Nestle Infant Formula as cause of child deaths

/in /by

Company Background

Heinrich Nestle and his family members started off producing carbonated water. They later on also combined cow’s milk with wheat flour and sugar to produce a substitute of mother’s milk for those children who couldn’t accept breast feeding. In 1866 a milk food formula was developed for infants who were unable to tolerate their mother milk. His product became a success, and it created a demand throughout Europe. By the 1960’s Nestle was one of Switzerland’s biggest company with over 200 factories around the world (Nestle, 2009).

Nestlé considers that research can help them make better food so that people live a better life.  Good Food is the primary source of Good Health throughout life. In the first months of life, a baby’s nutrition needs are very specific – and different than any other stage of life. Obtaining energy and nutrients is vital for babies’ healthy growth and development at this critical stage of life. To meet the specialized needs of infants, Nestlé Nutrition works with the Nestlé Research Center and R&D centers to provide infant formulas with total nutrition.

We strive to bring consumers foods that are safe, of high quality and provide optimal nutrition to meet physiological needs. In addition to Nutrition, Health and Wellness, Nestlé products bring consumers the vital ingredients of taste and pleasure. Research is a key part of our heritage at Nestlé and an essential element of our future. Nestlé believes that the best food for babies is mother’s milk.

Mission Statement

“Breast milk nutrients that nourish protect and promote growth and development. However, for different reasons, not all mothers are able to breastfeed their babies or choose to do so, and need a safe, high-quality alternative that provides babies with the precise nutrition they need in the first months of life (Nestle 1990).”

Infant formula Industry

Infant Formula Industry Development and marketing of milk food product for infants begin in 1867. The Creation of the product progressed due to the urgent need of a substitute for infants who could not consume any food Infant formula foods were matured around the 1920’s. As an alternative to breast milk the sales boost after WWII and reached its climax in 1957. The Market took a downturn around the 1970’s. Nestlé then decided to market to countries like Africa, South Africa and Far East because of population growth (Boycott, 2007).

Nestle and the Infant Formula

1800 was the century when Henry Nestle founded the infant substitute for breast milk for women who could breast feed their children at the time of their birth. Thus, this led to the death of millions of child infant death. Nestle in the early years marketed Infant formula as the best option for infants and also continued to aggressively promote the milk better then breast feeding. The containers had large writing in blocked letters claimimg the best choice for newly born babies which led to an excessive drop of breast feeding and high number of women feeding their children the infant milk. The stats were roughly around 80 % of Singapore three- month-old infants were being breastfed in 1951. By 1971 on 5% of mothers nursed their infants In Mexico around 1966, fewer than 40% mothers nursed their infants Chile experienced three times as many deaths of infants before they became 3 months old in 1973 (Ford, 2008).   There was marked shoot in the rate of gastroenteritis and malnutrition among the babies in the third world countries relating to the improper use of infant formula and the associated feeding equipment, such as bottles and nipples

During the 1970’s, British Charity Organization circulated a 28 page pamphlet called the Baby Killer which was targeted towards Nestle Switzerland and the poorly advertised marketing efforts in Africa. After the publication was well distributed it raised a concern for the general public and population of the affected countries and other countries. Later, Nestle was alleged as “Unethical and immoral behavior”.Nestle fought back and the trial lasted for two years therefore nestle was sued for defamation but inevitably Nestle won. But during this time nestle was given a set of code of ethics to follow by World health organization and UNICEF (Birbeck, 2007). The rules were as follows:

The key points of the Code as established in 1981 were:

Breast milk substitutes should not be advertised.

Mothers and health care members are not to be given free supplies and samples.

No promotion of products through health care facilities.

No the marketing personal is not supposed to be in contact with the mother

Information to health workers should be scientific and factual only.

All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the costs and hazards of artificial feeding.

Unsuitable products prohibited for babies.

Babies should not be depicted on infant formula packaging.

Labels should be set out in local native languages.

By the end of 1989, The MNC introduced “plan of Action for Infant and Young Child feeding” where it committed to put a stop to all low priced and free supplies of infant milk formula in developing countries except for the number of children who need it.

How Nestle breaks the Rule: Unethical Practises

Nido is promoted worldwide. In Bolivia and other countries, Community and health workers are given free samples of Nido which stirs a mixed feeling among the mothers for children above four months although there is no age limits for nido.

Neslac is promoted widely for babies for their first birthday although breast feeding is recommended for at least two years of age. Nestle promoted Neslac with the help of posters, gift offer and advertisements in all types of media.

In Mexico and in other countries, Nestlé provides pediatricians and nurses funds for congresses and other professional events

Nestle sponsors workers with boxed lunches and vouchers in Taiwan..

In Italy, Nestlé sponsored meetings and conferences under the brand name Guigoz.

Cerelac is promoted in Pakistan on huge posters and roadside banners. Labeled bowls and cups are given out with every purchase of cerelac.

The blue bear Logo that is seen almost in every country represents Infant formula and food.

In UAE, Nestles distributed Pens with Cerelac logo.

Company reps contact mothers though telephone in Hong Kong and Taiwan (Stafford, 1999). Nestlé- Baby Milk Ethical Issues

Ethical Issues

a) Infant Formula.

The most important ethical question that arises regarding the use of infant formula is that if it is moral to produce or use the formula as a substitute for breast milk? The point of concern is that, if the infant formula is a bad thing like tobacco smoking or does it lie on the same fronts as consumption of alcohol where misuse leads to harms? The International Baby Food Action Network (IFBAN) suggests that in theory the infant formula might not be a bad thing but, on moral grounds it acts as a substitute for a perfectly good thing that is breast milk.

b) Infant Formula cause of Child Deaths?

There is no point questioning the fact that hundreds of thousands of young infants die every year in the developing countries mainly because of water-borne disease, malnutrition and some other factors. In case of Nestle it is important to distinguish between the deaths caused by the use and misuse of the infant formula which is the result of improper marketing of the formula as a substitute of breast milk and the deaths caused by other reasons. The use or misuse of the infant formula may lead to child death for various reasons which include negligence to certain important facts regarding the usage or simple ignorance of the mother or the feeder. Non-availability of proper ingredients like pure or clean water, or usage of non-sterilized bottles which are used to feed the infants has proved to be the major health risks.

c) Supply of infant formula to regions with inadequate healthcare systems.

The supply and promotion of infant formula to areas with weak health care facilities leads to a ethical predicament that, if it is moral on the company’s behalf to supply their products in areas like Africa even if they are working within the frame work of the International code? Continue supply to these areas by infant formula companies is not considered an illegal issue as they follow the international code but their product is liked to deaths of young infants which surely make it an ethical issue. In such areas like Africa unsafe water and lack of sanitation are major factors underlying many of the 10 million child deaths every year. Repeated episodes of waterborne diseases like diarrhoea can push children to the brink of survival, leaving them too weak and malnourished to survive even common childhood illnesses (IBFAN, 2008). Illiteracy is another issue that these areas face as they are not able to read the instructions. In some cases, cans of formula were being sold with the instructions in the wrong language for the women being targeted which also proved to be an issue to some extent (Moorhead,2007).

d) Abiding by the Code

Out of all the other ethical issues one of the key issue revolving around the infant formula is the extent to which manufacturers are abiding by the International Code. According to the code article 1, the aim of the Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast milk substitutes, when necessary, on the basis of adequate information and through appropriate marketing and distribution (Ann,2007). Another article from the code states that there should be no advertising or any other form of promotion to the general public of products within the scope of this Code. The code was formed in 1981 reason being the manufacturers of the infant formula products were promoting their products as a replacement for breast milk and breast feeding was declining. Nestle even stated that the infant formula is better than the breast milk that lead to the boycott of Nestle products. After the boycott Nestle fell in line with the code but every now and then it has been seen that they find a loop hole in the code and take advantage. This is the reason boycott still continues.

