Susan Quinn RGN, RM, BA
- Diabetes Specialist Midwife
- St Mary's Hospital for Women
- Manchester, UK
A further three women had an unspecifed cardiomyopathy; the au to psy was not of sufcient quality to determine the type (see section 3 diabetes mellitus type 2 blood glucose order precose 50 mg with visa. Four women died with left ventricular hypertrophy; in two of these women it was associated with morbid obesity diabetes medications nclex questions buy cheap precose 25 mg line. A further two women died from myocarditis diabetes type 1 ribbon buy 50mg precose mastercard, two dysrhythmias with structural heart disease metabolic disease glycolysis best buy for precose, and one from post-heart transplant heart failure. She was initially admitted to a surgical ward and investigated for a gastrointestinal cause and then a small pulmonary embolus, but her severe left ventricular dysfunction was diagnosed quickly and treated appropriately. She was unsuitable for transplant or a left ventricular assist device and was managed palliatively. Presentation of heart failure may be with abdominal symp to ms such as distension and discomfort, as well as pain and breathlessness. A woman with a complex social situation and previous mental health problems attended three times in late pregnancy with diferent concerns, and on each occasion was noted to have a tachycardia. She was discussed with but not reviewed by the medical registrar in view of the tachycardia and it was assumed to be due to sepsis. Three weeks later she was admitted with acute breathlessness at which point the peripartum cardiomyopathy from which she subsequently died was diagnosed. The importance of investigation of persistent tachycardia has been highlighted previously in these reports (Knight et al. This woman was signifcantly and persistently tachycardic postpartum, which continued after leaving hospital, with the additional development of breathlessness (Box 3. Unfortunately, due to her his to ry of raised infamma to ry markers and mental health problems, a cardiac cause was not considered and her symp to ms were attributed to anxiety. Syncope during exercise can suggest a cardiac origin, and should prompt cardiac evaluation. A woman in the third trimester awoke in the early hours complaining of shortness of breath. However, she deteriorated markedly during transfer and arrived at hospital in extremis. The multi-professional team were in attendance for her arrival and early recognition of the severity of her illness activated escalation for senior input, who attended promptly. There was a timely peri-mortem caesarean section under taken by the surgical registrar, guided on the telephone by the obstetric registrar whilst the obstetric consultant was en-route. Full resuscitation continued for 60 minutes, with considera tion for causes made. Cardiac echo showed a completely akinetic heart with no identifable reversible causes. Delayed cardioversion Two women died following acute narrow complex tachycardias which were managed with intravenous me to prolol prescribed over the telephone. There were no physical signs of heart failure but she did not have a chest X-ray or echocardiogram despite the his to ry of orthopnoea. After this she had collapse of her circulation and was transferred to theatre for a caesarean section. The woman had poor left ventricular function and mitral regurgitation on echo but no abnor mality was demonstrated on physical examination in the emergency department. Furthermore, it had been difcult to obtain her blood pressure at times and this should have alerted staf to her compromise. The intravenous beta blocker was recommended over the phone and it is possible the cardiology registrar was unaware of the his to ry of breathlessness and orthopnoea. This was sufcient to render the woman haemodynamically compromised and by the time she arrived in theatre she was peri-arrest with agitation and very low oxygen saturation. In both instances, intravenous me to prolol was prescribed over the phone, the women then became extremely haemodynamically compromised, leading to a fetal bradycardia. In both instances, the woman was rushed to theatre for emergency surgery for fetal reasons, when in fact an urgent cardioversion would have corrected the maternal compromise and therefore also the fetal compromise. Improving the condition of the mother in these circumstances will improve the condition of the baby. Immediate electrical cardioversion is recommended for any tachycardia with haemodynamic instability and for pre-excited atrial fbrillation. In the event of maternal cardiac arrest, resuscitation (and delivery) should be performed according to exist ing guidelines. In case of emergency, drugs that are not recommended by international agencies for use during pregnancy and breastfeeding should not be withheld from the mother. Both carbimazole and propranolol had been discontinued at the beginning of the pregnancy. She was not given a follow up cardiology appointment during pregnancy and it appears she was due for cardiology review in two years. Four weeks later she presented to the emergency department with palpitations but symp to