Primary Health Care and Mental Health Notes

Primary Health Care

• Definition: PHC is a whole-of-society approach to health aiming to ensure the highest possible level of health and well-being and their equitable distribution.
  • Focuses on people’s needs early on.
  • Covers health promotion, disease prevention, treatment, rehabilitation, and palliative care.
  • Delivered in a close and feasible approach within people’s everyday environment.
• Rooted in: Commitment to social justice, equity, solidarity, and participation.
  • Based on the recognition that the highest attainable standard of health is a fundamental right of every human being without distinction.

Levels of Health Care

• Primary Health Care:
  • The first level of contact between the individual and the health system.
  • Provides essential health care (PHC).
  • Manages most of the prevailing health problems satisfactorily.
  • The closest to the people.
  • Provided by primary health centers.
• Secondary Health Care:
  • Deals with more complex problems.
  • Comprises curative services.
  • Provided by district hospitals.
  • The 1st referral level.
• Tertiary Health Care:
  • Offers super-specialist care.
  • Provided by regional/central level hospitals or institutions.
  • Provides specialized training programs.
  • Teaching hospitals, like Jordan University Hospital, provide Tertiary healthcare.

Guiding Principles of Primary Health Care

• Accessibility
• Public Participation
• Health Promotion
• Appropriate use of Technology
• Intersectoral Collaboration
• Equitable distribution
• Decentralization

Basic Elements of Primary Healthcare

• Education concerning prevailing health problems and methods of prevention and control.
• Promotion of proper nutrition.
• An adequate supply of safe water and basic sanitation.
• Maternal and child health care including Family Planning (FP).
• Immunization against major infectious diseases.
• Prevention and control of local endemic diseases.
• Appropriate treatment of common diseases.
• Providing essential drugs needed at the PHC level.

Extended Elements of PHC

• Expanded options of immunization
• Addressing reproductive health needs
• Provision of essential technologies for health
• Prevention and control of noncommunicable diseases
• Food safety and provision of selected food supplements.

The Basic Requirements for Sound PHC (The 8 A’s and the 3 C’s)

• Appropriateness
• Availability
• Adequacy
• Accessibility
• Acceptability
• Affordability
• Assessability
• Accountability
• Completeness
• Comprehensiveness
• Continuity

Alma Ata Declaration

• International Conference on Primary Health Care in Alma-Ata, Kazakhstan:
  • In 1978, ideas about health and health services shifted dramatically.
  • Organized by WHO and UNICEF.
  • Comprehensive Primary Health Care (PHC) was an approach and a philosophy of healthcare initiated in Alma Ata.
• Key Outcomes:
  • Comprehensive primary healthcare became a core policy for the World Health Organization.
  • Goal: ‘Health-for-All by the Year 2000’.
  • Global aim: To attain a level of health that will enable every individual to lead a socially and economically productive life through comprehensive primary healthcare.
• Principles:
  • Equity: Every individual has the right to health, requiring action across health, social, and economic sectors.
  • Participation: Need for full participation of communities in planning, organization, implementation, operation, and control of primary health care using national available resources.
  • Focus: Shifting towards preventive health, training of multipurpose paramedical workers, and community-based workers.
  • Partnership and collaboration: Between government, WHO, UNICEF, international organizations, NGOs, funding agencies, ministries of health, health workers, and communities.
  • Health promotion and effective use of resources.
• Comprehensive primary healthcare:
  • Defines health as complete physical, mental, and social wellbeing.
  • Addresses issues of equity and social justice.
  • Considers the impact of the social determinants of health.
  • Acknowledges the value of community development.
  • Recognises the expertise and the influence of individuals over their own health.

Components of Comprehensive PHC

• Integrated health services to meet people’s health needs throughout their lives.
• Addressing the broader social determinants of health through multisectoral policy and action.
• Empowering individuals, families, and communities to take charge of their own health.

Social View of Health

• Includes factors that can impact health including diet, housing, transport, education, safety and income, support from family & community, mental and social wellbeing.
• Access to health services, such as health professionals and hospitals, is also considered.