In Defense of Nestle

The key ethical issues to the substitution of the breast-milk feed, there are two main key points to discuss in this part, and to show how the company thinks that the infant formula is not unethical. First point will be the status and the position of the infant formula, Nestlé has a unique question to ask those whom are considering the infant formula as an ethical formula, and the question is “Is the infant formula a bad thing in itself, as bad as the gambling and tobacco? Second point to discuss is child death cases and relating it to the infant formula, where Nastle’s says that there are many child death cases all over the world, and there are people and organizations known as competitors or IBFAN where they relate some of those child death cases to the infant formula, and ignoring the other real facts which they were the reason behind those cases, for an example, these people or organizations are ignoring the fact of the death cases in some countries in South Africa, and these reason are, it is really hard and somehow impossible to find pure and clean water, although the UN is trying their best to provide that clean water for the people in South Africa, and those people want the infant formula to be withdrawn from there. Withdrawn the infant formula from that part of Africa can lead to some serious problems, where other competitors can enter South Africa with new non-efficient infant formula and cause more serious problems to those kids or the infant formula can be replaced sugar water or goat milk. Another causing of death cases to those poor kids is the weak health care system, those people or organizations are ignoring the fact of the weak health care system for instant in some countries in South Africa, therefore Nestlé argument here is that countries in South Africa are having a weak health system, and people there are not well treated medically, therefore death cases should be related to the weak health system there not to the infant formula, therefore it is unfair and unethical to relate the death cases to the infant formula and to Nestlé. These countries should have full medical health care, especially for kids to protect them and to make them strong in order to face other illnesses in the future. After providing full and strong medical health care to those kids, then people can start put the blame on Nestle’s side after considering the other serious causes of death. Based on these two argument points Nestlé sees itself doing an ethical and right thing by providing that part of the word with the infant formula.

In Conclusion

Breastfeeding is the best thing for baby because it’s containing the perfect amount of antibodies, water, carbohydrates, fat, protein, vitamins and minerals. Also mothers who can’t breastfeed there newborn babies they will select formula as the second option for there babies, also many business women who work most of their time

They don’t have time to feed their babies as a result they always try to choose alternative ways to feed their babies and in the same time it contains every thing the baby’s needs.

First of all when we talk about the advantages of breastfeeding we will find out a lot of good results that impact the children’s health and their bodies in the future. Breast milk is personalized for babies as a whole meal because this milk contains everything the babies’ need to protect their bodies from allergy so that they will be less likely to get allergies and protecting them from asthma. Also, breastfeeding may help reduce the chance of becoming over weight, reducing stomach infections, and support baby’s sensitive digestive system .more over breast feeding is a very comfortable for the mother and its easier than using other artificial milks , in addition to what I mentioned earlier , another advantage of breastfeeding is to save money and its available at anytime and everywhere while artificial milks can be expensive and unaffordable however the breast feeding has a strong relationship between the mother and their babies.

Secondly, on the other hand, The disadvantages of the artificial milks as we know that nestle is a leading consumer products companies in the world however it has many ethical issues relating to the breast milk substitutes, first of all , the moral status of the artificial milk or  the infant formula is more like tobacco or gambling where the problem arise from misusing it  such as the role of infant formula in child death , supplying infant formula in areas of weak healthcare systems

APA format. Each assignment paper must fit within the following parameters: 1. Format = typewritten- double-spaced 2. Margins = one-inch on top- bottom- left- and right of each page 3. Font style/size

/in /by

APA format. Each assignment paper must fit within the following parameters: 1. Format = typewritten, double-spaced 2. Margins = one-inch on top, bottom, left, and right of each page 3. Font style/size = Times New Roman or Courier/12 point Details regarding the required content for each assignment paper will be distributed under separate cover. The writing assignments will be assessed based on the following rubric. Consequently, use this rubric as a guide when completing all written assignments.


Rubric is attached

Define the attributes of the concept and relevant uses. Provide a summary of the concept as described in each article with examples of how the term was defined.

/in /by

Define the attributes of the concept and relevant uses. Provide a summary of the concept as described in each article with examples of how the term was defined.

The Assignment will focus solely upon the discipline of nursing with the inclusion of nursing scholarly sources to substantiate the literature review. Locate evidenced-based articles (based on research studies in nursing) that use the concept or discuss the concept. Please confer with your instructor if you are not sure about your concepts or sources. For this paper you will: Identify the concept and purpose for studying the concept. Describe reasons for this concept being of interest to nursing and its body of knowledge. Define the attributes of the concept and relevant uses. Provide a summary of the concept as described in each article with examples of how the term was defined. Provide the theoretical and operational definition of the concept based on the review of literature. (Theoretical is pure definition and operational is how it is used in practice.) Apply the concept as it relates to your practice and how you will use this concept in the future. My prctice is a CLinical Transplant Coordinator for Kidney and pancreas. Describe the value of these concept analyses to your understanding of nursing knowledge.

Describe primary, secondary, and tertiary methods of health prevention for this topic. Research community and state resources and describe at least two of these for your chosen topic.

/in /by

Describe primary, secondary, and tertiary methods of health prevention for this topic. Research community and state resources and describe at least two of these for your chosen topic.

 

As adolescents separate from their parents and gain a sense of control, sometimes they are unable to balance stresses. As a result, depression may occur, and, at times, suicide may be the outcome. Choose the topic of either adolescent depression or adolescent suicide. Discuss contributing factors and signs and symptoms that may be observed or assessed in these clients. Describe primary, secondary, and tertiary methods of health prevention for this topic. Research community and state resources and describe at least two of these for your chosen topic. What nursing interventions could you use to assist an adolescent you suspect is depressed beyond referring the adolescent to a state or community resource?

Action Research

/in /by

2 paragraph

 

The methodological or philosophical approaches include the following:

  • Action research (AR)
  • Appreciative inquiry (AI)

For this Discussion Board, introduce yourself to your colleagues, and focus your discussion on the following questions:

  1. What interests you most about action research and appreciative inquiry?
  2. In your current or past organizations where have you seen appreciative inquiry used, and how was it used? Was it successful? Why or why not?