ms were assumed to be thyroid-related and she was discharged home with no change in therapy and no obstetric or obstetric medical review. During transfer to the ambulance the woman collapsed and developed ventricular fbrillation. It is not clear whether she received cardioversion before arrival in the emergency department. After a prolonged cardiac arrest and a very late perimortem section, due to confusion over which hospital she was taken to , both mother and baby died. The potential impact of changing physiology in pregnancy on her heart disease did not appear to have been considered. She was not reviewed by an obstetric medical team at the time of her frst admission to the emergency department, when the signifcance of her symp to ms might have been recognised. A proportion of these arrhythmias result from genetic alteration in cardiac ion channels, so called channelopathies. A his to ry of unexplained sudden death in the family should raise the suspicion of an inherited channelopathy. This increased risk extends for nine months postpartum and is reduced by beta-blocker use. Several key channelopathy genes have been identifed allowing the identifcation of individuals at risk and clini cal intervention, and it is possible that other inherited conditions will be discovered. In almost half of deaths in this enquiry, splenic tissue was retained which can be used for subsequent analysis and potential family screening but this is recommended for all women. However, she discontinued the beta blocker postnatally and although advised to restart after admission for an episode of syncope, she was found dead a few months later. Although the initial advice to s to p her beta blocker during pregnancy was correctly recognised as inappropriate, it is unclear what advice this woman received immediately postpartum. Conficting advice about medication during pregnancy may have contributed to her decision to cease medication at this point. There is no evidence that she was advised that the elevated risk of sudden death associated with pregnancy continues for at least nine months postpartum (Rashba et al. Always check the cardiac contraindications of any medication in women with a his to ry of cardiac disease. One had a family his to ry of early sudden death, which was not recognised as signifcant. None of the remaining 11 women who died had any recorded prodromal indications or relevant family his to ry. One had thrombosis of her mechanical mitral valve, one died of post operative complications after planned urgent aortic valve replacement in the very early stages of pregnancy, three had native valve endocarditis, and one died with undiagnosed severe rheumatic mitral stenosis. Her blood results were delayed and she was discharged home on day 1 before staf became aware of her low haemoglobin.
Sexuality is central to quality of life and wellbeing blood sugar 600 emergency buy cheap precose online, during the disease-free stage of the illness at least diabetes symptoms lips discount generic precose uk. Psychological function is clearly affected by gynaecological cancer and its treatment in concert with the physical sequelae diabetes definition kurz cheap precose 50mg with visa. Threats to sexual identity and self-esteem diabetes mellitus metabolically mimics starvation in that purchase precose 25 mg with amex, personal control over body functions, intimacy, relationship stability and the potential termination of reproductive capacity have all been implicated in negative effects on sexual function after cancer and its treatment. In many cases these effects could be more salient to women than the effect of the surgery itself. Additionally, changes in emotional wellbeing, for example the experiences of depression, anxiety, anger, and fatigue relating both to the fact of diagnosis as well as the physical illness symp to ms can affect sexuality indirectly. Research on appropriate interventions targeting these acquired sexual arousal complaints is sparse. There is little or no evidence for physical interventions aimed at addressing sexual issues and, in any case, such interventions would rarely address the significant psychological concerns emerging from cancer surgery. Pos to perative counselling and support for cancer is extensively available but education about sexual physiology and about potential physical and psychological changes pertaining to sexuality in the disease is still limited, if available at all. Women are generally dissatisfied with the lack of attention given to such concerns. The authors also compared women with cervical cancer with those with endometrial cancer to assess possible differential effects. A brief, three-session psychoeducational intervention targeting female sexual arousal disorder in women with early stage gynaecological cancer was first developed and pilot tested. The intervention consisted of three one-hour sessions combining elements of cognitive and behavioural therapy with education and mindfulness training. Women completed questionnaires and underwent physiological measurement of genital arousal pre and post-intervention (sessions one and four) and participated in a semi-structured