Hidden Epidemic

Abstract

Rates of HIV infection among the seriously and persistently mentally ill contradict the widely held belief that this population is not at high risk for HIV exposure. The literature suggests that, in part, due to pervasive misconceptions around issues of sexuality and illicit drug use, HI V-positive, mentally ill individuals are not receiving appropriate care. This article focuses on the interplay of mental illness, HIV infection, and service provision through a review of the literature and the presentation of a case study. Available services are detailed and barriers to their success discussed. The importance of comprehensive community-based services specifically designed to address the multifaceted needs of this population is highlighted.     

Continuity,Engagement and Integration: Early Intervention in Remote Australian Aboriginal Communities

Over the last decade there has been at best limited implementation of preventive interventions for vulnerable Aboriginal and Torres Strait Islander children and their families in remote communities of northern Australia despite growing involvement in the child protection system. This paper describes challenges for services seeking to engage parents who are subject to child protection measures. Brief case studies from an early intervention program in a remote community illustrate that responsiveness and continuity of engagement of parents over time is a necessary basis for an integrated approach to meeting the needs of vulnerable children and families in very remote settings.     

Going the distance: serving the needs of older youth at scale

Few communities have developed successful strategies for attracting large numbers of older youth to their out-of-school-time programs. In addition to meeting the unique developmental and programmatic needs of this population, communities have struggled with the challenge of creating communitywide integrated approaches to service delivery and resource development. Communities wanting to build a system of supports for older youth must do so in the context of a communitywide strategy as opposed to fragmented, individually operating programs and services. A communitywide strategy creates greater opportunity for strategic mobilization of resources, greater funding leverage, evaluation and assessment consistency, and more powerful input into creating a public voice and public will for supporting and serving older youth as they make the transition to adulthood.     

Saviors and Services: The Interface of Neoliberal Deprivation,Hegemonic Christianity,Social Exclusion,and Rural Church Resource Provision☆

With one-third of rural areas in the United States living in persistently high poverty, churches are some of the most prolific—and often only—sources of resource-provision in rural places. This paper qualitatively examines the complex role that churches play as resource providers in rural areas. Further, we examine the ways churches are helpful and/or harmful in meeting the needs of those experiencing vulnerability. We fuse hegemonic Christianity with social exclusion and neoliberalism to argue that rural people may not only experience ostracization and othering, but can also lose access to already-limited resources in rural areas as a result. Using community-based action research, ethnography, 47 semi-structured interviews, and research participant-driven photography from a town we call Gordon, we find that while churches are important resource-providers, they perpetuate hegemonic Christianity, hold exclusionary power, and act as critical gatekeepers for resources. This often results in ostracization and jeopardizes resource provision for those most vulnerable. This is a critical finding that demonstrates the complexity of resource provision, church influence, and rurality. We highlight participants’ suggestions for ways to expand services in rural places without solely relying on religious organizations.     

Developing a community-based care system for seriously emotionally disabled children and youth

The needs of emotionally disabled children and their families are not optimally served within traditional mental health service delivery systems. Policies are inadequate, delivery systems are insufficient and underfunded, and supporting research is sparse. As communities begin addressing the needs of the seriously emotionally disabled child and family, planning should address community coordinated services. Such systems, however, are not easily established and maintained in communities accustomed to addressing children's needs in terms of existing fragmented categorical structures. National models exist but care and time are required to adapt critical elements from these models to local need. This article will review the rationale for integrated community-based, case management services for children and adolescents. A case example is offered illustrating issues affecting the development of one community support system.     

Police Encounters for Behavioral Health-Related Reasons in Rural and Remote Communities: A Canadian Study☆

Evidence suggests police officers are increasingly called upon to respond to incidents related to mental health issues, emotional problems, and substance abuse. Many have raised concerns regarding their involvement in such incidents. Yet, little is known about these encounters in rural and remote communities despite evidence suggesting that the context of non-urban areas should matter. Accordingly, this article proposes to examine variations in self-reported encounters with the police for behavioral health-related reasons across urban, rural, and remote communities. Using data from the 2014 General Social Survey, a representative sample of the Canadian population, we assess these self-reported encounters from two different angles: encounters for one's own behavioral health crisis and encounters for a family member's behavioral health needs. While findings on the former are inconclusive, those examining police contacts for a family member suggest that living in rural or remote communities is significantly associated with a greater probability of experiencing such situations relative to living in urban areas. Furthermore, this probability increases with the relative geographical isolation of communities. These results are discussed in light of the rising concerns regarding our reliance on the police for such incidents and the need to account for the situation of rural and remote communities.     