Antenatal Care In Primary Health Care Centers

/in /by

The antenatal period offers many opportunities to provide targeted health services. Antenatal care became associated with general health evaluation

as a result of the increasing recognition of these factors as nutrition, social conditions and birth spacing influence pregnancy outcomes.(1) It is

now accepted that maternity services should be centered on the woman and her needs. Each

woman should be given sufficient help and information to enable her to make an informed decision about her care. In addition, the processes of empowerment and communication have become a key factor; not only between health professionals and women but also among the different health professionals providing the service. This is essential factor for effective team working to provide continuity of care.(2)

In recognition of the potential of care during the antenatal period to improve a range of health outcomes for women and children, the World Summit for Children in 1990 adopted antenatal care as a specific goal, namely “Access by all pregnant women to prenatal care, trained attendants during childbirth and referral facilities for high-risk pregnancies and obstetric emergencies”. Similar aims have been voiced in other major international conferences, including the International Conference on Population and Development in 1994, the Fourth World Conference on Women in 1995, their five-year follow-up evaluations of progress, and the United Nations General Assembly Special Session on Children in 2002.(3)

ISSN 1110-0834The antenatal period clearly presents opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. The aim of Antenatal Care (ANC) is to detect, prevent or manage abnormalities in early pregnancy and prepare mothers for safe deliveries.(4-6) ANC should also provide support and guidance to the woman and her partner or family, to help them in their transition to parenthood. This implies that both health care and health education are required from health services. This broad definition of ANC is endorsed by national labor laws(7) and by evidence-based clinical guideline.(8) Moreover, it introduces the needed holistic approach (biological care and concern with intellectual, emotional, social and cultural needs of women, babies and families) during pregnancy.(5) Care during pregnancy should enable a woman to make informed decisions, based on her needs, after discussing matters fully with the professionals involved. Any interventions offered in the antenatal period should be of proven effectiveness and be acceptable to the recipients. Both the individual components and the full package of ANC should conform to these criteria. Complex examinations

and a variety of combination of interventions

are part of modern ANC. Nevertheless, there is a huge variety of tests and medical procedures included in routine ANC worldwide.(9) Some of these interventions are based on evidence, but many of them are only based on long-held traditions. The state of the scientific evidence of risks and benefits of ANC interventions is a concern of health policy-makers. Another important concern is the level of care sufficient to delivering high-quality care for pregnant women.

Most antenatal care protocols in developing countries were established along the lines of

those used in developed countries, with little adjustment for local conditions.(10,11) The content of ANC for a normal pregnancy is described in three main categories: assessment (history, examination and laboratory tests), health promotion and

care provision. There is inevitably some degree of repetition but it has been retained for the sake of completeness and ease of reference. World Health Organization (WHO) recommends that antenatal care for the majority of normal pregnancies should consist of four visits during pregnancy, and has outlined the key elements of the visits and their timing.(12)

Use of antenatal care in developing countries rose steadily during the 1990s. Information on trends in antenatal care use over the past decade is limited to countries where more than one household survey has been carried out. At the end of 2001, a total of 49 countries had trend data.(12)

Most of the antenatal care models currently in

use around the world have not been subjected

to rigorous scientific evaluation to determine

their effectiveness. Despite a widespread desire to improve maternal care services, this lack of “hard” evidence has impeded the identification of effective interventions and thus the optimal allocation

of resources. In developing countries, routinely recommended antenatal care protocols are often poorly implemented, clinical visits are irregular, and waiting time is prolonged with poor maternal satisfaction.(13)

Due to global concern over safe motherhood, evaluation of ANC in PHCC in Medina; one of the holy cities in Saudi Arabia, this study was carried out.

Aim

The aim was to evaluate the antenatal care services given for pregnant women attending the Primary Health Care Centers, Medina city, Saudi Arabia 2009.

METHODS

The study was conducted during March through July 2009. The study population included pregnant women attending primary health care centers in Medina, Saudi Arabia for antenatal care.

Simple random selection of seven major primary health care centers in Medina was done. The total number of the pregnant women included in the study was calculated using the following equation: n= (Z2 X p X q) / D2. A total of 394 pregnant women were included and were proportionally allocated based on attendants of each health center.

A specially designed format was designed and filled by the researcher herself. Collection of data from the selected centers was done after official permission. Ethics Review Committee reviewed and approved the proposal. The survey tool was pre-tested on a random sample of 35 participants obtained from 2 centers to ensure practicability, validity and interpretation of responses. The reliability of the questionnaire was assessed using Cronbach’s alpha (0.812). The format including information on: assessment of the service (at the initial visit and return visit), health promotion and care provision. The time spent for each visit was included as well as education, work status of pregnant women, and some socio-demographic data of the physician were included (nationality, mother language , qualification and age).

The centers were ordered according to the order of their visit.

Each of the items of antenatal tasks was scored as following: (0) for non performed task and (1) for performed one; giving a performance score ranging as follow:

1- Assessment: a. Initial visit: i. history taking: 0-21, ii. examination: 0-12, iii. laboratory investigations: 0-11

b. Return visit: i. history taking: 0-3, ii. examination: 0-9

2- Health promotion: 0-10

3- Care provision: 0-6.

The total performance score was calculated for each task at each center. Then the mean percent score was calculated.

Statistical Analysis

Statistical Package for Social Sciences SPSS version 10 was used. Frequencies, percentages and arithmetic mean were calculated. Chi-square test, and F- test were used. P value <0.05 was considered significant.

RESULTS

Description of the studied centers

A total of seven centers were recruited, from them 394 pregnant women were included in the study. The most populous center was center number 4 where it was serving 35000 inhabitants (fig. 1) followed by centers 3 and 7 which were serving 28000, with significant difference between centers (p=0.000).

There was only one physician per center who was carrying out antenatal care (in some centers, this physician had another tasks as examination of children in well baby clinic, etc.). Non-Saudi formed the majority of physicians where more than half (57.1%) were Egyptian, 28.7% were Pakistani and 14.2% Bangladeshi, with a mean age of 45.7±4.7 years.

General characteristics of the included pregnant

The minority of the included pregnant women

was illiterate (0.8%) (Table I), while 41.4% got secondary education and 33.2% got university one. Only 14.0% were working.

Regarding duration of pregnancy, 34.4% were in the first trimester, 36.3% in second and 29.4% in

the third trimester, and 51.5% were visiting the center for the first time. The mean duration of the initial visit was 10.3±2.3 minutes (Fig. 2), while

that of return visit 9.1±1.1 minutes; and there was a significant statistical difference between centers (p=0.000).

Poorly covered antenatal tasks

Social history and support, history of FGM, examination of general appearance, breast examination, examination for signs of physical abuse, planning for delivery and development of individualized delivery plan, smoking history and psychosocial support had lowest coverage percent (Table II).

Performance scores

In initial visit, history taking and investigations (Table III) had higher mean percent score (93.4 ±1.5 and 95.0±1.4 respectively) than return visit’ history taking (83.0±5.4). Meanwhile clinical examination in return visit was better performed than that of initial visit (86.1±7.7 and 75.6±11.7 respectively). All the centers had the same score for care provision (83.0±3.6). Nevertheless, health promotion had the worst score (64.9±12.7). The overall total mean percent score for antenatal care services in general was 77.1±1.1, with statistical significant difference between the studied centers (p=0.000).