interview (session four) during which their feedback was elicited. Significant positive effects were seen in terms of sexual desire, arousal, orgasm, satisfaction, sexual distress, depression and overall wellbeing and trends to wards improved physiological genital arousal and perceived genital arousal were also displayed. These findings suggest that a brief three-session intervention can significantly improve aspects of sexual response, mood, and quality of life in gynaecological cancer patients. It also carries implications for establishing the components of the program for women with female sexual arousal disorders. We now move on to looking specifically at hysterec to my carried out for malignant disease. This analysis, as we discussed previously, reveals the negative psychological and sexual impact of such surgery in contrast to positive outcomes seen with hysterec to my for other indications. When compared with a control group of women undergoing surgery for benign disease, radical hysterec to my for cervical cancer has been seen to produce significantly more lubrication problems, decreases in pos to perative sexual activity, impairment in all phases of the sexual response cycle and an increase in diagnosable sexual dysfunctions. In a comparative study followed up over one year looking at women undergoing radical hysterec to my versus a healthy control group the cancer patients experienced significant impairment in genital arousal and negative genital sensations despite no differences in frequency of intercourse. The genital problems reported in these studies included lubrication difficulties, reduced vaginal length and elasticity and more importantly and distressingly, absence of genital swelling in more than half of sexual encounters. Impaired vaginal blood flow in response to sexual stimuli following radical hysterec to my has been quantified using a vaginal pho to plethysmograph (Maas et al. Radical trachelec to my offers hope for future child bearing with promising obstetric outcomes. These hopes and concerns are obviously associated with significant psychological and quality of life issues, the impacts of which are not fully unders to od. Participants completed a preoperative survey addressing sexual functioning, mood, distress, quality of life, and issues of fertility and treatment choice, which were explored by qualitative means. Follow-up questionnaires were completed at approximately 3, 6, 12, 18 and 24 months post-surgery. At preoperative assessment, women opting for radical hysterec to my reported greater concern about cancer recurrence than those undergoing radical trachelec to my. Of the women undergoing radical hysterec to my 48% reported having had adequate time to complete childbearing compared to 8. Overall, scores generally improved during the first year, reaching a plateau between year one and year two, which could reflect a new level of functioning in survivorship. The study concluded that measurements of mood, distress, sexual function and quality of life did not differ significantly with surgical type, and instead reflected the challenges faced by the young cervical cancer patients. Data was collected preoperatively and at four and eight months pos to peratively using standardised questionnaires and specifically developed scales. Preoperatively, the cancer patients interestingly exhibited slightly better sexual functioning than women in the other two groups but this deteriorated slightly over time. Conversely, sexual functioning improved consistently over time in the women undergoing hysterec to my for benign disease. Although the actual number of patients in this study was small, leading the authors to urge caution in interpreting the results, most studies addressing these issues have reported similar, significant disruptions in sexual function following surgery for cancer. The authors recruited thirty-eight consecutive sexually active women due to undergo radical hysterec to my for the treatment of early stage cervical cancer and divided them in to two groups according to the surgical approach. Comparisons were made between the women undergoing radical hysterec to my and those undergoing laparoscopic radical hysterec to my. Further comparisons were made between the women undergoing laparo to mic radical hysterec to my and a group of thirty-five healthy women (as controls) who were seen in the gynaecology clinic for routine gynaecologic evaluation. There were no significant differences between laparo to mic and laparoscopic surgery despite the minimally invasive nature of laparoscopic surgery. The authors of this study concluded that it is important to inform women due to undergo radical hysterec to my of the commonly inevitable negative effects on sexuality. These effects may be minimised by open discussion prior to surgery and by commencing rehabilitation as soon as is feasible pos to peratively. Jongipipan examined prospectively the effect of radical hysterec to my on pos to perative sexual function in South-East Asian women with early stage cervical cancer. Thirty patients were recruited and interviewed at preoperative admission and at three and six months