Family Caregivers for Seniors in Rural Areas

In this article, the demographic characteristics of family caregivers for seniors in rural communities are assessed to examine whether their circumstances could facilitate or impede their well-being. Services available in rural communities for family members providing ongoing care to frail seniors is examined, particularly those that provide health and social services. How families access these services and whether there are specific barriers in service provision are analyzed based on current social work practice and the research literature. Trends for future services are identified as well as whether these trends support new roles for social workers in rural settings.     

Necessary Steps in Designing a Successful Contract

Abstract

Parents with a history of serious mental illness are vulnerable in many ways and are therefore likely to be accessing services from a range of government and community agencies. The use of multiple services, sometimes with conflicting practice frameworks, can result in sub-optimal management of these families. This study surveyed 77 service providers from a range of government and non-government agencies targeting their views regarding parents with a serious mental illness (specified in this study as schizophrenia, bipolar disorder and psychotic depression). They were asked what they perceived were difficulties for this population, interventions required to meet the needs of this group and finally, barriers to effective service delivery. We found that service providers reported that current services were inadequate for these parents. Parent-based interventions were seen as being more beneficial than those targeting children. Lack of liaison between agencies and lack of coordinated service provision were seen as the greatest barrier to effective service delivery. The results highlight the need for policy planners and service providers to develop strategies to ensure effective coordination between services that work with this population.     

Living with dementia in rural and remote Scotland: Diverse experiences of people with dementia and their carers

There is a lack of research into people's experiences of using services as dementia sufferers themselves, or because they care for someone with dementia, in rural areas. This article explores their experiences in the context of rural Scotland, drawing on data gathered from both people with dementia and their carers. Our research suggests that understanding the nuanced and co-constituted experience of dementia in rural communities is a pre-requisite for improving service provision. The paper explores the way in which participants linked their experiences to their spatial location in rural areas. Our findings suggest that participants used a narrative of idealised rurality which linked together interwoven and overlapping social networks, a physical relationship with place and a sense of self sufficiency. However, the participants’ stories also highlighted the diversity in experiences as service users between places, suggesting a disjunction between the generalising narrative of the rural idyll and their particular situations. These findings extend the literature on rural mental health issues and on the experience of dementia in particular, in turn helping to inform place and person centred policies.     

Give your child and adolescent mental health service a health economics makeover

Specialist child and adolescent mental health services (CAMHS) must make decisions about what treatments to provide to whom, when, where and how, within limited budgets. This raises questions about how services make such decisions, to best meet the mental health needs of their catchment. The methods and practices of Health Economics, a field with considerable expertise in measuring performance in health systems, can help CAMHS make better informed decisions regarding service provision. This paper identifies a process through a set of focused questions to help CAMHS examine and improve their performance. The aspects covered are service profile, costs, conceptualisation of outcomes and identification of value for money. The recommended approach should help CAMHS redirect resources to maximise benefits for their catchment population.     

Establishing a mental health service for young children in out-of-home care: The Gumnut Clinic for 0 to 5 year olds in Western Sydney

Objective

Children aged 0 to 5 years in out-of-home care represent a vulnerable population at high risk of social, emotional and developmental problems, yet there are few services specifically addressing their psychological needs. This paper is the first of two concerning the establishment of The Gumnut Clinic, a specialist mental health assessment clinic in Western Sydney for this population. The current paper provides the rationale for the development of the clinic and detail of the referral and assessment processes.

Method

The paper describes the establishment of The Gumnut Clinic at Redbank House in Sydney, Australia, the approach to assessment of these young children and their carers, and the challenges encountered.