DISCUSSION

Screening and monitoring in pregnancy are strategies used by health care providers to identify high risk pregnancies so that they can provide more targeted and appropriate treatment and follow up care and to monitor fetal well-being in both low and high risk pregnancies.(2,3)

This study aimed at evaluation of the antenatal care services given to pregnant women attending PHCC in Medina City, Saudi Arabia. The study

was conducted using specially designed format including 394 pregnant women attended seven PHCC in Medina City for antenatal care. Effective and appropriate ANC should be offered to all pregnant women. However, different countries offer different sets of routine ANC, which are hardly based on explicit effectiveness criteria, being mainly linked with long term tradition or other inexplicit criteria.(14)

Epidemiological studies have demonstrated the benefits of ANC in reducing maternal and perinatal complications, although the exact components

and timing of such ANC has been difficult to demonstrate. This uncertainty leads to the adoption of antenatal practices that are not comparable and are largely inconsistent between and within countries.(14-17)

Among safe motherhood advocates, antenatal care has been down played in recent years as an intervention for reducing maternal mortality. It is not surprising that little attention has been paid to patterns and trends in antenatal care use.(17)

Major barriers prevent the effectiveness of

ANC in low resource settings in Medina, Saudi Arabia. Poor knowledge of the general practioners about maternal and fetal risk factors and complications that are detected in pregnancy

which could prevent a large proportion of

maternal and fetal morbidity and mortality, together with the language barrier between pregnant

mother and health care provider, poor maternal education and nutrition and lack of strategies that improve the quality of care, all are factors behind poor performance of ANC.

Physician is the crucial person in the process of ANC. Availability of one physician only who

was carrying out ANC during the period of the study in the PHCC would never met the recommended time for ANC which supposed to be given for each woman to discuss her personal needs and for physician to respond appropriately especially for

the first visit, when full history has to be taken and an individualized birth plan should be started. It

was found that the mean duration of the initial

visit 10.3 ± 2.3 minutes compared to the desired

20 minutes. Furthermore, when the appropriate

number of physicians will be available, this duration will be feasible even in areas with high birth rate.(18,19) ANC performance of the studied centers correlated with age, language and qualification of the working physician. There was greater ability of younger, Arabic, qualified physicians to attain better performance scores especially for health care promotion.

More than three fourths of the included pregnant women had secondary (41.4%) or university (33.2%) education. It was noticed that in developing countries as a whole, women with secondary or higher education are more likely to have ANC than women with no education.(17) Not only that, but it was also found that the educational level and work status of the attending pregnant women have been positively correlated with the ANC performance of the studied center.

Nearly half (51.5%) of the studied pregnant women attended the PHCC for the first time during the first trimester. The early initiation of ANC is important to prevent and treat anemia and to identify and manage women with medical complications. Early care also allows for the development of interpersonal relationship between health care providers and pregnant women.(20,21)

Health promotion of pregnant women can improve their own health and that of her child and the

risks of maternal and perinatal complications can

be reduced; yet, in developing countries, ANC protocols are often poorly implemented.(22-29)

Although care provision should address psychosocial need of women and development of individualized delivery plan as well as their medical needs, (30-35) this study shows that aspects that were poorly implemented were psychosocial support (not done for 98.0%), planning for delivery (not done

for 94.2%) and development of individualized delivery plan (not done for 99.5%). This poor implementation could be attributed to the fact

that these items are not included in the maternal

card that is in use in the PHCC. Also the fact

that all pregnant women will be referred to

maternity hospital for delivery as no delivery is allowed outside hospitals cause reluctant and

neglect attitude in discussing the delivery plan. However, some items which are crucial and already present in the maternal card as general appearance (not done for 96.1%) and breast examination (not done for 91.1%) are just filled with symbols NAS which denoting no abnormal signs; even without examination.

Study limitation

This study carried out only for seven PHCC, and inclusion of all centers was needed which was not feasible to be performed by the researcher together with comparison of the urban and rural one. No detailed obestritic history was included. Also job satisfaction of health care providers was not fulfilled.

Conclusion and Recommendations

-This is the first study aimed at assessing the performance of the PHCC. We found variation between centers in their performance scores. Variation in performance scores of the studied PHCC denoting that improvement will be mandatory.

-A further study using specially designed interviewing format is needed to study in depth health care providers’ characteristics, and the obstacles they face in the work place to find out suggested solutions for improvement.

-Continuous medical education and training of all health care providers for ANC implemented protocol.

-Ensuring satisfaction of both health care providers and receivers of ANC.

-Clarifying the appropriate policy, decision-making and programmatic implications of adopting and implementing the new ANC protocols.

-Perinatal audit system which aims to improve quality of care by identifying deficiencies in care.

-Health promotion needs to be stressed upon especially nutritional care, rest and hygiene, and educational resources.

Start by reading and following these instructions: Quickly skim the questions or assignment below and the assignment rubric to help you focus.Read the required chapter(s) of the textbook and any addit 12

/in /by

Start by reading and following these instructions:

  1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
  2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
  3. Consider the course discussions so far and any insights gained from it.
  4. Create your Assignment submission and be sure to cite your sources if needed, use APA style as required, and check your spelling.

Assignment:

Complete ALL of the bullet points below:

  • Health care planners could be more effective and efficient if they used the concept of the natural history of disease and the levels of prevention to design services that intervene at the weakest link in the chain of progression of specific diseases. Instead, most focus on high-technology solutions to preventable problems. Assess the characteristics of the medical care culture that encourage the latter approach.
  • Hospitals and other health care institutions, whether voluntary or for-profit, need to be financially solvent to survive growing market pressures. Describe how this “bottom line” focus has changed the nature of the US health care system.
  • The insurance industry plays a huge role in the American health care system and absorbs a significant portion of the health care dollar. A single payer system, whether it is a private company or the US government, would eliminate the complex insurance paperwork burden and free substantial funds that could be diverted to support care for the under-served. Why do you believe that so much resistance to a concept used in every other developed country has continued in the U.S.?
  • Complete the time management Weekly Planner to show when you will make room for your school work and add the report as an addendum following the Reference Page of your essay. It is not necessary to include the information in the content of the essay.

Please submit one APA formatted paper between 1000 – 1500 words, not including the title and reference page. The assignment should have a minimum of two scholarly sources, in addition to the textbook.

Assignment Expectations

Length: 1000- 1500 words; Word count does not include the time management Weekly Planner

Structure: Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment.

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least two (2) scholarly sources to support your claims.

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

File name: Name your saved file according to your first initial, last name, and the module number (for example, “RHall Module 1.docx”)

M1 Assignment UMBO – 4

M1 Assignment PLG – 8

M1 Assignment CLO – 6

Does the RFP expressly state organization and user needs? If so, what are these? If not, why is the RFP failing to do so? What are the strengths and weaknesses of this RFP?

/in /by

Does the RFP expressly state organization and user needs? If so, what are these? If not, why is the RFP failing to do so? What are the strengths and weaknesses of this RFP?

