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Establish a Mental Health Information System. IV Trauma 1. All health services must be trauma-informed and competent. Increase the number of trauma-competent mental-health staff in general medical services. Develop an adequate referral network across sectors. Train mental-health professionals in trauma-focused psychotherapy and pharmacotherapy.

Ensure sufficient mental-health services are provided. Develop resources for the emergency placement of trauma survivors who may require such placement to ensure their safety.

Develop critical-incident stress-management programmes in workplaces with high trauma exposures. Prevent retraumatisation: train occupational groups working with trauma victims police, lawyers, and district surgeons in methods of dealing with trauma victims.

Develop post-graduate training programmes in trauma. Disaster plans should include a detailed psycho-social response plan. Develop quality ECD teacher-training programmes. Promote and support physical activity and sport.

Promote and support other leisure and recreational activities in arts, culture and leisure sports for example: Ballroom and Latin dancing, volleyball, chess, indigenous games, and pool. Design recreational projects to increase social capital. Evaluate the mental-health outcomes of existing sports and recreation programmes. Protect and promote green and natural spaces.

Provide affordable and safe transport to recreational facilities or areas. Target sports and recreation programmes at high-risk groups. The WHO Commission on Macro-economics and Health was established in to interrogate these assumptions and has ably demonstrated that investment in health is a key engine for economic development and poverty alleviation. For example, it is estimated that a six- fold return would be expected from investments in a set of essential health interventions WHO The review of evidence on the determinants of mental health shows that uneven development also impacts on mental health.

Income inequality and multiple deprivation are universally associated not only with poorer physical health, but also with poor mental health. Department of the Premier, The PGDS further aims to achieve these goals through shared growth and integrated development. The four interdependent elements of the iKapa Elihlumayo development strategy are: 1. Growth; 2.

Equity; 3. Empowerment; and 4. Enviornmental Integrity. The direct impact of the recommended interventions; the resulting expected improvement in mental health with regard to these four aspects of development; and the eight strategies of the PGDS are all depicted in Tables 3 and 4 on page From the tables it is evident that the interventions themselves, as well as the expected improvements in mental health, would contribute to realising the imperatives of iKapa Elihlumayo. As such, interventions should be targeted to areas with the greatest need for development.

Integrating interventions in multiply deprived settings While the recommended interventions may be adopted as stand-alone interventions, an effort should be made to integrate approaches in high-risk areas. Since the most vulnerable groups in the Western Cape Province are those who experience multiple dimensions of poverty or deprivation, multi- faceted interventions are likely to be the most effective.

An example of how interventions could be integrated is presented in Figure 2 on page Other Burden of Disease interventions may easily be added to this model. Monitoring and Evaluation Monitoring and evaluation is a key part of any system change and there are several reasons to monitor social issues. Firstly, the practice of monitoring provides useful data with which to influence policy development, and helps to determine the outcomes, effectiveness and efficiency of social programmes.

Secondly, a good monitoring system allows decision-makers to determine whether a programme was actually implemented; whether it was implemented in the manner originally intended; and — if those requirements have been met — whether it has proved to be effective. More broadly, the surveillance of mental illness and its determinants is a vital component of decreasing and planning for the burden of mental illness.

References Benjamin J. South Africa steps up the fight against drug abuse. Pretoria News. June 23; p5. Bradshaw D. Cape Town: Medical Research Council. Corrigall J. Results of scoping exercise on mental health morbidity surveillance. Provincial Government of the Western Cape. Cape Town. Draft October Fielding, D. Review of Development Economics. Mental Health promotion in Public Health. International Journal of Health Promotion and Education.

Murray, C. Census In Press. Prevention of Mental Disorders: Effective interventions and policy options. World Health Organisation. Mental health policies and programmes in the workplace. Geneva: World Health Organisation. Following an initiative from the provincial head of the Department of Health, a Project Task Team was appointed to delineate the extent of the burden of disease BoD in the Western Cape Province in order to identify the main contributors to the BoD in the Province. Five disease groups were identified as the largest contributors to the total burden of disease in the Western Cape, as shown in Table 5 below.

Five corresponding workgroups were constituted to develop policies aimed at preventing these diseases from occurring and in so doing significantly decreasing the burden of disease in the Province. Major Infectious diseases 2. Cardiovascular disease 4. Injury In order to develop effective preventive policy and programme recommend- dations, each of the five workgroups were tasked with identifying the main determinants risk and protective factors of their disease group.

In recognition of the strong links between disease and socio-structural factors such as poverty and the lack of sanitation, for example , the workgroups were asked to concentrate on developing interventions targeting the upstream 1 determinants of health. The group consists of a small number of authors and a larger group of peer and expert reviewers see Acknowledgements above. The main focus is on preventing common mental disorders such as depression, substance abuse, childhood behavioural disorders and Post-Traumatic Stress Disorder.

By implication, the aim is to provide interventions that promote and sustain mental health. In order to identify the most appropriate interventions, evidence on risk and protective factors relevant to mental health in the Western Cape was sought and discussed. Once appropriate interventions had been identified, the gaps in such interventions were noted. The recommendations presented here are thus the culmination of the analysis of risk factors, evidence for interventions, gaps in current programmes, and the policy context in the Western Cape Province, as shown in Figure 3 below on page 17 below.