Conclusions

Young children are overrepresented in child protection and out-of-home care services. Their social, emotional and developmental needs are under-recognized. Development of a specialist mental health service is a step towards improving health outcomes for these children.     

Employment services for persons with serious mental illness in northeastern Ontario: The case for partnerships

Objective: To better understand why employment success is low, a case study was conducted to examine the influence of place on access to employment for persons with serious mental illness (SMI) residing in two northeastern Ontario communities (Rebeiro, in progress). Methods: Community-based participatory research methods were used to engage persons who experience SMI, decision-makers and providers in the research. Forty-six interviews were conducted, complemented by primary and secondary quantitative data sources.Results: While most consumers consider employment to be a key element of their recovery, employment rates for persons with SMI remain limited in northeastern Ontario, Canada. The findings of this case study reveal the importance of collaborative partnerships to fostering better employment outcomes in northeastern Ontario. Conclusion: The challenges of collaboration due to rural and northern tensions, as well as various jurisdictional and funding tensions existing at the level of community support the case for partnerships in the provision of employment services in northern and rural places.     

Sources of Double Disadvantage for People with Disabilities Living in Remote and Rural Areas of New South Wales, Australia

This study demonstrates how people with disabilities living in remote and rural areas experience double disadvantage in regard to receipt of services. They tend to experience similar disadvantages to other remote and rural dwellers (as compared with their urban counterparts), but these disadvantages are compounded by those associated with living in an environment which does not cater for the needs of people with disabilities. Findings display how geographical, physical, cultural, social and psychological factors within the external environment create disadvantages for the individual. The project involved data collection from people with disabilities, disability groups, service providers, families and carers through consultations and field trips. Major issues emerging from consultations were concerned with: transport and distance, isolation, the need for more consumer involvement, the nature of service provision (appropriateness, flexibility, co-ordination and location), the need for community and professional disability awareness education, protection of rights, carers and respite care, accommodation and housing, education, employment, information dissemination and access to specialised equipment. Comparison with overseas studies indicates that findings from this Australian study have applicability in other countries which have large remote and rural areas.     

Changes in service provision in rural areas. Part 2: Changes in post office provision in mid Wales: A GIS-based evaluation

This paper develops themes set out in Part 1 of this paper relating to the importance of public service provision in rural areas, particularly for potentially vulnerable members of the community such as the elderly, unemployed and single parents. Changes in a key service sector, post office services, in rural mid Wales over a 15-year period are assessed and analysed in relation to the developing sociodemographic profile of the underlying population. A Geographic Information System (GIS) approach is adopted to chart changing levels of post office provision in the study area, and the subsequent impacts on accessibility to those post offices. The policy significance of developing measures of accessibility to services with a view to incorporating these GIS-generated measures into traditional area-based indicators of disadvantage is highlighted.     

Diversity Within Diversity

Summary

Asian American elderly form a heterogeneous group with respect to immigration history, ethnic/cultural background, socioeconomic position, and health and mental health status. This paper provides an overview of the internal heterogeneity within the Asian American elderly population and identifies those who experience multiple stressors affecting their quality of life. Then it discusses barriers to formal service utilization as well as strengths and deficits of informal support systems. To better serve Asian American elders with their multiple needs for health, mental health, and social services, increased funding is recommended for research on this group, diversification of social service programs in coethnic communities, and increased cultural competence in non-Asian social service agencies.     

Elderly migration and its implications for service provision in rural communities: an Ontario perspective

Following a discussion of the role of migration in the aging of rural populations and of consequent implications for service provision in rural communities, a case study featuring demographic and service use data for Grey County, Ontario, is presented. Cohort Survival Analysis of census data for the period 1971–1986 indicates a consistent net in-migration of elderly into the county and a complex but predictable pattern of elderly relocation from townships to villages and towns within Grey. The demographic analysis is complemented and extended by the examination of survey data on the residential history and service use of a sample of elderly residents drawn from two communities in Grey County. The survey results provide valuable clues for the interpretation of the demographic analysis and reveal residential history to be a potentially important pre-condition of dependence on formal services intended for the maintenance of elderly persons in the community. The paper concludes with a discussion of the need for local analysis of migration impacts and of the relationship between such impacts and longstanding problems of rural service provision.     

