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Mental Health Strategy and Policy

Rural vs Urbanized Communities and First World vs Developing World
  • Dutsadee JuengsiragulwitEmail author
  • Anula Nikapota
Living reference work entry
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Part of the Mental Health and Illness Worldwide book series (MHIW)

Abstract

Urbanicity is raising concern on mental health impact since 2000. The United Nations predict that the vast majority of the human population will live in urban rather than rural areas by 2030. Some previous studies have shown that urbanicity causes a negative impact on adults’ mental health as well as children’s, especially on emotional and behavioral problems. This chapter aims to discuss the impact of urbanicity on child and adolescent mental health (CAMH) in both lower-and middle-income and high-income countries. With regard to mental health strategy and policy, the PESTLE model for assessing opportunities and threats for the organization before planning mental health strategy in urban or rural areas will be discussed. Possible solutions to design appropriate child and adolescent mental health service in rural or urbanized areas will be proposed.

Keywords

Child and adolescent mental health High-income countries Low- and middle-income countries Rural Urban 

Introduction

Urbanicity is raising concern on mental health impact since 2000. The United Nations predict that the vast majority of the human population will live in urban rather than rural areas by 2030 (United Nations 2018). Some previous studies have shown that urbanicity causes a negative impact on adults’ mental health as well as children’s, especially on emotional and behavioral problems (Evans et al. 2018). This chapter aims to discuss the impact of urbanicity on child and adolescent mental health (CAMH). With regard to mental health strategy and policy, the PESTLE model for assessing opportunities and threats for the organization before planning mental health strategy in urban or rural areas will be discussed. Possible solutions to design appropriate child and adolescent mental health service in rural or urbanized areas will be proposed.

Urbanicity and Child and Adolescent Mental Health

Considering features of urban environments and the impact on mental health, two key dimensions were noted, urbanization and urbanicity. “Urbanization” refers to change in size, density, and heterogeneity of cities, while “urbanicity” refers to the impact of living in urban areas at a given time (Vlahov and Galea 2002). Although living in urban area is attractive for most people due to various reasons such as easier job access, higher salaries, accessibility to medical care, better transportation system, high-quality schools, child care centers, etc., growing evidence indicates that living in the cities is more stressful compared with living in semirural or rural areas. Air pollution, noise pollution, relatively nature-deficit area, limited social support from family or friends, higher crime rate, or higher living expenses can be causal factors of stress in urban residents and impair their quality of life (Kennedy and Adolphs 2011; Amato 1993; Hofferth and Iceland 1998; Paykel et al. 2000; Bernam et al. 2012).

Level of urbanicity results in different kinds of child and adolescent mental health problems. Rural area is suggested to be associated with adolescent parenthood, up to three times more prevalent in rural areas compared to urban areas globally (World Health Organization 2018a). In urban or megacities, especially in developing areas, air pollution such as dust, high NO2, or PM2.5 is unavoidable since air pollution regulation is not well established in such areas (World Health Organization 2013a). Association between child mental health problems and air pollution was found in a longitudinal cohort study from the UK. It noted that air pollutions received at age 12 were significantly associated with increased odds of major depressive disorder at age 18, even after controlling for common risk factors (Roberts et al. 2019). A seminal study comparing children living in rural towns on the Isle of Wight to those living in inner-city London found that rates of both conduct disorders and emotional disorders were higher in residents of urban compared to rural areas (Rutter 1981). The results were replicated by a Dutch general population study that examined whether urbanicity was independently associated with more behavioral and emotional problems in primary school-aged children and whether it remained after controlling for other major risk factors for mental health problems in children. Analysis of data in 4 age groups i.e., 8, 9, 11, and 12 years old showed that children who lived in more urban areas were significantly more likely to exhibit behavioral (p < 0.001) and emotional (p < 0.001) problems. This effect remained when controlling for neighborhood socioeconomic status, gender, ethnicity, family socioeconomic status, parental symptoms of psychopathology, parenting stress, and parenting practices (behavioral: p = 0.02, emotional: p = 0.009). Like research in adults, urbanicity seems to be independently associated with behavioral and emotional problems in children. A possible underlying mechanism is that the city is a stressful environment for children to grow up in, which contributes to an increased risk for mental health problems.(2) Disadvantaged neighborhoods increased the risk of developing emotional disorder twice for youths living in urban areas versus nonurban areas. In urban centers, living in a disadvantaged neighborhood was associated with 59% (95% confidence interval 25–103) increased adjusted odds of emotional disorder (Rudolph et al. 2014). Growing up in urban areas was found associated with a twofold adulthood psychosis risk, and this association replicates for childhood psychotic symptoms (Newbury et al. 2016, 2017). Urban poverty could be another factor affecting CAMH. In a Great Smoky Mountain Study, researchers conducted a naturalistic experiment to evaluate children’s emotional and behavioral problems before and after money provision for the Cherokee parents after opening the casino. Results showed that children’s emotional and behavioral problems decreased significantly after their parent’s poverty diminished. Possible mediator suggested in the study is parental supervision. The study suggested that poverty leads to inadequate parental supervision which eventually engenders the child’s emotional and behavioral problems (Costello et al. 2003). Urbanicity was associated with increased likelihood of having been racially bullied. Urban bully victims were also more likely to have been bullied about money than nonurban bully victims (Goldweber et al. 2012). Surprising results from a primary emotional traits study in parallel sample from Germany and China showed that higher scores in the urbanicity index in childhood were associated with fear and sadness only in adult Chinese females. These effects seemed to be driven by living in Chinese megacities (over ten million populations), because a parallel sample from Germany and China in smaller urban cities resulted in weaker but similar effects in females in both countries. Additional associations could be observed with higher play and urban upbringing in Chinese males. With small correlations and multiple testing issues in this study, interpretation should be done with caution, and researchers are encouraged to consider urbanicity variables in personality neuroscience and personality-oriented clinical psychiatric research (Sindermann et al. 2017).

Impact of urbanicity on child mental well-being is not only by direct effect of stressful or toxic environment but also from indirect effect of upbringing by stressful parents when they live in an urban compared to a rural area. Parenting stress plays an important role in child mental health outcomes. One study investigated the relationship between parenting stress and child behavioral problems from ages 3 to 9 years old and found that behavioral problems and parenting stress covaried significantly across time for children with normal or delayed development. The analyses supported that the relationship between two factors seemed to be bidirectional (Neece et al. 2012). Another study regarding parenting stress illustrated that parenting stress mediated the relationship between potentially traumatic events that the child experienced and internalizing problem behaviors at 6 months (Whitson and Kaufman 2017). The relationship between urbanicity, parenting stress, and child and adolescent mental health is shown in Fig. 1.
Fig. 1

Relationship between urbanicity and child and adolescent mental health

Rural communities can provide health advantages for their habitants. High levels of green space presence during childhood are associated with lower risk of a wide-spectrum of psychiatric disorders later in life. The association remains even after adjusting for urbanization, socioeconomic factors, parental history of mental illness, and parental age (Engemann et al. 2019). Children in rural areas are more likely than urban children to live in safe and supportive communities. However, they are less likely to have access to amenities such as recreation centers or parks or playgrounds as well as health-care center than their urban counterparts (U.S. Department of Health and Human Services Health Resources and Services Administration 2007; Imig et al. 1996). Although parental stress seemed to be lower in rural areas (Moore et al. 2005), various stressors, such as living in high poverty and distant areas, uncertain employment, experiencing agricultural difficulties, rural restructuring, or limited medical and behavioral health resource availability, could be sources of parental stress and influence their child’s development and mental well-being. The relationship between rurality, parenting stress, and child mental health is shown in Fig. 2.
Fig. 2

Relationship between rurality and child and adolescent mental health

Mental Health Strategy and Policy in Rural and Urban Area

CAMH strategy and policy in rural and urban areas may differ in various aspects. The Ottawa Charter for Health Promotion will be a core concept for discussion on CAMH promotion and prevention in rural and urban areas. For child and adolescent mental disorder treatment and rehabilitation, the six building blocks for health systems which were proposed by the World Health Organization will be used as a framework for discussion.