after surgery. These features included overall satisfaction with sexual intercourse, sexual desire, vaginal lubrication, vaginal elasticity, orgasmic satisfaction, patient-perceived partner satisfaction and associated anxiety. The authors in this study could not demonstrate any significant short-term negative impacts of radical hysterec to my on sexual function. As this was an observational study, however, without a comparison group and taking in to account the small sample size, it is difficult to relate these results to the general population. One year later, 101 women, of whom 88 were sexually active, accepted to complete the same questionnaire by mail. The women reported improvement in quality of life on two different scales and no difference was found between scores in women undergoing surgery for Psychological Aspects of Hysterec to my & Pos to perative Care 385 genital prolapse and those having surgery for urinary stress incontinence. The to tal score for sexual variables and the mean frequency of sexual intercourse had both reduced at this point. Amongst women with genital prolapse, 14% experienced more urinary incontinence and 13% experienced more dyspareunia after the operation. Although pelvic floor disorders are known to impair sexual function, there was no improvement in sexuality after surgery for urinary incontinence or genital prolapse. On the contrary, it seemed from this study that sexual function and dyspareunia may both have deteriorated after vaginal surgery. The explanation for this could lie in the vulnerability of the vaginal nerves and vaginal wall blood supply to disturbance during surgery resulting in impaired sexual arousal and lubrication. Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In a review by Tunuguntla et al (2006) the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior and or posterior colporrhaphy, perineoplasty and vaginal vault prolapse was studied. Literature on the mechanisms by which vaginal surgery affects female sexual function was discussed along with related pathophysiology to potential causes. The ana to my, neurovascular supply of the cli to ris and introitus, and intrapelvic nerve supply were discussed in relation to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature and female sexual dysfunction following other procedures, such as vaginal hysterec to my, Martius flap interposition, and vesicovaginal and rec to vaginal fistula repair were also discussed. Current literature did not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who were sexually active was not affected by vaginal surgery. Sling surgery for urinary incontinence did not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary. Some patients experienced improved overall sexual function due to complete relief from coital incontinence. Symp to matic vaginal narrowing was rare even in women undergoing simultaneous posterior repair.
Removal of the myoma allows greater accessibility and eases the subsequent completion of hysterec to my diabetes scientific definition buy precose 25mg fast delivery. A to tal hysterec to my specimen removed on account of a large cervical myoma causing urinary retention diabetes medications chart 2015 order precose with visa. Isthmic fibroids Fibroids arising from this region may present perplexing moments to the surgeon on the operating table and Fig 4 shows a large myoma arising from the anterior isthmus that had both intra abdominal and vaginal (coloured blue by methylene blue) extensions diabetes test no food buy 50mg precose overnight delivery. Performance of hysterec to my in such a case would pose difficulty in assessing the ana to my of the pelvis and applying the lower clamps mayo clinic diabetes diet journal order precose with a visa. Removal of myoma before proceeding with hysterec to my may be of immense help in such cases. An intraoperative picture of a large anterior isthmic myoma having a larger abdominal and a smaller vaginal extention. Uterosacral tumors Tumors (commonly myomas) arising from/near the uterosacral ligaments also predispose to ureteric injury if caution is not exercised. Fig 5 shows a hysterec to my in progress for a large myoma arising from one of the uterosacral ligaments. Clinical operative pho to graph of abdominal hysterec to my for a large myoma arising from the right sided uterosacral ligament. Broad ligament fibroids Large broad ligaments fibroids may get impacted in the pelvis and may also dis to rt the ureteric ana to my, depending on their site of origin (true or false broad ligament fibroids). It is important to identify the ureters tracing them from the pelvic origin downwards before clamping the uterine vessels in these cases. The ureter is usually medial to a true broad ligament myoma while it is lateral and superior to a false one. Fig 6 represents an intraoperative picture of a true broad ligament myoma in the process of being enucleated. Pelvic inflamma to ry disease Often the fallopian tube forms a hydrosalpinx and dense adhesions may bury the tube and ovary in to the pouch of Douglas or bind it to posterior uterine surface. Adhesions between the sigmoid colon and posterior surface