Prevention of child maltreatment in high-risk rural families: A randomized clinical trial with child welfare outcomes

Few studies have specifically examined prevention of child maltreatment among higher-risk populations in rural communities. The overarching goal of this study was to conduct a randomized clinical trial of SafeCare augmented for rural high-risk population (SC+) compared to standard home-based mental health services (SAU) to examine reductions in future child maltreatment reports, as well as risk factors and factors proximal to child maltreatment. Parents (N = 105) of young children (5 years or less) who had identifiable risk of depression, intimate partner violence, or substance abuse were randomized to SC+ or SAU. Participants randomized to SC+ were more likely to enroll (83% vs. 35% for SAU) and remain in services (35 h vs. 8 h for SAU). SC+ (for participants who successfully completed services) may have had limited impact on child welfare reports during service provision. Further, SC+ had fewer child welfare reports related to DV than SAU. Parent self-reports of parenting behaviors, risk factors, and protective factors did not demonstrate significant sustained program impact. Limitations include power constraints related to sample size. Promising next steps entail future trials with larger sample sizes examining service compliance and further augmentation of SafeCare to bolster service impact and address risk and protective factors.     

Problem Gambling in Non-English Speaking Background Communities in Queensland,Australia: A Qualitative Exploration

This paper provides an overview of qualitative research into problem gambling among non-English speaking background (NESB) communities in Queensland, Australia. The focus for this pilot study was the Chinese, Greek and Vietnamese communities. Using qualitative methodologies, this community-based research explored the motivations for gambling, and the impacts of problem gambling upon individuals and communities. Findings indicate that problem gambling is evident in each of the communities of study, but the issue is characterised by a pervasive sense of denial. Gambling is an issue of enormous shame and stigma, not only for the problem gambler but their entire family. As a result, most problem gamblers do not seek professional help but try to resolve the problem themselves or within the family unit. Research findings indicate that service access could be increased through a range of strategies including the provision of culturally appropriate community education and gambling help services, partnerships between NESB communities, gambling help services and community workers, and the development and implementation of preventative strategies.     

Social Work Students’ Interest in Working with Persons with Serious Mental Illness

Educating and recruiting practitioners to work in community-based settings with persons with serious mental illness has become a national health issue, particularly in underserved rural areas. To inform curriculum development and recruitment efforts, the authors conducted a needs assessment. Graduate and undergraduate social work students in a rural New England state university were surveyed about their interest, perceived competence, and perceived training needs in working with persons with serious mental illness. The findings indicated that almost half of the students expressed an interest in working with this population. The extent and nature of previous work with this population and educational level were shown to be related to students’ responses, in areas including interest in work with persons with serious mental illness and the perceived ability to handle a psychiatric crisis. The findings suggest important implications for the social work curriculum, additional needs assessment, and recruitment activity.     

Children with disabilities in out-of-home care: Perspectives on organisational collaborations

Many contemporary support services for children and young people (CYP) in out-of-home-care have adopted a collaborative approach to service provision in order to best meet the complex needs of clients. The purpose of this study was to gain a better understanding of the perceptions of Evolve Behaviour Support Services (EBSS) frontline and managerial staff delivering services to CYP in out-of-home-care with disability and complex behaviours regarding interagency/stakeholder collaboration. Views about the number and nature of collaborative partnerships, factors which facilitate or hinder effective relationships and advantages (including unintended benefits) of collaboration were sought. Qualitative interviews with 21 participants highlighted issues around: (1) general and agency/stakeholder specific issues and barriers, and (2) benefits of collaboration. The collaborative approach to service provision was seen as greatly enhancing the effectiveness of EBSS' response and ability to meet the range of CYP's complex needs, as well as having benefits for carers and service providers. Nevertheless, difficulties with collaboration were also encountered. Frequently identified challenges included reduced stakeholder engagement, differences in professional backgrounds and practice frameworks, unequal initiation of contact and follow-up, organisational disparities, communication and information sharing problems, frequent stakeholder turnover and geographical barriers in rural/remote areas.