Child and Adolescent Mental Health: Promotion and Prevention in Rural and Urban Areas

In 1986, the World Health Organization (WHO) arranged the first International Conference on Health Promotion, and the Ottawa Charter was first presented to achieve Health for All by the year 2000 and beyond (World Health Organization 1986). It is a socio-ecological conceptualization of health promotion that provides diverse actions from individual behavioral change to systems and policy level approaches (Kickbusch 1986). From this Charter, health promotion is “the process of enabling people to increase control over, and to improve, their health. To reach the state of complete physical, mental and social well-being, an individual must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector but goes beyond healthy life-styles to well-being.” The Charter articulates core values of “equity, participation and empowerment” and proposes a framework of three strategies (advocacy for favorable conditions for health, enabling all people to reach their full health potential and mediating between different interests in society for the pursuit of health) and mentioned five action means, i.e., building healthy public policy, creating supportive environments, reorienting health services, developing personal skills, and strengthening community action (World Health Organization 2009). Caring, holism, and ecology are essential issues in developing strategies for health promotion. Therefore, social ecology like urbanicity should be considered in each phase of planning, implementation, and evaluation of child and adolescent mental health promotion activities.

Building Healthy Public Policy

The WHO emphasized the importance of “Health in All Policies” to work on public policies across sectors and with communities (World Health Organization 2014). They illustrated steps in developing a child and adolescent mental health policy as shown below:
  1. (1)

    Gather information and data for policy development.

     
  2. (2)

    Gather evidence for effective strategies.

     
  3. (3)

    Undertake consultation and negotiation.

     
  4. (4)

    Exchange with other countries.

     
  5. (5)

    Set out the vision, values, principles, and objectives of the policy.

     
  6. (6)

    Determine areas for action.

     
  7. (7)

    Identify the major roles and responsibilities of the different stakeholders and sectors.

     
Summarizing these seven steps with CAMH local policy in rural and urban area, the steps should be contracted to five essential steps, i.e.,
  1. (1)

    Gather community context, CAMH information, and data for local policy development.

     
  2. (2)

    Gather evidence including local intelligence for effective strategies.

     
  3. (3)

    Set out the vision, values, principles, and objectives of the policy.

     
  4. (4)

    Public hearing including community stakeholder’s participation.

     
  5. (5)

    Identify the major roles and responsibilities of the different stakeholders and sectors.

     

CAMH promotion will be more effective if it is operated within non-health sectors like education sector or in community rather than in health sector. Hence, developing CAMH promotion policy is challenging due to the need for intersectoral collaboration. Generally, there are fewer stakeholders in rural or semirural areas and less complicated structure of local authorities comparing with megacities. This relatively simple context may be an advantage in building intersectoral linkage, but in the other way around, it reflects comparatively limited resources in rural communities and may restrict the variety of strategies used in such area.

Information about local intelligence is as important as evidence-based practice in community CAMH. The importance of local initiatives is highlighted in rural area where the initiatives may not be evidenced due to the lack of researchers or experts in CAMH although it was effective in that context. However, ongoing outcome evaluation or implementation research should be planned with community stakeholders to ensure the efficacy of such local initiatives in real-life practice.

Although these steps are essential components of developing healthy public policy, the third step “set out the vision, values, principles and objectives of the policy” and the fourth step “public hearing including community stakeholders participation” were considered the most important key success factors for community mental health projects. Shared vision and values with all community stakeholders will unite them together with sense of belonging. Their ownership and participation will enable a long-term teamwork which eventually lead to sustainable outcome. Creating community participation in megacity or urban areas is a challenging process since social cohesion in such areas is lower than its counterpart. Community in a big city may include people living in the same habitat or online social group or even parents of children in the same school. Community context and information will guide CAMH community practitioners who are community leaders and stakeholders in such area.

Another issue about public policy in low- and middle-income countries (LAMICs) is a special economic zone, which is an economic strategy deployed in many countries. The environmental impact assessment (EIA) and health impact assessment (HIA) policy are always included in operational plan, but mental health impact assessment (MHIA) policy is not yet established. Evidence from the US National Survey of Drug Use and Health (NSDUH) in 2009–2011 suggested that the prevalence of major depression or serious mental illness in adolescence and adulthood in small metropolitan areas and semirural areas was slightly higher than in large metropolitan areas, with statistically significant odds ratios after adjustment ranging from 1.12 to 1.19 (Breslau et al. 2014). This information should be considered, and the MHIA especially in terms of parenting stress and the impact of parents with mental illness in children and adolescence should be surveilled.

Creating Supportive Environments

Creating supportive environments was defined as “developing physical and/or social environments in ways which support health and protect against physical hazards and socially and psychologically damaging practices” (Ottawa Conference Report 1986). The core elements of effective interventions leading to supportive environments are described below (CYCC Network 2014).

Family Centered

Family relationship is an essential social environment in a child’s life. Healthy family relationships shield children from developing emotional and behavioral problems, while poor family function has a negative impact on a child’s mental health. A family-centered program with a focus on enhancing positive family relationships by improving communication and problem-solving skills will provide protective factors for children and reducing risk factors for developing disruptive behavioral problems (Thompson et al. 2005). Parenting programs can be targeted at parents of children with, or at risk of, developing conduct disorder and are designed to improve parenting styles and parent-child relationships. Reviews have found parent training to have positive effects on children’s behavior and that benefits remain 1 year later (Dretzke et al. 2009; Lundahl et al. 2006).

In LAMICs, rural families are more likely to be extended and skipped-generation households since domestic migrations from rural to urban areas are common. Thus, CAMH practitioners should take family structure into account when designing family-centered intervention in such areas.

Community Based

A famous proverb “It takes a village to raise a child” reflects the importance of building a supportive community for a child. Physical and social environments are embedded in communities which will have direct and indirect influences on children’s behaviors and upbringing. Social risk factors like poverty, vulnerable community, deviant peers, and neighborhood characteristics are interconnected, dynamic, and reciprocal. Community-based interventions create social connectivity and support families by identifying, empowering, and utilizing children’s natural support networks together. Since CAMH resource in LAMICs is scarce, community-based action should be done under a family-community-schools collaboration.

Youth Engagement

Meaningful adolescent and youth engagement is “an inclusive, intentional, mutually-respectful partnership between adolescents, youths, and adults whereby power is shared, respective contributions are valued, and young people’s ideas, perspectives, skills, and strengths are integrated into the design and delivery of programs, strategies, policies, funding mechanisms, and organizations that affect their lives and their communities, countries, and world”(World Health Organization 2018b). Engaging youths regardless of their socioeconomic status, ethnics, gender identity and orientation, religion, disability, political affiliation, or physical location will create sense of belonging and being accepted as part of communities. Youth engagement will eventually empower them to lead the project with support of adults.

Cultural Sensitivity

Cultural bias or lack of understanding contributed to inequalities and disparities in mental health care. It is essential to ensure access to equitable services to culturally diverse communities. CAMH promotion and prevention in ethnic minorities in LAMICs are not usually given priority since such service for general population is still lacking. Cultural sensitivity is a fundamental issue that should be considered when implementing effective CAMH strategy for ethnic minorities. For example, in some ethnic groups, parents are respected as god so they will not hug or play with their children when applying child developmental stimulation program. Reading books for their kids is almost impossible because there is no writing in their language. In such situation, engaging the literate siblings or childcare staff in the program would be helpful. Cultural sensitivity in urban areas tends to be less diverse than that in rural areas or megacities. CAMH practitioners should refine CAMH program before implementation in that areas.

In short, combination of action by youths, families, and communities with consideration of cultural sensitivity forms core elements of creating a supportive environment. Moreover, since the emergence of the digital age, social environments move toward social online and network. This surreal social environment provokes various CAMH problems, e.g., game or Internet abuse, cyberbullying, sexual or emotional abuse on social media, etc.

Reorienting Health Services

Reorienting health services is essentially about shifting the focus of health-care sector from treatment and rehabilitation to an increasing focus on health promotion and prevention. The Ottawa Charter mentioned “Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.” In other words, it expands health-care service from medical approach to well-being approach which needs a change of health personnel’s mindset and service reorganization to capture the total needs of the individual as a whole person (Ottawa Charter). Interpreting this principle into practice, health-care practitioners should gradually shift their focuses from clinical tasks to community health works since most well-being improvement strategies occur in non-health sectors which are based in the community.