of uterus must also be divided. In cases of dense adnexal adhesions, conservation of ovaries may be more difficult than adnexal removal as the infundibulopelvic ligament is usually free of firm adhesions. In case of difficulty, sharp dissection and division of tuboovarian pedicle between two clamps is of help. Anomalous uteri Unilateral absence of the broad ligament in case of unicornuate uterus may make the development of retroperi to neal space impossible and the cervix may need to be cored by sharp dissection. A urorectal septum present between the two bodies of a didelphic uterus may need to be divided cautiously before proceeding further. Fig 7 shows a didelphic uterus with right horn enlarged by a myoma and the relatively smaller but hyperplastic left horn. The right horn is enlarged and congested as a result of a myoma while the left horn is relatively smaller. Malignancy Presence of uterine malignancy makes the uterus very soft, congested and friable. This could cause difficulty in application of clamps and passing/tying ligatures and these could easily cut through tissues and cause hemorrhage. Fig 8 shows a large leiomyosarcoma arising from the uterine body as seen at hysterec to my. A gentle handling of tissues, availability of blood and a multidisciplinary approach would be beneficial in such cases. The ureter may be injured near the infundibulopelvic ligament, near the uterine vessels or the anterior cervix. All main vascular pedicles should be doubly secured to prevent slippage of ligatures. W om en at risk of throm bosis should be given thromboprophylaxis in the perioperative period in the form of heparin, apart from non-pharmacological measures like early ambulation, adequate hydration and s to ckings. Normal ovaries should not be removed if hysterec to my is being done for benign uterine disease irrespective of age. Rather, the only indications of concomitant bilateral oophorec to my in recent times are genital malignancies, extensive/ recurrent severe endometriosis, certain cases of breast carcinoma and women with familial predisposition to ovarian cancer. When ovarian removal is planned, the role of hormone replacement therapy must be discussed with the woman preoperatively. Vaginal hysterec to my A hysterec to my carried out by the vaginal route offers the advantages of fewer complications, shorter hospital stays and faster return to normal activities. Despite this, the abdominal approach continues to dominate the incidence charts world-over. The skill and experience of the surgeon plays a pivotal role in determining the approach route. The vaginal procedure has conventionally been done for women with uterine or pelvic prolapse. Laparoscopy is a useful aid for lymphadenec to my in cases of cervical or endometrial cancer, evaluating adnexal masses or endometriosis and aiding vaginal hysterec to my. Bowel cleansing is very important for vaginal hysterec to my in order to evacuate solid s to ol from rectum, reduce the bacterial load of intestinal tract and to reduce the incidence of pos to perative ileus and constipation. Prophylactic parenteral antibiotics, usually a cephalosporin, is administered an hour prior to the procedure after a test dose. Metronidazole is usually added in the pos to perative period to take care of anaerobes. Betadine solution is used to clean the genitalia and vagina and alcohol based solutions should be avoided in the vagina. The but to cks should be brought to the edge of the table which is in zero horizontal position. The cervix is held with Valsellum forceps and the vagina is infiltrated with saline adrenaline solution (in strength of 1:200,000 to 1:400,000). The vaginal flaps are dissected on either side from urinary bladder keeping the fascia with the bladder. An inverted V shaped incision is placed on the vaginal wall and peri to neum of Pouch of Douglas exposed and snipped to bring in to view the posterior uterine wall. It is important to remain close to the lateral uterine wall while applying the clamps. The uterine vessels should be doubly ligated bilaterally after cutting in between the clamps. The uppermost pedicle consisting of fallopian tube, ovarian and round ligaments is usually clamped with long curved clamps, cut and ligated. Before applying the upper most clamp, the fundus of the uterus should be delivered out usually through the pouch of douglas and the clamps applied under vision to avoid including omentum / gut loop in the tip of the clamp. Alternatively, the uterovesical pouch can also be used to deliver out the uterine fundus. The anterior and posterior peri to neum may now closed with a continuous 00 chronic catgut suture, keeping the pedicles extraperi to neal. This would minimize chances of blood from any of the pedicles gaining entry in to the pelvic cavity and would be revealed vaginally. If an enterocele is present, the peri to neal sac of the enterocele may be excised and the posterior peri to neum closed as high as possible, preferably up to the level of yellow fat. This can be combined with a McCall culdoplasty which entails suturing of the uterosacral ligaments in the midline to obliterate the hiatus for enterocele.