 

frank solutions
5
Implementation of EHRs
Please read carefully. Make sure you understand the assignment.
You have to download this template and fill in as part of the assignment. You have to worry about the name of the organization. I will do that. However, this is for a newly built assisted living and nursing home. Can accomodate 25 assisted and 65 nursing home patients. $25 million is in the budget.
You will conduct system selection, which requires completion of the following steps:
Reviewing a Request for Proposal (RFP)—this invites selected vendors to submit a proposal to you that outlines details of their proposed information system or systems.
Evaluation of the proposed system through on-site demonstration, site visits, reference checks, and making a decision.
Contract negotiation.
Assume that your healthcare organization has conducted an RFI, or a fact finding part of the system implementation and helps to select the potential vendors. It has requested information from vendors about their products and services. With the information gathered, the organization has screened the potential vendors and issues the RFP (request for proposal).
Download this RFP for EHR Implementation: UA_RFP-EHR. This is an actual RFP. Review the document and answer the following:
Does the RFP expressly state organization and user needs? If so, what are these? If not, why is the RFP failing to do so?
What are the strengths and weaknesses of this RFP?
How would you change this document?
Information Systems homework help
This is property of essayprince.org. Log in to Pay someone to write my paper

Reflective Essay on Stress Management

/in /by

  • Wong Wing Sze

Nowadays, many Hong Kong people have stress, which are come from some external factors likes some changes, difficulties or challenges in their life, such as change of job, examination, marital problem whatever in any age group. Apart from external factors, internal factors may also causing stress such as personality, thinking style, attitude in facing problem and ability to relax, etc. Some people may think that stress is something negative that needs to be got rid of. In fact, an adequate level of pressure can motivate us perform well in our work, study or other areas in our life and enhance our efficiency, also when face some problems, we may seek for solutions. However, when stress level are too high or under prolonged stress may have negative effect, for example, decrease our efficiency, job performance and harm for our psychological health.

In this course, stress management is the most impressive topic that i have learned, as I am a student, I always face a lot of stress in my study life likes examination, assignment, presentation. At this time, I will afraid that the result, how can I do it well, so many reasons causing stress. I am agree that too high level of pressure may decrease efficiency, I have the experience of deadline fighter, it means work hard just before the deadline. At this time, I am fear that I cannot complete my assignment before the deadline, so I am very careless in my work, such as in the data research part, I just found from internet and only come from 2-3 websites and then write it. Eventually, the final result is bad as it is not deeply to analyze the data, it shows that the pressure affects my performance. After I learned how to release stress, I never delay a job task until the last minute.

According to the research fromRegus, World-renowned office solutions provider in 2012, it shows that Mainland China workers work pressure level is the highest in the world. 16,000 people in the workplace of 80 countries and regions, they think that the pressure is higher than last year. 75% is Mainland China and 55% is Hong Kong, which are rank the first and the forth, it have exceeded the global average of 48%. As we want to develop economic and enhance social development in a very short period to contend with other nations, hope that become a powerful country in economic and culture aspects, such things can causing pressure. Besides, happy sex life can release pressure, according to the study of Pfizer, Hong Kong people have sex an average is only 3.55 times per month, compared with the most romantic French is less than half, while most people are dissatisfied with their sex life. Expert analysed that poor diet, stress and smoking can affect performance in sex life. Expert explained that Asians being poor diet, smoking and the pressure of life is directly affecting the sex performance. Hong Kong is the one example. DR Kwan Ka Mei, Betty said that Hong Kong people live in stress, many people suffer from insomnia or mood disorders, some workers in order to avoid dismissal by company, sacrifice sleep time and sex time. What’s more, a research done by Reader’s Digest about politeness, the survey conducted in 35 countries have published the magazine and regions with three tests as indicators, including the local people will open the door for others, while shopping, salesclerk will say “Thank You” or not and fall document in a busy street, passer-by will help to tidy up initiatively or not etc. The result show that Hong Kong people rank in 25th in this 35 countries. Some scholars think that Hong Kong people have much stress of life is one of reason cause to impolite. Professor Eva Kit Wah Man, the Head of the Humanities Programme and a professor of the Religion & Philosophy Department of Hong Kong Baptist University said that because the people in Hong Kong have life stress, emotion will vent to someone else such as buying things will vent to the salesman. The above cases shows that the people in Hong Kong always face lots of stress from work, family, study, so they are really need to learn how to release stress. For example, having reasonable demands and expectations on self, cultivating a good work habit, taking a new perspective in your thinking, maintaining a healthy lifestyle and adequate sleep hygiene, doing relaxation exercises regularly, it can can life well.

Managing stress and health in gender are different, female are more acutely aware of their stress than men. Even male and female suffer the same reason of stress, women are more likely to report symptoms of stress than male. For example, fatigue, feeling nervous or anxious, overwhelmed, depressed or sad, like crying, lacking interest, motivation or energy, having headaches, changes in sleeping habits, e.g., oversleeping, night waking, difficulty falling asleep. Although both of male and female are believe that social networks can support in making lifestyle and behaviour changes, female report getting more value from them compared with male. Also both men and women will seek help from a mental health professional or a psychologist to manage their stress, women are more likely to believe that psychologists can help them to manage stress and make lifestyle and behaviour changes.

To concluded, stress management is as important in our daily life, as every people will face stress, mood disorder is become more and more universal in Hong Kong. There are some courses holds in Hong Kong about stress management. Timway Education is an example, such course aim to using a variety of orthodox psychological principles, so that everyone becomes motivated, energetic, use a positive attitude of view to manage pressure. Last but not least, we need to understand that ways always more than problem and we need to face positive. Anyways, if everyone can manage their stress well, they can have a better life.



References

  1. American Psychological Association.(2012).

    Stress by Gender

    Retrieved April 11,2014, from

    http://www.apa.org/news/press/releases/stress/2012/gender.aspx?item=2#
  2. Appledaily. (2006).

    35


    城市調查排名


    25


    港人無禮貌　學者：因為壓力大

    Retrieved April 11,2014, from

    http://hk.apple.nextmedia.com/news/art/20060621/6047031
  3. Institute of Mental Health Castle Peak Hospital.(2012).

    Stress Management

    Retrieved April 11,2014, from

    http://www3.ha.org.hk/cph/imh/mhi/article_01_02.asp
  4. Peopledaily.(2006).

    香港人壓力大


    每月僅做愛


    3.55


    次

    Retrieved April 11,2014, from

    http://hm.people.com.cn/BIG5/42276/4421460.html
  5. Peopledaily.(2012).

    “


    壓力全球第一


    “


    呼å-šç©æ¥µå¿ƒç†å­¸

    Retrieved April 11,2014, from

    http://opinion.people.com.cn/BIG5/n/2012/1018/c159301-19303911.html
  6. Timway Education.(2014).

    Stress Management Course

    Retrieved April 11,2014, from

    http://edu.timway.com/stress_management_courses.php#aqueryForm

Case Study and Treatment Plan: Major Depressive Disorder and Alcohol Use

/in /by

Part 1 – Case study and treatment plan


Summary

Jacob is a 63 year old man with a history of Major depressive disorder and Alcohol use disorder. He lives alone and has had many failed relationships, leaving him feeling isolated and worthless for the last 10 years or so. He has cycles of binge drinking and his physical health has deteriorated as a result leading to multiple hospital admissions for alcohol related issues.