The role of CAMH practitioners in CAMH service reorientation is particularly important since knowledge and skills on CAMH promotion and prevention are not well established in social and public sectors so the tasks are relying on CAMH practitioners’ guidance. For example, a study from the UK revealed that detecting the signs and symptoms of mental illness in young people is a challenge even for general practitioners (Hinrichs et al. 2012). A qualitative study from Nicaragua unveiled that doctors and nurses were reluctant to deal with young people with suicidal problems at primary health care which was more likely to be caused by feelings of incompetence, lack of time, lack of privacy, and lack of human resources and difficulties in communicating with young people rather than from negative attitudes (Medina et al. 2014). With this challenge, either in developed or developing countries, CAMH practitioners are invited to reconsider their roles on CAMH promotion and prevention in collaboration with primary health-care practitioners and local communities. Integrating CAMH into primary care services can contribute to greater equality of access, because such services will serve more people in need (World Health Organization 2018c).

For urbanized cities, shifting the mindset of CAMH practitioners could be more challenging since CAMHS in higher-resource areas are far more advanced and tend to be designed as specialized clinics: either disorder-based clinic or intervention-based clinic rather than mental well-being clinic. Without CAMH promotion and prevention, the clinics will gradually become overcrowded over time since most CAMD are chronic illnesses, and the patients are aggregated in the clinic. If so, clinicians will be overwhelmed and end up with endless requests for more resources which lead to wider inequitable service comparing to those in rural areas. Service reorientation will cut off this vicious cycle and engender better CAMH resource management.

In rural areas where CAMHS is scarce, it is a chance for CAMH practitioners who establish the service to “orientate and organize” the service in balance of clinical approach and well-being approach. If CAMH practitioners engage CAMH promotion and prevention strategy in their plan earlier, they may be overwhelmed with all four dimensions of CAMH work (promotion, prevention, treatment, and rehabilitation) in the first step. But after the system is set up, their team will enlarge to include staffs in non-health sector. For example, the project entitled “Health and Educational Regional Operation: HERO” developed in northeastern of Thailand is a collaborative platform between community hospitals and schools under supervision of CAMH specialists. At that time, there were 17 child psychiatrists for four million children; therefore, it is impossible to provide individual working with the whole population. Schoolteachers were trained with a scalable experiential learning workshop to gain behavioral modification skills for managing children with emotional and behavioral problems. Outcome shown by the SDQ improved in all domains with moderate effect size including children’s academic achievement. About half of at-risk children returned to normal range and were not referred to specialist clinics. Those with persistent emotional or behavioral symptoms were referred for diagnosis and treatment, which increased service accessibility of ADHD from less than 5% to 21.4% within a year. Teachers eventually deploy the skills learned in the workshop to normal children and effects in increasing positive behaviors (Juengsiragulwit et al. 2018). The study supported a transdiagnostic approach in early intervention. Specialists’ clinical task will be focused on treatment of complex CAMD, leaving noncomplicated case management to nonspecialists in their areas.

Developing Personal Skills

Developing personal skills aims to empower the individual and give them more control over health or, in other words, promoting health through providing health information, education, and enhancing life skills. It includes the development of health literacy, promoting protective behaviors, understanding of the links between risk behaviors and lifestyle diseases, and enhancing the individual’s skills for navigating the health system and appraise health information (World Health Organisation 1986). Health literacy was defined by the European Health Literacy Consortium as “people’s knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course” (Kickbusch et al. 2013).

Inadequate mental health literacy is a major barrier for help seeking in adolescents with mental health difficulties (Gulliver et al. 2010; Evans-Lacko et al. 2012), societal stigma, and discriminating behaviors (Rusch et al. 2011; Thornicroft 2008). Various studies from developed countries focus on improving child and adolescent mental health literacy. A qualitative study entitled “NePP: Needs for primary prevention in families affected by parental mental illness” conducted in 2015–2017 confirms earlier results of the study on international health literacy and emphasizes that shame/stigma are important determinants of help seeking and mental health literacy. The results have been translated into the conceptual framework of the research project “IMPRES: Improving mental health literacy to reduce stigma” which aims at development, implementation, and evaluation of an intervention to address mental health literacy and stigma in children and adolescents. The researchers hope that destigmatisation in children and adolescence may lead to destigmatization in the future society (Wahl et al. 2018). To improve service accessibility through anti-stigmatization, an educational program is a potential method for enhancement of mental health literacy (Kelly et al. 2007). However, there were limited studies regarding mental health literacy in adolescence, especially in LAMICs (Rahman et al. 1998). A randomized controlled trial in 380 students in 22 classes from 10 nongovernment secondary schools examines the impact of “Head Strong,” a school-based educational intervention, on mental health literacy, stigma, help seeking, psychological distress, and suicidal ideation. Participants were randomly allocated to receive either Head Strong or Personal Development, Health and Physical Education (PDHPE) classes. Outcome was assessed pre- and post-intervention and at 6-month follow-up. Literacy improved, and stigma reduced in both groups at post-intervention and follow-up, relative to baseline. However, these effects were significantly greater in the Head Strong condition (Perry et al. 2014).

Developing CAMH personal skills involves not only knowledge and skills specific to mental health but also includes impact of general health on mental health, family contexts, social, and spiritual perspectives. Therefore, it requires multi-sectoral involvement, e.g., schools, primary care, social welfare or social institution, NGOs, and community.

Child and adolescent personal skills sets are various and overlapping. School-based social and emotional learning (SEL) programs help children and young people to recognize and manage emotions, set and achieve positive goals, appreciate the perspectives of others, establish and maintain positive relationships, make responsible decisions, and handle interpersonal situations constructively (Elias et al. 1997). Repeating evidence shows that SEL participants demonstrate significantly improved social and emotional skills, attitudes, behavior, and academic performance. The SEL consists of five components, i.e., (1) self-awareness, (2) self-management, (3) social awareness, (4) relationship skills, and (5) responsible decision-making. All five components overlap with the life skill components recommended by the WHO. Life skills training/education is a transdiagnostic intervention which has been proven for prevention of substance dependence, teenage pregnancy, conduct behaviors, behavioral addiction, etc. (Weisen et al. 1997). Analyzing both programs, child and adolescent personal skills encompass cognitive, social, and emotional skills development for promoting protective behaviors and prevent negative mental health outcome from their life experiences. Quality of SEL or life skills training in urban and rural areas may differ based on quantity and quality of the teachers. In remote areas, especially in LAMICs, there may be only 1–2 teacher in a primary school. It is almost impossible to accomplish mental health skills training for children in such schools. In that case, family and community participation would play a major role in arranging life skills training for children in cooperation with schools.

Strengthening Community Action

Health promotion generally operates by engaging community and cooperating with the community to set goals, priority, and plan and implementing it together to achieve better health outcome. Rural and urban communities are markedly different. Simplicity and stronger social cohesion are advantages of rural communities, while higher CAMH resources and advocacy in urban settings are superior. Generally, practical steps in community mental health action that can also apply for CAMH are as follows:

Community Engagement and Collaboration

Building strong coalition with various stakeholders in community, e.g., community leader, school director, traditional healer, local authorities, etc., is a fundamental step of community mental health work equal to building therapeutic alliance in individual psychotherapy. If the alliance does not exist, the next step cannot be done. Since community stakeholders are diverse, community mental health works are more complicated than school mental health. Engagement and collaboration with school and other educational partners are important in community CAMH. Schools are often the strongest social and educational institution for CAMH intervention. Teachers can actively involve in CAMH programs, and the intervention can reach generations of children (Hendren et al. 1994). However, teachers in limited resource areas are as overwhelmed as CAMH practitioners. Therefore, engaging schools and teachers should be done in empathic ways.

In LAMICs or in indigenous areas, traditional healer or wisdom elites can be part of influential community leaders. A systematic review on effectiveness of traditional healers in treating mental disorders in 2016 concluded that traditional healers can provide an effective psychosocial intervention which might help to relieve distress and improve mild symptoms in common mental disorders, e.g., depression and anxiety, but not change the course of severe mental illnesses like psychotic disorder. There was no research mentions efficacy of traditional healers in CAMH (Nortje et al. 2016). From adult evidence, building good rapport with indigenous healers could be useful, for instance, if CAMH knowledge can be provided and disseminated through ritual procedures that children and families are familiar with.