The results of this process are presented in this report. In South Africa, data of this kind is not available, but - for alcohol abuse alone - the annual economic costs are estimated at between 0,5 and 1,9 percent of the country's Gross Domestic Product. This translates to about R8,7-billion a year, and — when the costs of drug abuse are added — rises to at least R billion a year Benjamin, It is noteworthy that across the globe, the majority of financial costs incurred are due to absenteeism and decreased productivity rather than costs of mental health care.

In terms of population health, mental illness results in significantly greater disability than most physical illness and as such accounts for a large proportion of the Burden of Disease.

Five of the ten leading causes of disability, moreover, are classifiable as psychiatric conditions including depression and alcohol abuse WHO, Depression is further predicted to become the second leading cause of disability worldwide in WHO, The state of mental health is also a determinant of multiple socio-economic outcomes: the mentally ill are more likely to be unemployed, live in inadequate housing and in poor neighbourhoods, and are less likely to complete schooling.

Socio-economic factors are also significant determinants of mental health, with unemployment, poverty, low social capital and community violence all associated with increased mental illness.

Multi-component mental health interventions can therefore improve a broad range of outcomes, as suggested by this report. The results show a The mortality data on injuries provides a proxy measure for the extent of mental-health problems, including substance abuse, in the Western Cape Province. In considering which component of injury data is the most accurate marker of mental illness one must recognise that only a small fraction of those with mental health problems commit suicide.

Homicide and road-traffic accident rates are better proxy measures of the impact of mental illness on mortality, given that the majority of homicides and road-traffic accidents are associated with substance abuse, which falls within the spectrum of mental illness. Certainly it will be an underestimate of the extent of the morbidity due to mental disorders, but it is far superior to suicide rates as a measure of the impact of mental health problems on Provincial mortality.

As a marker of the comparative prevalence of mental disorders across the Provinces of South Africa, it is noteworthy that the Western Cape has the highest proportions of premature deaths due to homicide, road-traffic accidents and suicides in the country, as illustrated in Table 6 below Bradshaw et al, Figures from Bradshaw et al, In terms of future trends, global projections indicate that the situation will worsen with depression predicted to be the second leading cause of disability worldwide in WHO So, for example, poverty upstream may lead to food insecurity upstream , which leads to poor nutrition downstream , which can result in B12 deficiency downstream , which causes mental illness.

A simplified version of this model is presented in Figure 4 below. This model also takes account of how downstream factors are nested within upstream factors. An example of this would be the influence that the lack of access to recreational facilities a structural factor may have on adolescent alcohol use a behavioural factor , which in turn has mental health consequences.

For each postulated upstream factor, searches of the literature were conducted to determine the strength of evidence for a causal relationship between this factor and common mental disorders.

The strength of any piece of evidence was assessed using standard epidemiological principles study design, potential for bias, and so on. Wherever possible, South African data has been presented. Where data from other settings is utilised, applicability to the South African setting has been considered.

In the CD version of this report, each item is hyperlinked to the relevant text in the review. It is important to note that many of the relationships between variables we examine are likely to show bi- directional causality, for example: mental illness can lead to unemployment and unemployment can cause mental illness.

Reciprocal relationships were found almost across the board, which illustrates significantly the vicious cycle among risk factors and mental illness. Treating mental illness, therefore will have a cascading positive effect on a range of socio-economic factors. Similarly, addressing socio-structural risk factors will improve mental health. Also, owing to the nature of the factors considered, cross-sectional study designs are often the most practical design to use.

A limitation of this design is that the exposure and outcome are measured simultaneously and it is therefore impossible to impute the direction of causality, in other words: Can a particular cause be shown to precede the effect?

Figure 6 below illustrates the impact of social and structural factors on each other, as well as on the individual. For example, poor access to quality education may expose a person to unemployment, which in turn may expose that person to poverty and community violence. The ability of the individual to respond to these stressors may be limited by their cognitive skills through a lack of education , the lack of mental health services, and the accumulation of stressors such that they have cumulative effects on stress.

The occurrence of mental illness will put such a person at further risk for unemployment and social isolation, and further inhibit their ability to cope with stressors.

Clearly, there are also individual-level factors that determine both exposure and response to stressors, but this is not the focus of this review. Once each possible risk or protective factor had been examined in this way, each member of the Expert Workgroup was asked, independently, to rank each of the core-risk factors. These rankings were then combined to yield a rank-ordered list. This rank ordering was further discussed by the Expert Workgroup until consensus was reached.

Trauma the prevention of mental illness after exposure to violence ; 2. Multiple Deprivation poverty, unemployment, food insecurity and housing ; 3. Pre-school access to affordable, high quality pre-school facilities ; 4. Recreation access to a range of sports and other recreational facilities ; 5. Substance Abuse alcohol and drug abuse ; and 6. Mental-Health Services prevention and screening, access to treatment Table 7 on page 26 presents a summary of the reasons why these areas were selected.