Interventions needed to help Jacob address both his depression and alcohol use revolve around abstinence from alcohol, coping strategies, and social connection within his small community. Jacob’s motivation for change is unclear at present and the keyworker will need to develop a therapeutic relationship in order to engage him to develop a clear sense of motivation for change and desire to make positive changes for his future health and wellbeing.


Circumstances

Jacob is was referred to Community Drug and Alcohol Service (CADs) by CADS Consult Liaison team during an alcohol induced hospital admission for further assessment. Jacob had realised that he needed help with his alcohol consumption and agreed to seek help. This is the first time Jacob has sought help for his alcohol use in many years. The assessment was conducted in a two-hour Comprehensive Assessment session, face to face with Jacob. Jacob did not bring any support people to the assessment.

Jacob agrees to seeking help with his alcohol use, although does not believe it to be overly problematic for him.


Assessment


Background information

Jacob grew up in England and immigrated to New Zealand in his late twenties. He currently lives alone in a small town, in a block of council owned units. His is twice divorced and has three children. He has regular contact with one of his daughters Jane by telephone as she lives in Wellington. He has many failed relationships which leave him depressed when they end.

Jacob is an ex high school teacher and is retired. He likes to help in the Trust gardens in his spare time with the support workers for company. He is an avid reader and likes to go mountain biking when he can. He has not engaged in these activities in the last few months as his alcohol consumption has increased.

Jacob has multiple health issues including Psoriasis, Barrett’s Oesophagus, Gastritis, and history of previous stroke.

Jacob has had 17 hospital admissions since late December (last six months), for alcohol related issues usually around GI bleeds. Hospital stay varies from 2-6 days each time and is progressively becoming more frequent and longer stays.

Jacob recently was charged with Excessive Breath Alcohol and disqualified for driving for 6 months. It was deemed that Jacob was still driving whilst under the influence of alcohol, and CADS submitted a request to the Land Transport Authority to have the licence revoked. This was approved.


A&D assessment


Alcohol

– Jacob reports that his pattern of drinking is binge drinking rather than regular drinking. He is prescribed Disulfurim but will stop taking this when he is planning on drinking. Jacob advises that he has 750mls of spirits (usually Vodka) and once he starts drinking, he cannot stop. He binge drinks 3-4 times a month. This is a pattern that has been going on for years, and increases with various situational stressors.

Indicators of Substance Use disorder (DSM-V, 2013, p.490-1).

-A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects

-There is a persistent desire or unsuccessful efforts to cut down or control alcohol use

-Important social, occupational or recreational activities are given up or reduced because of alcohol use.

-Recurrent alcohol use in situations in which is physically hazardous

-Alcohol use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

-Withdrawal as manifested by the classic withdrawal syndrome

Jacob meets at least six of the criteria for Substance use disorder and can be classed as having a Severe Alcohol use disorder.

Consequences of his drinking include falls, driving under the influence of alcohol charges and hospital admissions for Gastrointestinal (GI) bleeds.

His withdrawal symptoms include tremor, perspiration, sensitivity to noise and light, hallucinations, nausea and anxiety.

Jacob has had 2 arranged medical detoxifications and numerous detoxifications in the Medical Ward when he has a GI bleed. He has not been to residential rehabilitation as yet.


Other Substances

– Jacob denies use of any other substances. Blood and urine screening would substantiate this claim.


Mental health assessment

Jacob has a long history of depression. He has been depressed since his divorce from wife just over 20 years ago. He is prescribed Citalopram 30mg and Zopiclone 7.5mg by his General Practitioner. It could be assumed that his depression was secondary to his alcohol use,  however the depression still remains even in abstinent periods.

Jacob meets the DSM-V criteria for Major Depressive Disorder (2013, p.160-1). He has more than five of the symptoms,

and

the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning, and the episode is not attributable to the physiological effects of a substance or to another medical condition.


-Depressed mood most of the day, nearly every day, as indicated by either subjective report (ie; feels sad, empty, hopeless).

Jacob reports that he feels hopeless and worthless. He is constantly sad.


-Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or objective observation).

Jacob


-Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% body weight in a month), or a decrease in appetite nearly every day

. Jacob has lost nearly 10kgs in recent months, and has a poor appetite.


-Insomnia or hypersomnia nearly every day.

Jacob finds it very difficult to sleep


-Fatigue or loss of energy nearly every day.

Jacob has no energy to do the usual things he would do – exercise, gardening, reading.


-Diminished ability to think or concentrate, or indecisiveness, nearly every day (either subjective or as observed by others).

Jacob finds it hard to make decisions on both small and big things in his life and is finding it hard to concentrate


– Recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Jacob has recurrent thoughts of stabbing himself although not acted on these. They scare him.

Jacob in the past had thoughts of stabbing himself. At present her has the occasional fleeting thought of self-harm and/or suicidality but has never acted on these thoughts. He seeks help when feeling this way and has had a short inpatient admission in 2016 after the separation from his Malaysian girlfriend.


Impact of substance use on mental health

The impact of alcohol use on Jacob’s mental health has been significant for him. Initially a depressive episode, with poor coping skills has turned into a cyclic pattern of binge drinking for Jacob. His alcohol use helps him cope with his mood and anxiety symptoms for the time he is drinking, and then when sober he can’t cope once more and returns to binge drinking. When he can not remain sober, Jacob becomes more and more depressed as he feels like a failure.


Socio cultural assessment

Jacob grew up in England and immigrated to New Zealand in his late twenties with his wife. His wife was a Nurse and they were granted permanent residency. They had two daughters who are now 29 and 27 years old. He separated from his wife approximately six years after the arrived in New Zealand and then remarried a teacher that he met whilst teaching at a school together. He had a son (now 15 years old, and that relationship lasted seven years). When they separated Jacob got the custody of his son however his ex-wife abducted him from school and that led to much stress for Jacob.

He then had a relationship with a European lady, and this lasted for about ten years. They separated as she was torn between living with Jacob in New Zealand and her family in Europe. This separation led to a major depressive episode for Jacob.

Most recently Jacob has been in a relationship of long distance with a Malaysian lady. She has visited Jacob and he made plans to go and live in Malaysia with her. Unfortunately, his visa application was denied on the basis of poor health. This has led to another depressive episode for Jacob.

Jacob’s children live in Christchurch, Wellington and Te Awamutu and he has regular contact with them. He also has regular contact with his first wife who lives in Hamilton.

Jacob as worked as a Teacher, boat builder, welder and manager of backpacker’s accommodation.

Jacob currently lives in a council owned flat on his own.

Jacob is currently on the sickness benefit. He recently received a large inheritance from his Aunt in England.


Major Problem clusters


Alcohol use disorder

– as indicated by Jacob in his assessment.

Jacob meets the DSM-V criteria (2013) for Alcohol Use Disorder as follows;

–

A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects

Jacob spends much time in hospital recovering from his alcohol use


-There is a persistent desire or unsuccessful efforts to cut down or control alcohol use

Jacob has tried many times to stop his alcohol use and has been unsuccessful. He sabotages each attempt by binge drinking


-Important social, occupational or recreational activities are given up or reduced because of alcohol use.