Community Analysis

Community contexts are varied across settings. CAMH practitioners should collect adequate information until the community concerns and community resources are identified. Community key players may not engage in the first step at the same time. So, information recollection may need to be done if indicated. In CAMH, community concerns encompass the child’s emotional-behavioral-social difficulties, parent’s and teachers’ attitudes and concerns on the child’s difficulties, and community participant’s perspectives on CAMH. For example, a 3-year-old child with delayed speech may be recognized as normal variation in underdeveloped areas, while in high-resource setting, their counterparts may have much earlier access to CAMHS or pediatric unit for developmental assessment. Community concerns help practitioners understand and formulate nature of CAMH problems in that community, but community resources will guide them for possible solutions. Resource holders and resource persons either specialized or nonspecialized in CAMH should be engaged as early as possible to participate in planning of community CAMH projects.

Setting Shared Goal and Setting Priority

It needs empathic negotiation to achieve the shared goal with school and community. Shared goal will encourage sense of teamwork and strengthen coalition between community and CAMH practitioners. CAMH work can support teachers in classroom management and improve children’s academic achievement. It can support social workers in the institution to manage the child’s emotional and behavioral problems and improve their quality of life. While setting shared goal, either well-being approach or symptomatic approach is recommended. Disorder approaches that medicalize children’ emotional and behavioral problems should be avoided. If the project starts with mental disorders, all stakeholders will perceive the child’s difficulties as a disease and therefore refer them for treatment in health-care setting rather than trying to help or support the child by themselves.

Basically, CAMH problems are various. Prioritizing CAMH issues will guide direction for CAMH work. To prioritize, there are criteria for decision-making suggested by the WHO and allied organization (World Health Organization 2017) which can be modified into “4-I” abbreviation, i.e.,
  1. (1)

    “Impact”: Magnitude of the problems, e.g., number of death or injury or prevalence of risk behaviors

     
  2. (2)

    “Identification”: Identifying groups of children and adolescents most affected, e.g., vulnerable group like children with poverty, parental loss, parental mental disorders, etc.

     
  3. (3)

    “Intervention”: Availability of effective interventions and its feasibility in delivering in particular community with different socioeconomic and cultural differences

     
  4. (4)

    “Implementation”: Potential for scaling up the intervention to achieve expected outcome in target group

     
Formula of success in implementation science which comprise of effective intervention, effective implementation, and enabling contexts is useful in developing implementation plan (Hanson et al. 2016). Setting priority by school or community will enhance their sense of ownership and eventually sustain the CAMH work either in rural or urbanized area. Suggested targets for CAMH care across intervention levels are depicted in Table 1 (Garland et al. 2013).
Table 1

Care improvement targets for children’s mental health care across intervention levels

Level of intervention

Care improvement targets

Service access and engagement

Delivery of evidence-based practices

Outcome accountability

Federal and state policy or funding

Expand coverage for behavioral health services and coordinate across service sectors

Incentivize evidence-based practice and support training and infrastructure development

Build incentives for outcome accountability

Provider organizations

Support integration of mental health and primary care services and outreach to underserved communities

Build/reinforce sustainable infrastructure for evidence-based practices, including optimal organizational culture and climate and secured time for training/supervision

Utilize measurement feedback systems (MFS) to assess treatment processes, client outcomes, and costs

Individual providers

Train on evidence-based engagement strategies, with attention to cultural sensitivity

Provide effective training in evidence-based practices (assessment and treatment) that provides ongoing consultation/supervision

Train on collection and use of MFS outcome data in clinical care

Client/family

Train and support family advocates/peer educators; reduce stigma; empower consumers to engage providers; teach self-advocacy

Educate consumers regarding evidence-based practices and expectations and encourage consumer activation

Educate consumers regarding differential quality in providers and value of outcome monitoring

Evidence-based stands for evidence based

Community Empowerment

Enhancing community capability in promoting health conditions of the people is a pivotal point of community mental health work. Empowering them to provide evidence-based interventions is a sensible method to leverage CAMH and well-being and support sustainable health promotion. Lists of evidence-based intervention for adolescent mental health can be explored in the Global Accelerated Action for the Health of Adolescents (AA-HA!) Guidance to Support Country Implementation. For example, after a disaster, promoting normal recreational activities for young people, restarting formal or informal education and involvement in concrete and purposeful common interest activities (Regional Office for the Eastern Mediterranean, World Health Organization 2012), and deploying psychological first aid techniques to provide general support for adolescents and their parents (Stone 2016) are evidence-driven practices that CAMH practitioners should empower the community to engage and take part in. Community empowerment and creating sense of ownership are the most critical steps in community mental health action. Powerful community will raise community awareness on health promotion and draw community resources to enhance self-help and social support.

Child and Adolescent Mental Disorders: Treatment and Rehabilitation in Rural and Urban Area

The challenge of poorly developed child and adolescent mental health service (CAMHS) in LAMICs has been described for more than 40 years (Patel et al. 2007a). Despite this long-standing recognition, the gap between needs and the resources provided remains large. For example, in a cross-sectional study of children and adolescents in a low-income urban area of Brazil over 1 year, only 14% of the children with mental health problems could access treatment (Lund et al. 2009a). Challenges in closing this treatment gap include difficulty in accessing and using services, stigma associated with mental disorder, urban-based specialist provision of CAMHS in countries where most of the population is concentrated in rural areas, and few inpatient beds allocated for CAMH care (Juengsiragulwit 2015).

To provide equitable and efficient CAMHS, a well-functioning health system working in harmony is required. In 2007, the World Health Organization (WHO) proposed an analytical framework to describe health systems. It consisted of six core components, i.e., service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance as illustrated in Fig. 3 (World Health Organization 2010a). The WHO six building blocks will be used as a tool to analyze CAMH provision in rural and urbanized communities.
Fig. 3

The six building blocks of a health system: aims and desirable attributes (World Health Organization 2007)

Service Delivery

Since resources in LAMICs are scarce, the stepped care model will provide appropriate service design that utilizes the limited resource efficiently. The model has two principles: treatment should always have the best chance of delivering positive outcomes while burdening the patient as little as possible and a system of schedule review to detect and act on non-improvement must be in place to enable stepping up to more intensive treatments, stepping down where a less intensive treatment becomes appropriate, and stepping out when an alternative treatment or no treatment becomes appropriate (National Institute for Health and Clinical Excellence (NICE) 2011). Applying this model in LAMICs, CAMHS in rural and urban area can be merged into one service system in some areas due to shortage of CAMHS specialist. The author proposed four steps for developing CAMHS in LAMICs.

CAMHS Need Assessment

Child and adolescent mental disorders are far from the center of attention in LAMICs, where communicable diseases are more prevalent. Rahman and colleagues discussed the three broad methods used to analyze CAMH needs – epidemiology of mental health problems and their risk factors, comparative need assessment, and corporate need analysis. The latter involves synthesis of views on the mental health needs of children from those agencies involved in their care and seems to be a reasonable approach in LAMICs (Rahman et al. 2000). For example, in rural or remote areas, services for children with neurodevelopmental disorders (NDD) seem to be prioritized and settled before those of emotional and behavioral disorders (EBD). There are several reasons that could explain this phenomenon. Firstly, developmental problems are more concrete compared with emotional and behavioral problems. Generally, parents or caregivers can observe developmental delays more easily than detecting childhood emotional disorders. Secondly, maternal and child health (MCH) were significant health aspects leading to well-established MCH services. CAMHS for children with NDD then can be appended on existing MCH service and structure. Lastly, children with NDD present their deficit in their preschool age which is the window of opportunity for human development and eventually attracts stakeholders to engage in the service. Comprehensive assessment of CAMHS demand will guide CAMH practitioners in developing an appropriate service plan either in rural or urban areas.

Clients Classification Based on Clinical Severity

Categorizing the patients by their clinical severity is a fundamental process for stepped care model. For example, patients with prodromal or mild symptoms could be placed at primary care center, while patients with severe NDD or EBD should be referred directly to tertiary care center. Resource in the area will determine characteristics of the patients in each group and level of classification. Characteristics of the patients including referral criteria for each group need to be defined precisely so it can be applied effectively in referral system. Patients with prodromal or mild symptoms who do not respond to low-intensity intervention in primary or secondary care center should be referred to CAMH specialists in proper time to avoid adverse outcome of delay effective intervention provision. The figure below proposed a service model for NDD or EBD in LAMICs.