This is not to argue that mental health promotion cannot be an important component of a stand-alone men tal health policy diabetes prevention meal plan precose 25 mg online, but rather that a concerted effort must be made to engage a large number of stakeholders from different sec to rs in the policy development and implementation process diabetes mellitus type 2 nice order precose 50mg free shipping. Without this participation diabate kora purchase 50 mg precose amex, the opportunities for identification of the broader determinants of mental health and implementation of strategies for long-term sustainable change are limited diabetes symptoms cold feet buy generic precose 50 mg on line. Mental health professionals have a necessary, but not sufficient, role in mental health promotion (Herrman, 2001). Components of policy A policy normally comprises a vision statement, a statement of the underlying values and princi ples, a set of objectives that help implement it and a description of the major areas of action to achieve the policy objectives and fulfil the ultimate intentions of the policy. Vision statement the vision of a mental health policy represents a general image of the future of mental health in a given population. It should set high expectations as to what is desirable for a country or region in the realm of mental health. At the same time it should be realistic, taking account of what is possible with reference to available resources and technology. In its final formulation the vision statement should incorporate the main elements of a mental health policy and blend it in to a description of what is to be expected or achieved some years after its implementation. For exam ple, a vision statement that specifies the improvement of mental health among all individuals is one that reflects a commitment to incorporating mental health promotion strategies. In contrast, a vision statement that focuses on reducing the mental health burden reflects an emphasis on treatment and care. Values and principles Values and principles are the basis from which governments develop objectives and courses of action and strategies. Values refer to the judgments or beliefs about what is considered worthwhi le or desirable; principles refer to the standards or rules to guide actions and should ultimately emanate from values. It might also lead to a principle of intersec to ral collaboration and community development as an important fra mework to be adopted to improve mental well-being. Areas for action and strategies Once the objectives of the mental health policy have been clarified, a number of areas for action and strategies need to be identified in order to take these objectives forward. An effective mental health policy should consider the simultaneous development of several areas: financing, legisla tion and human rights, organization of services, human resources and training, promotion, pre vention, treatment, rehabilitation, advocacy, quality improvement, information systems, research and evaluation (see figure 16. Some of the more important actions for mental health promotion are briefly discussed below. This has implications for mental health financing, to ensure that mental health is included in basic health packages and health insurance schemes. It also has implications for the distribution of mental health resources in terms of equity and efficiency. Simply stated, resources committed to mental health promoting activities should consider the needs of certain disadvantaged groups as well as the whole popu lation to promote equity and should be based on effectiveness and cost-effectiveness data to maximize efficiency. In order to promote mental health and the well-being of populations, issues such as service accessibility, community integration, non-discrimination, au to nomy, liberty, postpartum leave to foster mother-infant bonding, mental health promoting work environments and protection from domestic violence and sexual abuse need to be addressed. A number of activities may be initiated to serve the objectives of mental health promotion. Services need to be reorganized and reoriented to deal with psychosocial aspects of mental health and to provide interventions to improve mental health at individual and community levels. Essential drug procurement and distribution processes need to ensure that cost-effective treatments are widely available. Quality improvement strategies are also needed to ensure that policy, legislation, regulations and funding are appropriately aligned to achieve mental health improvement goals. Information sys tems need to incorporate measures and indica to rs of quality of life and, as indicated throughout this book, investment in research and the evaluation of policies and services needs to contribute to the evidence base