Factors Affecting Health

• Health
• Parenting styles
• Geographical mobility
• Family dynamics
• Social resources
• Biological factors
• Family finances
• Culture
• Employability
• Age
• Gender

Models of Primary Health Care

Goal of Achieving Health for All

• Has not been achieved until today.
• There have been reasonable improvements in immunization, sanitation, and access to safe water, still, there are barriers for providing equitable access to essential healthcare worldwide.
• There is no standard guidelines for Alma-Ata, but individual governments must develop their own strategies to meet their needs.
• Alma Ata failed in some countries because some Governments refused to allocate resources and put strategies towards sustaining a strong PHC.

Reasons for Slow Progress in “Health for All”

• Misconception that PHC as a 2nd rate health care for the poor.
• Centralized planning and management
• Difficulty in achieving intersectoral action for Health
• Unbalanced distribution of resources
• Insufficient political commitment
• Failure to achieve equity in access to all PHC components
• The continuing low status of women
• Slow socio-economic development
• Weak health promotion efforts
• Weak health information systems and lack of baseline data
• Pollution, poor food safety, and lack of water supply and sanitation
• Rapid demographic and epidemiological changes
• Inappropriate use and allocation of resources for high-cost technology
• Natural and manmade disasters

Relevance of Alma Ata Founding Principles Today

• It brings health care to people's doorstep.
• It encourages training of PHC staff and Community health workers to efficiently and effectively deliver health services.
• Access is improved, participation and partnership is encouraged, and health is improved in general.
• Evidence has shown that there is a greater range of cost-effective interventions that can be delivered at the PHC level now
• Forty-seven years ago, the values of equity, people centeredness, community participation and self determination embraced by the Alma Ata were considered radical but today these values have become widely shared expectations for health.
• The technological advancement and the increased wealth of knowledge and literature on health.
• The growing health inequalities between and within countries provide a relevant foundation to support the Alma Ata to deliver effective Comprehensive Primary Healthcare Services.

Aging World

• The world’s population is aging.
  • In 2024, 10% of the population is ages 65+ (800 million people).
  • Between 2015 and 2050, the proportion of the world's population over 60 years is expected to increase from 12% to 22%.
  • By 2050, the world’s population of people aged 60 years and older will be around 2.1 billion.
  • The number of persons aged 80 years or older is expected to triple by 2050 and reach 426 million (WHO forecasts).
• Shift is occurring globally.
  • Started in high-income countries (e.g., Japan, where 30% of the population is already over 60 years old).
  • Low- and middle-income countries are now experiencing the greatest change.
  • By 2050, 80% of older people will be living in low- and middle-income countries.
• Implications:
  • Not necessarily a cause for concern but something to plan for.
  • All countries face major challenges to ensure that their health and social systems are ready to cope with the anticipated demographic shift.
• Challenges Posed by Population Aging:
  • Shifts in the burden of disease to include more chronic diseases such as hypertension and diabetes.
  • Higher demand for caregiving.
• Role of Primary Health Care (PHC):
  • Includes preventive measures that are crucial in delaying the onset of age-related diseases and maintaining older adults’ health.
  • Helps reduce the long-term burden on health systems.

The Demographic Transition Model

• Used to represent the transition from high birth and death rates to low birth and death rates as a country develops from a pre-industrial to an industrialized economic system.
• Useful for determining the economic development of a country using their demographic statistics.
• Stages:
  • Stage 1: High birth and death rates. Population growth is low and fluctuating.
  • Stage 2: Birth rate remains high. The death rate is falling. Population growth is high.
  • Stage 3: Birth rate starts to fall. The death rate continues to fall. Population growth is moderate.
  • Stage 4: Both the birth and death rate is low. Population growth is very low.
  • Stage 5: Birth rates fall slightly. Death rate is steady. Decline in population (slow decrease).

Epidemiology

• Epidemiology is a branch of medical science that studies the distribution of DISEASE in human populations and the factors that determines its distribution, principally by using STATISTICS.