Identification of Effective Intervention for Each Category

Evidence-based biological and psychosocial interventions for children with CAMD in each category should be collected and assigned to differential health-care setting in the model. Discussion with all stakeholders regarding which setting should provide what kind of treatment is essential. For example, although stimulant is a drug of choice for treatment of ADHD, access to stimulant is restricted due to stimulant control regulation or financial problems in some LAMICs. Therefore, agreement and commitment of all stakeholders should not be omitted. For primary care setting, psychosocial interventions such as developmental stimulation, behavioral intervention, and individual counseling are basic services that could be deliverable even in LAMICs. Medication and in-depth psychotherapy would better be provided by secondary or tertiary care.

Implementation Design

Several authors stressed the potential of CAMHS delivery through existing pediatric or primary health-care services, especially for rural populations (World Psychiatric Association 2005a). Kieling and colleagues noted that integration of child mental health care with other pediatric and primary care services, such as the integrated management of childhood illness and Mother and Child Health Programs, might benefit both mental health outcomes and physical outcomes for children and adolescents (Kieling et al. 2011). There are three models for integration of CAMHS in primary care services, i.e., (1) replacement model, CAMH specialists work and take charge of the patients in that setting instead of primary care practitioners, (2) collaborative care model, CAMH specialists collaboratively work with primary care practitioners to provide CAMHS, and (3) consultation-liaison model, primary care practitioners are in charge of the service and consult CAMH specialists for planning and treatment (Thornicoft et al. 2011). In LAMICs and rural areas where there is shortage of CAMH specialists, the first model is almost impossible. Collaborative care model in combination with consultation-liaison model would be appropriate and can provide a sustainable CAMHS in the target area. From the author’s experience, applying an “intermittent replacement model” in countries with high urban-rural resource disparity is helpful. By this fashion, a group of CAMH specialists who generally work in an urban area move to provide CAMHS in rural or low-resource areas intermittently. This strategy, in other words “Caravan model,” will be sustainable only if collaborative care model is deployed in parallel. However, implementing CAMHS in areas with differential levels of urbanicity should be done with caution. Adopting effective model developed in urban areas to local areas or vice versa is not recommended. Socioeconomic and cultural contexts should always be reviewed.

Due to emerging of the digital age, telepsychiatry and/or digital applications begin to play a role in CAMHS provision. Research about telemedicine usage in children and adolescents launched more than 20 years ago, and the outcome indicated that telepsychiatry is feasible, acceptable, and well tolerated. It can be used in various purposes such as pharmacologic care, psychotherapeutic care, consultation and psychosomatic care, or applying as school-based telepsychiatry or telepsychiatry in juvenile corrections (American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Telepsychiatry and AACAP Committee on Quality Issues 2017). Telepsychiatry would be of great benefit for dispersed rural populations who encounter difficulties in accessing CAMH care. However, studies in child telepsychiatry are limited even in high-income countries. Hence, clinicians should apply telepsychiatry with socioeconomic context and practice with caution (Fig. 4).
Fig. 4

Proposed service model for CAMHS in LAMICs

Chatbot therapy is another solution to close the service gap for digital natives. Woebot, Wysa, Joyable, and Talkspace are examples of mental health chatbots in a niche market (Legg 2018). The World Health Organization also established “The STARS project” in March 2018. This aims to create digital psychological intervention for adolescents aged 15–18 years old globally who are experiencing high levels of psychological distress. The initial prototype is tested in five settings, i.e., Jamaica, Nepal, Pakistan, South Africa, West Bank, and Gaza Strip. The results show that most adolescents had access to a smartphone, and they enjoyed using chatbot technology. Digital self-help, accessed through smartphones and computers, provides opportunities for overcoming barriers to mental health treatment, as the user can choose when and where to use it (World Health Organization 2019).

Health Workforce

Geographical distribution of health workers is skewed toward urban and wealthier areas worldwide. The geographical imbalance of health workforce exacerbates the inequity of health services (Araujo and Maeda 2011). This situation is particularly true for LAMICs where shortage of CAMH workforce is one of the major challenges for CAMHS provision (Patel et al. 2007b; Syed et al. 2007). Compounding staff shortages, most mental health professionals are required to work in adult mental health services and therefore have less time for CAMHS. Overloaded services, shortage of funds and personnel, and under-recognition of the importance of CAMH can lead to low motivation for primary health-care workers to provide CAMHS (Nikapota 1991).

Regarding mental health workforce, the WHO recommended workforce planning and training in 2005 as revealed in Fig. 5 (Funk 2005). Workforce planning must be done in correlation with service delivery model. For example, in urbanized area where there are adequate and accessible CAMHS clinics, community health practitioners may be required only to assess CAMH problems and proper referral to specialist clinic. But in rural areas, they may have to assess CAMH problems, early or brief intervention, and postintervention assessment before proper referral to distant specialist clinic.
Fig. 5

Assessing current staff supply at all services level (WHO 2005)

In terms of quantity, estimating the number of mental health workforce started from (1) CAMH needs analysis, (2) service delivery design, (3) task or function assignment, and (4) workforce competency identification which finally bring about the number and type of personnel. In the examples from South Africa, Lund and colleagues developed a spreadsheet model to calculate the human resources and costs required to improve the poor coverage of CAMHS. They calculated that per 100,000 population (of which 43,170 would be aged under 20 years), the minimum coverage of full-time staff would need to be 5.8 in primary health-care facilities; 0.6 in general hospital outpatient departments; 0.1 in general hospital inpatient facilities; 1.1 in specialist CAMHS outpatient departments; 0.6 in specialist CAMHS inpatient facilities; 0.5 in specialist CAMHS day services; and 0.8 in regional CAMHS teams. These minimum requirements were substantially less than that being provided (Lund et al. 2009b). To alleviate the workforce shortage, evidence supported the use of “task shifting strategy” in transporting evidence-based practice for CAMHS in LAMICs (Huang et al. 2015). Task shifting involves (1) modifying the intervention for provision by nonmental health providers, (2) training nonmental health providers in the modified intervention, and (3) establishing regular supervision and monitoring by mental health specialists (Gopalan 2016). Nonetheless, task shifting approach may increase workload for nonmental health providers which may be inadequate as well. In 2010, the WHO suggested the member countries “to increase the availability of motivated and skilled health workers in remote and rural areas through improved attraction, recruitment, and retention of health workers in these areas.” Possible strategies for attraction, recruitment, and retention of health workforce in rural or distant area included (1) education, e.g., recruit students from rural backgrounds, establish health professional schools outside major cities, assign clinical rotations in rural areas during studies, and develop curricula that reflect rural issues or continuous professional development for rural health workers; (2) regulation, e.g., subsidized education for return of service, enhanced scope of practice, and provide different types of health workers; (3) financial Incentives, e.g., provide appropriate financial incentives, professional and personal support, distribute better living conditions, and create safe and supportive working environment; and (4) outreach support, e.g., career development programs, professional networks, public recognition measures, etc. (World Health Organization 2010b).

Regarding workforce quality, or in other words, workforce competency, continuous educational and training is a continuous process that should be integrated in CAMHS planning. Fundamental competency is listed as diagnosis, prescription, referral, communication, administrative task, counseling, crisis intervention, knowledge of psychotropic drugs, psychoeducation, support advocacy, prevention, and promotion (Kelly et al. 2007). Especially under task shifting strategy, workforce competency should be a central concern to ensure success of CAMHS (Fig. 6).
Fig. 6

Comparison of the density of child and adolescent psychiatrist between the northeast and capital city of Thailand

Health Information Systems

A mental health information system (MHIS) is a system for collecting, processing, analyzing, disseminating, and using information about mental health service and mental health needs of the population it serves for enabling planning and decision-making in all aspects of the mental health system. Moreover, developing service system is a dynamic process which contributes to activate change of information system. Information can be divided into four types (World Health Organization 2005a):
  1. (1)

    Episode-level information is required to manage an individual episode of service contact.

     
  2. (2)

    Case-level information is required to care for an individual service user.

     
  3. (3)

    Facility-level information is required to manage the specific service facility.

     
  4. (4)

    Systems-level information is required to develop a policy and plan for the mental health system.

     

MHIS development process is similar to that of service design. It started from need assessment, followed by situational analysis, implementation, and evaluation. In LAMICs, developing MHIS is usually incomplete due to resource constraint and leads to imprecise decision-making. The “start small but keep the big picture in view” principle suggested in the WHO documentation is pivotal for MHIS planners in LAMICs. Minimum dataset of CAMH needs and CAMHS in LAMICs were suggested below.