Jacob has not attended the gardens for some months and does not engage with his support worker when his alcohol consumption increased.

–

recurrent alcohol use in situations in which is physically hazardous

Jacob continues to drive his car after drinking alcohol and was caught for excess breath alcohol and charged.


-Alcohol use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Jacob has had 15 hospital admissions since December and these are all related to the alcohol consumption and his Barrett’s oesophagus

–

Withdrawal as manifested by the classic withdrawal

syndrome Jacob suffered from severe withdrawal symptoms when he was admitted to hospital and had a forced abstinence from alcohol.


Conclusion/diagnosis

It is clear from above, that Jacob meets the criteria for both Major depressive order and Severe Alcohol use disorder. An intervention plan needs to be developed to meet the needs of both disorders, and that Jacob sees as a positive plan to make changes for his future health and wellbeing.


Intervention Plan


General Aims

Central areas for change for Jacob include;

-Abstinence form Alcohol

-Deal with past/present grief

-Develop and maintain Social networks


Intervention 1

Therapeutic goal –

Abstinence form Alcohol

  • Medical supervision for Alcohol Withdrawal (inpatient admission for detoxification)
  • Residential rehabilitation
  • Pharmacotherapy for post detoxification support and in an attempt to prevent relapse
  • AOD counselling weekly for support
  • AA Meetings weekly for peer support in relapse prevention



Rationale

Jacob needs a combined approach to achieving abstinence from alcohol. This should give Jacob a better chance to abstain from alcohol use long term. On admission to Medical Detoxification, Jacob will have a full medical examination and this will give the team a clear picture of likely complications. Residential rehabilitation is appropriate to help Jacob adapt his lifestyle and for long term abstinence. Ongoing AOD counselling will help Jacob to stay focussed on his goals and his values. AA meetings are necessary for peer support. It is beneficial to Jacob as his peers understand and given his isolation, it will benefit him socially also.



Procedures

A referral to Medical detoxification ward needs to be completed by Jacob’s key worker. Jacob will need to have full blood tests with his General practitioner. Medical Detoxification is carried out in an inpatient ward in the hospital setting with access to Doctors and Nursing staff around the clock. This is followed (usually) by Pharmacotherapy of Disulfurim, Naltrexone, Thiamine and Multivitamins. Medications can be dispensed daily under pharmacist supervision for matters of compliance and in Jacobs case, it is important that he is compliant with his medication



Context

The physical examination may show that Jacob is not a candidate for pharmacotherapies. However, if he can take the pharmacotherapies, his current level of motivation may impede his compliance in continuing taking medications to aid his abstinence from alcohol. This could lead to relapse given the medications are only effective if one is compliant with taking them.


Intervention 2

Therapeutic goal –

Deal with past/present grief

  • Personal counselling
  • Psychology sessions (ie Cognitive Behavioural Therapy (CBT))



Rationale

Personal counselling sessions for both past and present grief will allow Jacob to process these issues more appropriately, and manage his emotions around them long term. Psychology CBT sessions will help change past patterns of thinking for Jacob and aid him to better manage his emotions and anxiety.



Procedures

CADS key worker to refer Jacob to Community based counselling service which is a free service to consumers by the local NGO. CADS key worker to refer Jacob to Adult Mental Health Psychology service.



Context

It is difficult to gage where Jacob sits in the stages of change. He may be on the Contemplative stage of change in terms of his Alcohol use but may be in pre contemplative stage with grief issues. If he does not have the motivation to address past and present grief issues then it is unlikely that he can make any progress in this area. If he is in the Contemplative stage of change however, then the fact that the service is free removes a financial barrier for Jacob, and he can attend sessions to begin to manage his grief issues.


Intervention 3

Therapeutic goal –

Develop and maintain Social networks



Rationale

Jacob is currently living on his own and feeling very lonely. He feels like he is worthless and unwanted. To gain some self-worth, Jacob needs to develop his social networks or rekindle/maintain previous ones. He needs to redevelop support networks between his friends and his family. Adams (2007) stated that Addiction is not really the attribute of an individual, rather than a relationship between other relationships. The extended family (or Taha Wanau) is a vital part of Te Whare Tapa Wha- Mason Durie’s model of wellness (1998). Social and whanau relationships are integral to Jacobs mental health and wellbeing.



Procedures

Jacob needs to identify his key relationships and who he may need to rekindle a relationship with. Maintaining his connection with his family is important, as is his connection with support people in his small town.



Context

Jacob needs to be able to acknowledge the effect of his behaviour and drinking has had on the relationships with his key relationships. He needs to be in the preparation state of change so that he can redevelop these relationships. This may be an issue if he does not acknowledge that his alcohol consumption is problematic (and therefore can not accept responsibility for associated behaviour).


Evaluation/review plan and periods

When reviewing the intervention plans, in order to have successful outcomes the following anticipated outcomes would be expected

–

Jacob is

living a sober lifestyle

as evidenced by;

  • Taking medication as prescribed
  • Attending weekly AOD counselling sessions
  • Attending weekly AA meetings

Jacob has

begun to process his past and present grief issues

as evidenced by;

  • Attending regular counselling
  • Attending psychology (CBT) sessions
  • Able to indicate some positivity and hope for his future

Jacob has

begun to develop/rekindle/maintain social relationships

as evidenced by;

  • Regular attendance at gardens with support worker
  • Regular conversations with family members and support people

The intervention plan will have a four-week review of Jacobs progress in meeting goals, and how the interventions are progressing. Given Jacobs past history with various interventions, a shorter timeframe is necessary as he has a tendency to relapse into drinking in a shorter timeframe. This will enable the key worker to keep a close watch on what is or isn’t working for Jacob and make changes as necessary.


Part 2 – Discussion

Clients with co-existing depression and alcohol use disorders typically can be a challenging group of clients to engage with. Each disorder has a significant impact on the other and estimates of co-morbidity of the two disorders are almost two times higher than that of the general population (Regier et al, 1990). As treating clinicians, we need to be aware of this impact and the effect it will have on outcomes for this group of clients.

An important part of an intervention plan is to address co-existing depression and alcohol treatment. Psychology attempts to do this and address both together for more positive long-term outcomes for clients with co-existing disorders. Brown and Ramsey (2000) believe that Cognitive Behavioural Therapy (CBT) is an intervention that can teach co-existing clients coping skills for managing their depression. They go on to say that they believe that CBT “carries little to no risk to the patient” (p.419).


What is CBT?


CBT

is a type of

psychotherapy

that treats problems and increase mood by modifying dysfunctional emotions, behaviours, and thoughts. It is a solution-based approach to challenging distorted cognitions and changing destructive patterns of behaviour delivered by trained professionals (generally psychologists).

CBT operates on the idea that our thoughts and perceptions can directly influence our behaviour. CBT aims to identify harmful thoughts, assess whether they are an accurate depiction of reality, and if they are not, seeks to employ strategies to challenge/overcome them.

CBT is appropriate for people of all ages, including children, adolescents, and adults. CBT can be delivered effectively online, in addition to face-to-face sessions. CBT is tailored to each client individually.