The Epidemiologic Transition Theory (Abdel Omran, 1971)

• Describes the stages of development that are characterized by a shift in population growth, life expectancy, and disease patterns.
• Describes the process by which the pattern of mortality and disease is transformed from one of high mortality among infants and children, episodic famine, and epidemics affecting all age groups to one of degenerative and man-made diseases (such as those attributed to smoking) affecting principally the elderly.
• Involves:
  • Timescales spanning decades or centuries.
  • Reduction in mortality followed by a reduction in fertility.
  • Increased proportion of aging population.
  • Shift from communicable to non-communicable diseases.
  • Less malaria, diarrhoeal diseases, TB and HIV/AIDS.
  • More non-communicable diseases: cardiovascular diseases, cancer, COPD, road traffic accidents and diabetes mellitus.

Stages of Epidemiologic Transition

• Stage I: Pestilence and Famine
  • Infectious and parasite diseases were principle causes of death along with accidents and attacks by animals and other humans.
  • Most violent Stage I epidemic was the Black Plague(black death) probably transferred to humans by fleas from infected rats.
  • 25 million Europeans died between 1347 to 1350.
• Stage II: Receding Pandemics
  • Improved sanitation, nutrition, and medicine during the Industrial Revolution reduced the spread of infectious diseases.
  • Death rates did not improve immediately and universally during the early years of the Industrial Revolution.
  • Poor people who crowded into Industrial Cities had high death rates due to cholera, due to acute diarrhea and vomiting that can kill within hours if left untreated.
• Stage III: Degenerative Diseases
  • Associated with the chronic diseases of aging.
  • Cardiovascular diseases and cancer
  • Sub-Saharan Africa and South Asia have low incidences of cancer primarily because of low life expectancy.
• Stage IV: Delayed Degenerative
  • Life expectancy of older people is extended through medical advances.
  • Cancer medicines, bypass surgery and better diet.
  • Consumption of non-nutritious food and sedentary behavior have resulted in an increase in obesity in this stage.
• Stage V
  • Reemergence of infectious and parasitic diseases; diseases thought to have been eradicated or controlled return, and new ones emerge

Possible Reasons for Stage V

• Evolution – new strains due to drug resistance (malaria)
• Poverty- more infections due to unsanitary conditions (TB)
• Increased globalization – spread through relocation diffusion (H1N1/swine, severe acute respiratory syndrome (SARS) and COVID-19.

Epidemiologic Transition - Causes of Shift

• Aging of the population (non-communicable diseases affect older adults at the highest rates).
• Improvements in medical care (children no longer die from malnutrition or easily curable conditions).
• Public health interventions (vaccinations, clean water, and sanitation reduce infectious diseases).
• Wealthier countries are more advanced along this transition.

Leading Causes of Death Globally (2000 vs. 2019)

• Shift from communicable to non-communicable diseases.
• Includes global and income-specific data for 2000 and 2019. (See Slides 48-52 for Detailed Breakdown)

PRIMARY HEALTH CARE

• About 50% of the world’s population lacks access to good primary health care.
• PHC is a platform for integrated health service delivery to meet people’s changing needs at every age: such as pregnancy care, childhood immunizations, and care for noncommunicable diseases like high blood pressure (hypertension).
• PHC supports people to live longer, healthier lives
• Investments to scale up access to quality PHC across low- and middle-income countries can prevent as many as 60 million deaths by 2030 and average life expectancy could increase by 3.7 years.
• To realize this, we must ensure quality PHC that is centered on people and is continuous, comprehensive, and coordinated to meet their evolving health needs at all stages of life.

Mental Health

• WHO Definition: a state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities
• Concepts: subjective well-being, perceived self-efficacy, autonomy, competence and recognition of the ability to realize one’s intellectual and emotional potential.

The Health Triangle

• Health is the measure of our over-all well-being.
• The health triangle is a measure of the different aspects of health.
• The health triangle consists of: Physical, Social, and Mental Health.
• Integral part of health; no health without mental health.
• More than the absence of mental disorders.
• Mental health is determined by a range of socioeconomic, biological and environmental factors.
• Deals with how we think, feel and cope with daily life.
• Encompasses learning to cope with stress , stress management, and mental illnesses or disorders.

Global Burden of Mental Illness

• Mental disorders are important risk factors for other diseases, as well as unintentional and intentional injury.
• Mental disorders increase the risk of getting ill from other diseases such as HIV, cardiovascular diseases, diabetes, and vice-versa.