Example of a relationship between health information system and CAMHS decision-making was shown in the infographic below. Information about location of CAMHS and child psychiatrists between the northeastern, the distal and less developed region in Thailand, and Bangkok, a megacity, was graphically compared in the infographic below. Information about poor distribution of health-care workforce was presented to policy makers and professional training institute and eventually influenced a resource allocation and recruitment of health care workforce from rural areas as a priority (Child Psychiatric Association of Thailand 2019).

In general, case-level information or, in other words, CAMH clinical outcome indicators in each setting are varied. It is hard to compare and identify national treatment goals without a single set of indicators. Hence, developing single national set of CAMH service and clinical outcome indicators is highly recommended. With shared indicators, each setting in the same level with similar context can benchmark and learn from each other how to provide effective CAMHS. Noteworthy, benchmarking is not developed for a competition but rather a learning process that encourages CAMH practitioners to improve their service provision and follow the good practice setting.

Another problem of information system in the LAMICs is the linkage of service information between settings. Without information linkage, it is possible that the patients may receive redundant services from different settings they were referred. This is a waste of service provision that can be eliminated by service model design and effective information linkage. Service bundle should be analyzed and linked with information system. In urban areas, information linkage can be easier in terms of technology and staff, but the challenge may be in the cooperation of various stakeholders. In contrary with urbanized areas, cooperation with fewer stakeholders may ease the linkage of information in rural areas, but major obstacles might involve technological problems like poor Internet signal or lack of staff for putting data in.

Access to Essential Medicines

Even essential adult psychotropic medicines are routinely unavailable in public health facilities in LAMICs (Wagenaar et al. 2015), availability of child and adolescent psychotropic medication is undoubtedly restricted. In 2013, the WHO launched the 18th WHO model list of essential medicines including medicines for mental and behavioral disorders as described in Table 2 (World Health Organization 2013b). However, prescribing of psychotropic medicines for CAMD is somehow different from that of adult mental disorders, e.g., “start low, go slow” principle, lack of evidence to support usage of Amitriptyline for treatment of depressive disorders in children and only marginal evidence for that of adolescents (Hazell and Mirzaie 2013), etc. The author suggested the evidence-based medication use for CAMD that would be available in LAMICs in Table 3.
Table 2

Recommended minimum dataset of CAMHs in LAMICs

Category

Suggested minimum dataset

Episode-level 52

(1) Patient identification and demographic information: Name, date of birth or age, gender, address, education

(2) Parental information: Name, age, gender, current employment status, housing/living arrangements, education, citizenship, language, religion

(3) Administrative data: Admission and discharge dates, category of payment

(4) Clinical data: Prior receipt of care, medical history, presenting problems, discharge diagnosis

(5) Discharge data: Place of referral, guardian/person to notify

(6) Event data: Date and time of event, event type, place of service and responsible clinician, staff member reporting, patient(s) involved, event program, and event identifier

(7) Workforce registry data: Name, gender, date of birth, specialty, educational and certification data

Case-level

Percentage of children with neurodevelopmental disorders that improved after intervened

Percentage of children with neurodevelopmental disorders that are included in educational system

Percentage of children with ADHD improved after intervened

Percentage of children and adolescents with emotional disorders improved after intervened

Facility-level

Average number of children with CAMD in each service setting

Average number of referred in and referred outpatients

Top CAMD rankings in each setting

System-level 36

Prevalence of common CAMH problems (either developmental or emotional or behavioral problems based on stakeholder concern) Prevalence of CAMD in each area

Number of CAMH practitioners per 10,000 populations

Distribution of CAMHS practitioners by occupation/specialization, region, place of work

Annual number of graduates of health professions educational institutions per 100,000 population, by level and field of education

Number and distribution of health facilities per 10,000 population

Number and distribution of inpatient beds per 10,000 population

Number of outpatient department visits per 10,000 population per year

CAMD accessibility rate

Total expenditure on CAMH

General government expenditure on CAMH as a proportion of general government expenditure (GGHE/GGE)

The ratio of household out-of-pocket payments for health to total expenditure on CAMH

Table 3

Model list of essential medicines for mental and behavioral disorders by the WHO and the suggested evidence-based medication usage in children and adolescents in LAMICs

Indications

List of medicines for adults

Suggested evidence-based medication for children and adolescents

Psychotic disorders (Kumar et al. 2013)

Essential list –

chlorpromazine

fluphenazine

haloperidol

risperidone

Complementary list –

clozapine

Second-generation antipsychotics,

e.g., risperidone, clozapine

Other typical antipsychotics

In the adult list

Depressive disorders (Hetrick et al. 2012)

Amitriptyline

Fluoxetine

(aged above 8 years old)

Fluoxetine

Bipolar disorders (Cox et al. 2014)

Carbamazepine

Lithium carbonate

Sodium valproate

Second-generation antipsychotics, e.g., risperidone

Lithium carbonate

Sodium valproate

Anxiety disorders (Ipser et al. 2009; Patel et al. 2018)

Diazepam

Selective serotonin reuptake inhibitors (SSRIs)

Obsessive- compulsive disorders (60)

Clomipramine

Selective serotonin reuptake inhibitors (SSRIs)

Disorders due to psychoactive substance use

Nicotine replacement therapy

Methadone

Suggested as adult list

As the evidence illustrated, the most of essential psychotropic drugs for CAMHS are part of essential medicine list in adults except for methylphenidate hydrochloride (MPH) which is a first-line medication for children with ADHD (Storebo et al. 2015). According to the prevalence and service user’s profile, methylphenidate should be placed in a high rank of essential medicines in CAMHS. However, since it is an amphetamine derivatives, MPH is categorized as a Schedule II drug under the Convention on Psychotropic Substances that requires medical prescriptions for supplying or dispensing and therefore limited the usage as an essential medicine (International Narcotics Control Board 2003). The regulation is sensible, especially in urban or developed areas where methylphenidate was illegally used for attention focusing, weight loss, or euphoric effects by college students and adolescents (Bogle and Smith 2009). But the possibility of this illicit usage is low in distant areas where the drug availability is limited. To increase service accessibility, MPH prescription should be viewed as an essential medication that can be prescribed by child psychiatrists, general psychiatrists, pediatricians, or family physicians who receive adequate training for CAMD diagnosis and treatment.

Financing

Financing is a mechanism by which plans and policies are translated into action through resource allocation (World Health Organization 2003). With adequate financing, CAMH service delivery, CAMH workforce development and training, essential medicines for CAMD, and management of information system and other infrastructures are possible. In 2016, the World Bank estimated that the annual cost for scaling up basic package of cost-effective mental health-care interventions is approximately US$2 per capita for low-income countries, US$3-US$4 for LAMICs, and US$7-US$9 for Latin America and the Caribbean. For LAMICs, this corresponds to 4–6% of total health expenditures (Mnookin 2016). Disproportionately, between 2007 and 2013, total spending on mental health in LAMICs came to only US$0.61 per capita which was five to eight times fewer than that expected (Gilbert et al. 2015). CAMH expenditure is generally subsumed into the mental health expenditure and therefore is squeezed into a smaller proportion of general health expenditures (World Health Organization 2005b). Nevertheless, it is irrational and unfair to request more CAMH expenditures while the budget for life-threatening conditions is still insufficient. In 2003, the World Health Organization published a guidance package on mental health financing and recommended eight steps to achieve adequate financing for mental health, i.e., (1) understand the broad health-care financing context, (2) map the mental health system to understand the level of current resources and how they are used, (3) develop the resource base for mental health services, (4) allocate funds to address planning priorities, (5) build budgets for management and accountability, (6) purchase mental health services to optimize effectiveness and efficiency, (7) develop the infrastructure for mental health financing, and (8) use financing as a tool to change mental health service delivery systems (WHO MH financing).

Since children and adolescents are not directly responsible for mental health, care payment is not by themselves but taken via their parents or carers. Their carers’ attitude toward benefit of treatment comparing with the cost they spend could be an obstacle for young people’s access to CAMH care. This phenomenon could be more prevalent in rural or high-poverty area, especially in LAMICs, which eventually left CAMD untreated or delayed treatment. Considering this difficulty and applying the WHO recommendation, possible strategies for effective CAMH expenditure management were discussed below.

