retrieved articles. Meta-analysis provided a pooled prevalence estimate and both univariate and multivariate meta-regression analysis was done to explore heterogeneity of results across studies. RESULTS: We found 61 data points from 45 studies involving 41,310 participants. Of the 45 studies, 41 involved children and 10 involved women. The pooled MOI prevalence was 32.2% (95% CI: 26.8-37.7) among children - with no change during the study period - and 46.9% (95% CI: 29.7-64.0%) among women of child-bearing age. The prevalence varied by region and study methodology but these two variables together accounted for only 12% of study heterogeneity. Among 352 identified reasons for MOIs, the most common categories were health care practices, false contraindications, logistic issues related to vaccines, and organizational limitations, which did not vary by time or geographic region. CONCLUSIONS: MOI prevalence was high in low- and middle-income settings but the large number of identified reasons precludes standardized solutions.