The clinician first has to assess the client – usually by way of a comprehensive assessment, and then develop a treatment plan to target a key problem list. The early focus of CBT usually revolves around behavioural activities and the client functioning getting back to usual , taking into consideration both substance use and mental health domains Baker, Bucci, Kay-Lambkin and Hides in Baker and Velleman (2007).


How might the use of CBT be effective with the client group who have a co-existing substance use and mental health disorder?

Baker, Bucci, Kay-Lambkin and Hides in Baker and Velleman (2007), believe that in the case of a co-existing depression/substance use disorder integrated treatment may result in more substantial treatment outcomes. This is due to the disorders sharing common features like low mood, low self-efficacy, pessimism and other factors they have in common.

There is a close relationship between depression and alcoholism, and co-existing depression has been linked to poor prognosis after having treatment for alcoholism (Brown, et al; 1997). Depression can trigger poor engagement and relapse among co-existing clients. CBT as an intervention to manage coping skills and manage depressive symptoms in clients with co-existing alcoholism can change this in even just a small way. There is no risk to the client in engaging in CBT unlike medications and the risks they may/may not carry. Brown and Ramsey (2000) looked at clinical trials evaluating the effectiveness of antidepressant medications as a treatment option for alcoholics who had co-existing depression, and found that the results were equivocal. Some studies showed that they helped, and others found that there was no significant change for the client.

Tuener & Wehl (1984) study found that co-existing clients with alcoholism and depression who participated in CBT alongside their alcohol treatment had better outcomes for bother their mood and alcohol use than those who had alcohol treatment alone. This has to be a positive result for co-existing clients seeking treatment, to maximise their chances of having successful outcomes and productive lives as a result.

In 1997, a different study by Brown, Evans, Miller, Burgess & Mueller attempted to address the shortcomings of previous studies around the use of CBT in co-existing clients with depression and alcoholism.  The study looked at the efficacy of CBT and relaxation training control (RTC) combined with hospital treatment for alcoholics with increased depression. The first group received CBT and alongside hospital treatment and the second group received only RCT alongside the hospital treatment. The participants in the study had to meet the Diagnostic and Statistical Manual of Mental Disorders (3

rd

ed.,rev.;DSM-III-R; American Psychiatric Association, 1987) criteria for alcohol dependence

and

score 10 or more on the Beck Depression Inventory.  Exclusion criteria included active suicidal or homicidal risk, acute psychosis, and current opiate abuse or dependence (Brown and Ramsey 2000, p.419-20). The CBT sessions took place over eight 45minute sessions with individual clients. Results from the study shoed

-during sessions clients showed greater reduction of depressive symptoms in the CBT group

-during the first three months the clients had a larger percentage of abstinent days, but overall not any major change in alcohol abstinence or consumption of fewer daily drinks

-during second three months of follow up CBT clients showed significantly better outcomes on total abstinence (47% vs 13%), Percentage of days abstinent (91% vs 68%), and drinks per day 90.46 vs 5.71). (p.420)

The outcomes for these clients were significant, and suggest that if CBT is added to the normal treatment for alcoholism- then the decrease in depressive symptoms, and improvement in abstinence can be beneficial to those with co-existing alcoholism and depression. It shows that over a longer term these outcomes have a better chance of being maintained – which can only improve outcomes in all areas for these co-existing clients.

Brown and Ramsey (2000) do elude to the fact there are limited studies on the treatment outcomes of co-existing clients with depression and alcoholism. Future studies need to be carried out, and with a larger population, to reiterate the importance of integrated treatment such as CBT with treatment for substance abuse for more effective evidence-based practice. This will only benefit the outcomes of future co-existing clients seeking treatment.


Strengths and limitations of CBT

Firstly, the limitations of CBT are based around engagement. Engagement is a key factor to make CBT effective for the client. Motivational Interviewing of the client may help change where their level of motivation sits and is an essential tool to use prior to starting CBT sessions. If the clinician is unable to develop and maintain a therapeutic relationship with the client, then engaging them and working on motivation may not lead to the client engaging meaningfully in their treatment to get to the point where they are able to undertake CBT.

Whilst the research does show that integrated treatment for co-existing clients can undoubtedly create better outcomes in both Substance use and mental health, there are many clinicians that remain firm in their belief that parallel or sequential treatment is more appropriate. Brown et al, (1997) believe that depression is associated with poorer outcome in alcohol treatment” (p.715). It makes sense to use an integrated approach given the outcomes of the research studies done in this area, but quite often clinicians work in the mindset that the client cannot have mental health without being abstinent, without addressing the fact that abstinence alone is likely to increase the depressive symptoms without appropriate treatment alongside alcohol treatment. Clinicians in the field of Mental Health all too often forget that we can remove the substance, but the reasons that the substance is used still remain. It isn’t until effective treatment occurs, that constructive changes can be made within the client themselves. So when offered CBT, often it is expected that a client is first abstinent from alcohol in order to start CBT. This limits the client’s ability to participate, as abstinence is not always achievable – especially in clients with co-existing depression and substance use disorders.

Strengths of CBT include the fact that it is of no real risk to the client. It will either work or it won’t, but there are no long-term side effects of CBT. The clients have nothing to lose for participating in CBT. A significant strength of CBT is that the research (albeit limited to a few studies) shows that whilst in the short-term outcomes are not dramatically different for co-existing clients, the long-term outcomes for depressive symptoms and substance use are extremely positive. That the clients can see the relevance of the skills they have learned in CBT and use these for living their daily lives. And therefore, in giving the co-existing client back their power is certainly a strength of CBT.


References

 

  • Adams, P. J.(2007)

    Fragmented Intimacy: Addiction in a social world.

    Springer Science &Business Media
  • American Psychiatric Association (1987).

    Diagnostic and Statistical Manual of Mental Disorders

    (3

    rd

    ed.,rev.) Washington, DC
  • American Psychiatric Association:

    Diagnostic and Statistical Manual of Mental Disorders,

    Fifth Edition. Arlington,VA, American Psychiatric Association (2013).
  • Baker, A., & Velleman, R. (Eds.). (2007).

    Clinical handbook of co-existing mental health and drug and alcohol problems

    . Routledge.
  • Brown, R. A., Evans, D. M., Miller, I. W., Burgess, E. S., & Mueller, T. I. (1997). Cognitive–behavioral treatment for depression in alcoholism.

    Journal of consulting and clinical psychology

    ,

    65

    (5), 715.
  • Brown, R. A., & Ramsey, S. E. (2000). Addressing comorbid depressive symptomatology in alcohol treatment.

    Professional Psychology: Research and Practice

    ,

    31

    (4), 418.
  • Durie, M. (1998).

    Whaiora: Maori health development.

    Oxford University Press
  • Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B. Z., Keith, S.J., Judd, L. L., & Goodwin, F.K.(1990) Comorbidity of Mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) Study.

    Journal of the American Medical Association,

    264,2511-2518
  • Turner, R., & Wehl, C. (1984). Treatment of unipolar depression in problem drinkers.



    Advances in behavioural research and Therapy, 6,

    115-125