Prioritizing Areas of CAMH Investment

There are several aspects for considering areas of CAMH investment, e.g., age group and societal concern on CAMH, cost of untreated CAMD, socioeconomic status of the individual and the country, etc. Regarding age group, the groundbreaking study, “The life-cycle benefits of an influential early childhood program,” showed that high-quality early childhood development program targeting disadvantaged children from birth to five generates 13.7% per annum, and the benefit-cost ratio is 7.3. It produces substantial beneficial impact through better outcomes in education, health, social behaviors, crime, and employment with greater monetized benefits for males after following the participants through their mid-30s (Garcia et al. 2016). A well-known study from Nobel Laureate economist, Professor James J. Heckman, found that comprehensive early childhood programs for children under 5 years old can produce higher return on investment (13% per annum) than those previously established for preschool programs serving at 3–4 year-old (7–10% per annum). For school-aged children, an economic study from the UK suggested that (1) parenting programs are cost-saving to the public sector over the long term with the main benefits accruing through the health care and criminal justice system with the benefit-cost ratio of 8:1 when the costs of crime are included, (2) school-based social emotional learning is cost-saving to the public sector after 5 years through reduction of heath care cost and crime-related impacts of conduct problems from 9% to 3%, and (3) school-based intervention to reduce bullying appears to offer good return on investment on long-term outcome based on improved future earnings (Knapp et al. 2011). The evidence suggested that early childhood development should be a priority for children under 5 years old especially for disadvantaged families like in LAMICs, rural areas, or even urbanized high-poverty areas (Richter et al. 2016). Parenting intervention, school-based SEL, and anti-bullying program are important CAMH interventions that would be worthwhile for investment in school-aged children.

Considering untreated CAMD, ADHD places a substantial economic cost on patients, families, and third-party payers, and its treatment which focused on methylphenidate is cost-effective with the ratios ranging from $15,509 to $27,766 per quality-adjusted life year (QALY) gained (Matza et al. 2005). Costs for individuals with conduct disorders rose around ten times higher than those with no problems by age 28, with a mean cost of £70,019 accruing by criminality, educational provision, foster, and residential care, and only small proportion of the costs fall on health services. The costs per family of parent skills training or education range from £629 to £3839 which lead to a ratio ranging from £6288 to £38,393 per quality-adjusted life year (QALY) gained (Dretzke et al. 2005). For emotional disorder, a Dutch study revealed that cost of illness in adolescent depression is €37.7 million a year in adolescents aged 12–21 (Bodden et al. 2018). Another review of economic studies on CAMD in 2014 found that most articles focused on autism spectrum disorder, ADHD, conduct disorder, and anxiety or depression. The reviewer concluded that the support costs for children and adolescents with ASD may be higher than both ADHD and CD. Nevertheless, the differences between the samples and methodology are employed making the comparison between studies difficult (Beecham 2014). Due to the limited amount of economic study for CAMD treatment, research gap on economic burden, social return on investment, and benefit-cost ratio of CAMD treatment are highlighted.

Regarding socioeconomic status of the individual and the country, it is suggested that investment for CAMH promotion and prevention should be prioritized in low resource settings, e.g., rural area, high-poverty area, and remote area. For children and adolescents under socioeconomic adversity, government financial support for accessing CAMH promotion, prevention, and treatment will provide a great benefit toward the whole life of the child. In urban or high-resource area, CAMH professionals, who are concentrated in urban areas, tend to focus more on clinical tasks rather than community or public mental health work. Their attentions move toward treatment and rehabilitation rather than promotion and prevention which are cheaper and effective in reducing their work burden. Therefore, the balance between CAMH promotion and prevention and CAMD treatment and rehabilitation should be thoughtfully considered.

Building of a Coalition with CAMH Stakeholders

After prioritization for areas of investment, the issues will determine the stakeholders involved in the financing process. Coordinating effectively with CAMH stakeholders like educational sectors or social welfare sectors or justice system is a fundamental step for CAMH financing management. Financing always depends on politics, advocacy, and social expectations. The coalition will expand concern and importance of CAMH to all stakeholders and raising higher societal expectation (WHO MH Financing). In urban areas, coordinating with NGOs or private sector to co-provide standard CAMHS is another strategy to increase accessibility to CAMH service for the families that can afford for the service and leave the government resources for those who cannot.

To achieve this process, CAMH practitioners need to understand the goal and the context of the stakeholders including the goal or target of the funders in order to develop a win-win proposal to the policy makers. For example, the project proposal request for funding from the World Bank should mention the economic outcome of CAMH interventions. The projects proposed to educational sector should focus on academic achievement or school benefits of CAMH interventions.

Financial Resource Allocation

The characteristics of good financing for mental health are the same as those of good financing for general health services (World Health Organization, 2000). There are three principal considerations. Firstly, “people should be protected from catastrophic financial risk,” i.e., minimizing out-of-pocket payments on affordable goods or services. Most CAMH problems are chronic so it is important to consider not only the cost of individual treatments or services but also the whole cost of long-term treatment. Secondly, the healthy should subsidize the sick. Finally, the well-off subsidize the poor. This is the hardest characteristic to ensure, because it depends on the coverage and progressivity of the taxation system and on who is covered by social or private insurance. As always, the magnitude and direction of subsidy depend on the services that are covered.

For the area with underdeveloped CAMHS, a major focus is the development of a mental health infrastructure that includes legislation and the proposed initial activities so-called a pilot or demonstration projects, while in urban or high-resource settings, funding may be arranged for CAMH institutions or pooled into adult mental health service (WHO MH financing). To reduce inequity between rural and urbanized area, financial allocation can be used as a tool to encourage equitable CAMHS in which underserved children and adolescents should be provided broader support to leverage their quality of life.

Leadership and Governance

Without guidance for developing child and adolescent mental health policies and plans, there is the danger that systems of care will be fragmented, ineffective, expensive, and inaccessible (World Health Organization 2005b).. From the six building blocks framework, the indicator of leadership and governance is policy index that can archive from review of national health policies in respective domains. Leadership and governance in building a health system involve ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system design, and accountability. Accountability in governance involves (a) understanding of how services are supplied, (b) financing to ensure adequate resources are available to deliver essential services, (c) performance around the actual supply of services, (d) receipt of relevant information to evaluate or monitor performance, and (e) enforcement or rewards for performance (World Health Organization 2010c).

Mental health policy refers to an organized set of values, principles, and objectives to improve mental health and reduce the burden of mental health disorders in a population (World Health Organization 2005c). The Atlas: child and adolescent mental health resources, published by WHO in 2005 (World Psychiatric Association 2005b), reported a survey of information on countries worldwide; 192 countries were contacted and 66 responded. Of the responding countries, fewer than one third had an institutional or governmental entity that had clear responsibility for CAMHS (Belfer and Saxena 2006). A 2010 overview of policy and legislative frameworks in four African countries – Ghana, South Africa, Uganda, and Zambia – found that two had published or drafted policies, but none had a recent national mental health plan to support implementation of CAMHS (Kleintjes et al. 2010). Current draft or new legislation in these countries addressed none or only a few of the six provisions in the WHO legislation checklist for the protection of minors, e.g., a recommendation for separate mental health facilities for children and adults in Ghana and a recommendation for provision of age-appropriate services in South Africa (Minde and Nikapota 1993). According to the situation above, conclusion can be drawn that CAMH policy is not well established in LAMICs where most of their population live in rural areas. This hampers the situation of CAMHS provision in remote areas.

Despite consensus on the importance of leadership and governance in improving health outcomes, they remain inadequately monitored and evaluated. There are two types of indicators proposed for measuring governance, i.e., rule-based indicators and outcome-based indicators. The former measures whether countries have appropriate policies, strategies, and codified approaches for health system governance, e.g., whether the country endorses a national essential drug list or mental health policy. The latter measures whether rules and procedures are being effectively implemented.

Retrieving the recommended core indicators from the WHO documentation, there are five indicators that can apply with CAMH. Firstly, existence of an updated national mental health strategy that linked to national CAMH needs and priorities. Formulating national CAMH policies and strategies is a basic function of government sector. CAMH strategy should encompass the future vision, objectives, and strategic focus and outlines the measures to achieve the objectives. It should also outline priorities and expected roles of different actors and estimate resources needed to achieve the goals. It reflects national needs and priorities which will foster political support and ownership of policies.