Underestimation of Global Burden

• High prevalence, early age of onset, chronicity and associated functional impairment.
• Overlap between psychiatric and neurological disorders;
• The grouping of suicide and self-harm as a separate category;
• Blending of all chronic pain syndromes with musculoskeletal disorders;
• Exclusion of personality disorders from disease burden calculations;
• Inadequate consideration of the contribution of severe mental illness to mortality from associated causes.

Statistics (2021)

• 13.9% of the world’s population experienced mental disorders.
• 17.2% of the total DALYs in the world were due to mental disorders
• 71% of global anxiety disorder burden could be avoided if all people with anxiety disorders accessed optimal treatment.
• Mental disorders are among the top 10 leading causes of DALYs worldwide.
• Since 1990, mental disorders have jumped up in the ranking of top causes of burden of diseases worldwide – from 9th to 6th place.
• Depression affects over 300 million people worldwide, regardless of culture, age, gender, religion, race or economic status.
• More than 75% of people in low- and middle-income countries receive no treatment for depression.
• 284 million people suffer from an anxiety disorder worldwide
• Anxiety disorders disproportionately affect women more than men; 2.8% of males suffer from an anxiety disorder, where 4.7% of females suffer from anxiety disorders
• In the first year of the COVID-19 pandemic, global prevalence of anxiety increased by a massive 25%

Global Suicide Statistics

• Mental disorders and harmful use of alcohol and drugs contribute to many suicides around the world.

• More than one in every 100 deaths result from suicide.

• 800 000 persons approximately die from suicide globally each year

• 80% of suicides occur in low- and middle-income countries.

• Suicide is the fourth leading cause of death globally in 15-29-year-olds.

• Young adults and elderly women in low- and middle-income countries have much higher suicide rates than their counterparts in high-income countries.

• There are indications that for each adult who died of suicide there may have been more than 20 others attempting suicide.

Suicide, Globally

• Women are more likely to be diagnosed with depression and to attempt suicide.
• Globally, more than twice as many males die due to suicide as females.
• More substance use and alcohol use among men, due to masculinity perceptions and social norms, men less likely to seek mental healthcare and they use more violent suicide methods.
• Suicide rates among men are generally higher in high-income countries
• For females, the highest suicide rates are found in lower-middle-income countries.
• The lowest suicide rate was are seen the Eastern Mediterranean region

Substance Abuse Disorder Statistics

• 178 million people worldwide suffer from a substance abuse disorder, including drugs and alcohol.
• Globally, substance abuse is responsible for 11.8 million deaths annually This is one in five deaths globally.
• More than half of those who die from alcohol or drug overdoses are younger than 50.
• Substance abuse disproportionately affects more men than women, with 2% of males experiencing a substance abuse disorder, where only 0.8% of females experience a substance abuse disorder.

Global Access to Mental Health Services

• Mental health care services are often not available or are under- utilized, particularly in developing countries.
• In developed countries, the treatment gap (the % of individuals who need mental health care but do not receive treatment) ranges from 44% to 70%.
• In developing countries, the treatment gap can be as high as 90%.
• Huge inequity in the distribution of skilled human resources for mental health
• Shortages of psychiatrists, psychiatric nurses, psychologists and social workers in low- and middle-income countries.

Determinants of Mental Health

• Multiple social, psychological, and biological factors determine the level of mental health of a person at any point of time.
• For example, violence, sexual abuse and persistent socio-economic pressures are recognized risks to mental health.
• Poor mental health is also associated with stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, physical ill- health and human rights violations.
• Psychological and personality factors that make some people vulnerable to mental health problems.
• Biological risks include genetic factors.
• War and disasters have a large impact on mental health and psychosocial well-being
• Rates of mental disorder tend to double after emergencies.
• Human rights violations of people with mental and psychosocial disability are routinely reported in many countries
• These include physical restraint, seclusion and denial of basic needs.
• Few countries have a legal framework that adequately protects the rights of people with mental disorders.