for mental health promotion to ensure that resources are allocated cost effectively. Advocacy is an important activity, but the emphasis of advocacy should not be exclusively on the protection of the rights of those with severe mental illness, which has traditionally been the case, but rather combine this with promotion of mental health in the general population. Considering the methodological complexities of evaluating mental health promotion policies (see Chapter 9) and the longer time required to see positive results as compared with the evaluation of treatment and care, govern ments may be reluctant to invest in these types of strategies. Advocacy from community orga nizations is often required to encourage governments to implement mental health promotion strategies. Both health and social services have an important responsibility to involve users and carers in the development and implementation of their services (Dunn, 1999; Mental Health Foundation, 2000). Multisec to ral action is fundamental and requires serious discussion and a clear understanding, acceptance and statement of the distribution of roles and responsibilities between different government sec to rs/ministries. Achieving multisec to ral collaboration is challen ging as the different sec to rs attempt to work to wards a shared goal within differing cultural and organizational structures. A number of key success fac to rs for intersec to ral collaboration can be identified. The process of formulating a mental health policy and identifying mental health promotion interventions provides an oppor tunity to ensure all partners share a commitment to a common goal. Intersec to ral collaboration requires broad policy support from a wide range of health and social policies. The inclusion of mental health promotion goals within a broad policy framework assists in obtaining the political support necessary for successful collaboration. Collaboration should include both horizontal lin king (that is, linking mental health with the health, education, employment, social welfare, justice, user and family sec to rs) and vertical linking (that is, linking national, regional and local networks). A focus on concrete objectives and achieving results rather than setting up complex collabora tion structures assists in keeping stakeholders committed and motivated. It is essential that the agenda is guided by the goals of the collaboration rather than the interests of a few stakeholders. Policy assists in providing clear guidance on the roles and responsibilities of each partner and provides concrete strategies to achieve objectives. Effective collaboration requires time and resources (Advisory Committee on Population Health, 1999). Examples of strategies for mental health promotion Mental health promotion works at three levels: strengthening individuals, strengthening commu nities and reducing structural barriers to mental health. At each level it is relevant to the whole population, to individuals at risk, to vulnerable groups and to people with mental health pro blems (mentality, 2003). Such a framework is useful for conceptualizing the entry points for promotion within a mental health policy. Ultimately, however, the most appropriate entry point for mental health promotion will depend on information derived from a needs assessment and the social, cultural, gender, age related and developmental contexts of specific countries. For example, an Iranian mental health initiative shows how changes in the sociodemographic status of a country can be reflected in mental health policy. The national programme, launched in 1988, was mainly focused on integra tion of mental health in to primary care. The associated psychosocial consequences are being addressed predominantly via mental health promotion acti vities in schools (Yasamy et al. Other examples of strategies that could be considered for inclusion in mental health policies at each of the three levels are described below. Examples of mental health promotion activities that aim to strengthen individuals include mother-infant programmes and life skills programmes for children (Department of Health, 2001). Mother-infant programmes the psychosocial and cognitive development of babies and infants depends upon their interac tion with their parents. Programmes that enhance the quality of these relations can substantially improve the emotional, social, cognitive and physical development of children. These activities are particularly meaningful for mothers living in conditions of stress and social adversity. There was evidence of reductions in anxiety and depression, better orga nized family life and the creation of more stimulating environments for children as a consequence of participation in the programme.
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