Secondly, existence of an updated national medicine policy should include essential drug for CAMD with good governance on procurement. It should cover three objectives: (1) ensuring equitable availability and affordability of essential medicine; (2) ensuring that all medicines are safe, efficacious, and of high quality; and (3) promoting rational use of medicines by health-care professionals and consumers.

Thirdly, the WHO recommended indicator on child health includes only immunization program. When applying with CAMH, ensuring nurturing parenting and caring and supportive environment should be considered as mental immunization. Children either in rural or urban areas, high- or middle- or low-income countries should be assured a growing up with adequate nurturing and supportive environment. Provision of such mental immunization should be integrated in primary care of early childhood service.

Lastly, there should be mechanisms, such as surveys, for obtaining opportune client input on appropriate, timely, and effective access to health services. Surveys of patient satisfaction and utilization of health services are useful tools for obtaining information on the quality and responsiveness of health services. Such surveys may measure inputs (including whether facilities are properly equipped with essential medicines), processes (including whether waiting times are reasonable and treatment protocols are followed), and outcomes (including whether CAMH interventions improve quality of life). Hence, an indicator that measures whether consumer satisfaction is considered in the assessment of CAMH reflects the responsiveness of health systems.

With good governance and supporting policy, the other five building blocks of CAMH system will be able to operate effectively. However, policy and governance for CAMHS in urban areas tend to be scrutinized closer by consumers comparing with its counterpart since people living in big cities are more likely to engage in policy advocacy and human rights protection. Empowering people in rural areas to advocate on their needs will improve CAMH service gap and in the end improve their quality of life.

SWOT Analysis and Strategic Planning

In organizational strategic planning, a situational analysis is a first step that needs to be done thoroughly. One well-known analysis model is SWOT analysis. SWOT stands for strengths, weaknesses, opportunities, and threats. The former two elements, strengths and weaknesses, are internal or intra-organization factors, while the latter two elements, opportunities and threats, are external or extra-organization factors. To gather and assess external factors, PESTLE analysis is a framework broadly used in business companies and in hospital administration (Ritson 2008). Urbanicity is clearly an external factor that can be both opportunities and threats for any organizations. In Table 4, both positive and negative aspects of urbanicity toward CAMH will be illustrated.
Table 4

Possible opportunities and threats in urban and rural area – a situational analysis for child and adolescent mental health strategic planning with the “PESTLE” (Penkalla and Kohler 2014)

PESTLE

Urban

Rural

Political

+ Actively involvement in political system

– Quality of local governance is varied and unpredictable

Economic

+Better employment opportunity– High poverty in specific areas

+ Lower cost of living

– Higher prevalence of poverty

Social

+Wider stakeholders’ involvement and social resources

– Deprived neighborhoods with lower social cohesion

– Higher criminality

+ Higher social cohesion

– Limited resources for educational and health care services

Technological

+/− Easily access to electronic or digital equipment/signal

– Limited access to digital technology

Legal

+ Actively advocate for rules and regulations

+ More flexible rules and regulations

Environmental

+Better transportation and access to CAMH care– Air pollution

– Traffic noises

+ Better green space

+ Lower population density

– Difficulty in transportation

+ possible opportunities – possible threats

Considering CAMH promotion, prevention, service, and SWOT analysis in LAMICs discussed above, possible strategies that apply strengths and opportunities of urbanicity and rurality to tackle CAMH problems are proposed in Table 5.
Table 5

Possible strategic actions for CAMH promotion, prevention, and service applied in urban and rural areas

Urban

Rural

Child and adolescent mental health promotion and prevention

Building healthy public policy

 Ensure financial and social support for vulnerable children and adolescents

 Online social marketing for CAMH public policy

Building healthy public policy

 Ensure financial and social support for vulnerable children and adolescents

 Empowering and engaging people in policy advocacy

Creating supportive environments

  Parent skills training for supportive family environment either face to face or digital channel

  Enlargement of green spaces in public areas of megacities

Creating supportive environments

  Parent skills training for supportive family environment

Reorienting CAMH service

 Provision of effective, low-intensity, transdiagnostic CAMH promotion or prevention intervention by nonspecialists or non-health practitioners, e.g., SEL, life skills training, etc.

 Initiating brief and simple early detection measures which does not increase burden CAMH-related workforce

 Increasing physical activities and reducing screen time.

Reorienting CAMH service

 Provision of evidence-based, low-intensity, transdiagnostic CAMH promotion or prevention intervention by nonspecialists or non-health practitioners, e.g., SEL, life skills training, etc.

 Initiating brief and simple early detection measures which do not increase burden on CAMH-related workforce

Developing personal skills

  E-learning for child and adolescent mental health literacy

  Chatbot therapy for children and adolescents with psychological distress

Developing personal skills

  E-learning for child and adolescent mental health literacy

  Group-based mental health literacy learning in underdeveloped area

Strengthening community action

  Strengthening online social network for CAMH promotion

  Encouraging public private partnership (PPP) for CAMH promotion and prevention

Strengthening community action

 Enhancing community cohesion and community empowerment Applying effective implementation model for demonstrated CAMH promotion and prevention project

Child and adolescent mental health service

Service delivery

 Either replacement model, collaborative care model or consultation-liaison model of community mental health service are possible

 Integrating CAMHS with primary health care

 Controlling quality of telepsychiatry service

 Integrating service provision with private sectors for early child development or CAMH plan (Khan et al. 2018)

Service delivery

 Collaborative care model of community mental health service is suggested

 Applying stepped care model

 Integrating CAMHS with primary health care

 Establishing and expanding telepsychiatry service

Health workforce

 Encouraging CAMH promotion and prevention mindset

 Increase health workforce by partnership with nongovernment stakeholders

  E-learning for workforce capacity building

Health workforce

 Integrating community mental health session in professional training course including experience in rural areas

 Intermittent replacement model to allocate urban resources to rural CAMHS needs

Health information systems Developing digital CAMHS database

 Co-creation of benchmarking CAMH indicators across the country

Health information systems

 Developing digital CAMHS database

 Co-creation of benchmarking CAMH indicators across the country

Access to essential medicines

 Ensure compliance and continuation on essential medicines

Access to essential medicines

 Requesting for essential medicines subsidization in low-resource setting

Financing

 Advocating for bundle payment to decrease redundant costs between health care setting

 Advocating for financial allocation to encourage equitable CAMHS for underserved children and adolescents

Financing

 Advocating for financial allocation to encourage equitable CAMHS for underserved children and adolescents

Leadership and governance

 Strengthening law enforcement in child protection to ensure safety and nurturing social environment for all children.

 Campaigning with non-health and nongovernment sectors in advocating CAMH policy

Leadership and governance

 Strengthening law enforcement in child protection to ensure safety and nurturing social environment for all children

Possible strategic actions above are only some examples of measures that could be utilized in rural or urban areas. CAMH practitioners should analyze and develop CAMH action plan based on the socioeconomic and cultural context of their own countries.

Conclusion

Conceptual framework for health promotion and prevention is different from treatment and rehabilitation. CAMH practitioner should identify their objectives clearly in order to apply proper framework before strategic planning. Taking urbanicity in to account would support practitioners in understanding context of such areas and will eventually lead CAMH plan in a proper direction.

Summary

Urbanicity is growing up and affects CAMH problems. CAMH promotion and prevention and service provision are also influenced by the level of urbanicity. CAMH practitioners in LAMICs are encouraged to explore strengths of urbanicity or rurality in their contexts and apply such strengths in CAMH strategic planning.

Cross-References

Notes

Acknowledgment

This chapter would not have been possible without the support and encouragement of Dr.Anula Nikapota. The chapter is in remembrance of her contribution to child and adolescent mental health services in LAMICs. I would like to also express my great appreciation to Dr.Kiattibhoom Vongrajit, Dr.Prawate Tantipiwattanasakul, and Dr.Phunnapa Kittirattanapaiboon in supporting and supervising me in practicing community and public mental health development in Thailand. Special thanks for professor Dr.Eric Taylor and associate professor John Wong Chee Meng in your kind advice and guidance on this chapter.

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Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Rajanagarindra Institute of Child and Adolescent Mental Health, Department of Mental HealthMinistry of Public HealthBangkokThailand
  2. 2.Institute of Psychiatry, King’s College LondonUniversity of LondonLondonUK

Section editors and affiliations

  • Eric Taylor
    • 1
  1. 1.Child and Adolescent Psychiatry Department, Institute of PsychiatryKing’s College LondonLondonUK

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