Barriers of Mental Health Care

• Lack of mental health Governance
• No prioritization of mental health in the public health agenda and insufficient mental healthcare policies.
• Lack of universal health coverage and poor funding of mental health care.
• Limited availability and affordability of mental health care services
• Deficiency in the organization of mental health services at all levels and lack of integration at the primary healthcare level.
• Challenges in accessing mental health clinics
• Under diagnosis of problems and underutilization of mental health services
• Stigma of mental illness
• Lack of awareness of mental health problems
• Denial or underreporting of symptoms
• Attributing behavioral change to physical illness
• Inadequate human resources for mental health
• Financial resources to expand services are relatively modest
• Governments, donors and groups representing mental health service users and their families need to work together to increase mental health services, especially in low- and middle-income countries.
• Access Transportation cost, geographical distribution and lack of services, e.g. rural area residents versus urban.
• Quality (Donabedian framework)
  • Structural problems
  • Process problems
  • Outcome problems
• Cost

Stigma of Mental Illness

• Stigma and discrimination against patients and families prevent people from seeking mental health care
• Misunderstanding and stigma surrounding mental ill health are widespread.
• Despite the existence of effective treatments for mental disorders, there is a belief that they are untreatable or that people with mental disorders are not intelligent, or incapable of making decisions.
• This stigma can lead to abuse, rejection and isolation and exclude people from health care or support.
• Within some health systems, people are too often treated in institutions which resemble human warehouses rather than places of healing.

Community and Social Exclusion

• Marginalization and exclusion are regressive.
  • Exclusion leads to greater exclusion.
  • Exclusion can lead to lost opportunities for employment, housing, and other opportunities. This in turn leads to further isolation and exclusion.
• Social Capital:
  • Exclusion means less social capital.
  • An example of the importance of social capital. 40% to 70% of people find their jobs through contact persons in their social network

Mental Health Services at the Primary Care Level? Why?

• Physical and mental health problems often occur at the same time.
• Most people try to seek help for their mental Health problems from their Primary Care Provider.
• One half of all care for common psychiatric disorders can be managed at the Primary Care settings.
• People with mental health issues experience a statistically higher rate of common medical disorders like diabetes, obesity, addiction to nicotine, and high blood pressure.
• Many prefer to receive MH services in Primary Care because it is not taken as “mental healthcare”
• With exception of seriously mentally ill, basic MH services can be managed in Primary Care setting
• Growing evidence that MH integrated at the primary care is cost- effective
• Separating patients’ problems into physical & mental leads to:
  • Duplication of effort
  • Undermines comprehensiveness of care
• Primary Care Providers deal with patient’s untreated psychological problem- identified or not
• Psychosocial/behavioral problems take up Primary Care Provider time regardless of degree to which problems are the explicit focus of his/her practice
• Many mental health (MH) Primary Care patients will refuse referral to a MH professional
• Patients who refuse referral tend to be high utilizers of PHC with unexplained physical symptoms
• Mental illness can increase the risk of a person developing physical illnesses such as cancer, diabetes, heart and neurological disease.
• Mental illness can exacerbate the severity of existing illnesses and compromise recovery from illness and injury.
• Early identification and effective management are key to ensuring that people receive the care they need.

Barriers to Providing Mental Health Services to Primary health Care Patients

• Competing Demands and Tasks of Primary Care Providers
  • Average primary care visit last 10- to 15 minutes
  • Inadequate time to adequately assess for mental health problems and manage once assessed
  • PHC Providers are not trained to address mental health problems common in primary care settings
• Patient Barriers to Providing Mental Health Services
  • Concerns about the stigma of psychiatric diagnosis
  • Fear of the negative consequences for pursing mental health care -Stigma, criticism, violence or abuse from family or community
  • Patient Somatization: Problems not perceived as psychological
  • Patient has no psychiatric diagnosis, but still in need of psychological care

WHO Recommendations

• Strengthen effective leadership and governance for mental health;
• Provide comprehensive and responsive mental health at the PHC level integrated with social care services in community-based settings;
• Implement strategies for promotion of mental health, combating stigma and prevention of MH disorders.
• Strengthen information systems, evidence and research for mental health.
• Protection and promotion of human rights and strengthening and empowering civil society are at the core of community-based care.