It was also felt that all interventions should aim to increase social capital and employment, both significant determinants of mental health. Mental-Health promotion in Public Health. Yes, but inadequate trauma High Strong Yes Injuries, HIV mental- health considerations in children's services violence courts and disaster-management programmes Multiple Can address income through job-creation Can supplement Deprivation programmes, micro-credit programmes, and existing HIV, Injuries, Poverty, Strong- access to existing welfare grants.

Current policies and legislation relevant to each topic were consulted to establish the existing policies with regard to interventions, but formal consultation with Government and other stakeholders remains outstanding and is crucial to the development of policies and programmes based on the recommendations presented here. Since this intergovernmental and cross-sectoral consultation will occur at the Development and Health Summit planned to take place in June , the reader should regard the recommendations recorded in this report as subject to further discussion and input from stakeholders.

The findings of the review are presented below; each focus area is discussed in turn and summary boxes of the key points are provided in the text. References WHO. Promoting Mental Health: concepts, emerging evidence and practice. According to Townsend , poverty can be distinguished from deprivation as follows. Poverty refers to the lack of resources required to obtain the conventional norms of nutrition, clothing, housing, and basic services, as well as the usually healthy environmental, educational, working and social conditions, activities, and facilities, which characterise a normal society.

Deprivation on the other hand, refers to the unmet needs themselves. The poor can thus be considered as multiply deprived where they have unmet needs in more than one domain. As such, people in informal dwellings have unmet needs in terms of income, employment and housing, each with their attendant health risks, and can be said to be multiply deprived. How one defines the various domains of deprivation is debatable.

For the purposes of this review, multiple deprivation refers to deprivation in income, employment, housing and food security — all of which are causally associated with mental health, as discussed in the risk-factor review.

Interventions targeting the other domains are addressed elsewhere in this review and in the Burden of Disease Project as a whole. Given the PERO findings on the particular vulnerabilities of women and youth, particular emphasis is given to these groups. Nature of the evidence There are two main difficulties with obtaining evidence on the efficacy of poverty-alleviation interventions for preventing mental illness and promoting mental health.

Lastly, since far less research is conducted among developing nations, there is little evidence from these countries Patel, a. Patel et al b suggest that — … the best action for promotion of mental health in developing countries will come not from evidence-based programmes, but from our acknowledgement that human development and mental health are inextricably linked.

For a detailed breakdown of the dimensions of poverty that these indicators represent, see the PGDS p. Evidence for interventions According to the literature, several types of interventions have been tried which aim to reduce the mental health consequences resulting from deprivation in income, employment, housing and food security.

Some of the interventions presented simultaneously address several domains of deprivation while others are more circumscribed. The interventions identified are classified as follows: 1. Housing and the Built Environment 2. Community Development and Micro-credit 3. Employment 4. Economic Assistance social assistance 5. Child Care 6. Adult Literacy 7. Food Security 8. Other 1. Urbanisation is also particularly rapid in developing countries.

Should this strategy be successful, the Western Cape will experience rapid mass urbanisation first-hand. Under such conditions the City of Cape Town itself will face a massive demand for housing in addition to its current backlogs.

A proper understanding of, and planning for, the impact of housing and the built environment on health — and mental health in particular — is therefore crucial to containing the Burden of Disease in the province. The impact of the residential environment on mental health results from the physical built and social environment at both the housing and neighbourhood level Thomson et al, They report that a large randomised controlled trial demonstrated a dose- response relationship between housing improvement and mental health such that the greater the number of housing improvements, the better the mental health outcomes of the intervention population Thomson et al Evans et al evaluate the evidence on the mental health effects of housing interventions in terms of housing type and housing quality.

The authors identify 18 studies, three of which used random assignment to housing type Evans et al Most of the studies, including all three randomised trials found that multi- dwelling housing is associated with worse mental health psychological symptoms and social connectedness. Six of the studies compared the mental health of high versus low-floor residents and found consistently worse mental health in those on higher floors compared to low floors confirmed by one RCT.

The authors also reported greater childhood behavioural problems and restricted play opportunities in high-rise dwellings. A randomised, controlled trial also reported increased rates of juvenile delinquency in high-rise versus low-rise residents, which has also been confirmed by observational studies. Several mediators of the effects on children have been postulated more strict parenting, resulting from safety concerns; lack of recreational spaces; and lack of contact with natural spaces Evans et al Housing quality includes both objective and subjective appraisals of housing quality: structural deficiencies, pest control, dampness and housing dissatisfaction.

Evans et al identified 26 studies four of which used experimental designs which measured the effect of housing quality on mental health. All found a positive association between housing quality and psychological well-being. Table 8 below indicates other housing factors that have been associated with mental health outcomes in observational studies.

According to Evans et al — … sufficient evidence exists to claim that housing does matter for psychological health. This is particularly true for low-income families with young children. Both housing type and housing quality impact on psychological health, social connectedness, crime and child development.

As Saegert and Evans note - Resource-poor residents located in places with poor housing, poor schools and services, and socially fragmented neighbourhoods would be likely to experience ill health, lower levels of education and occupational attainment, and, over time, less access to resources and choices.

This assertion is confirmed by the finding that families who have relocated to similar housing types in a middle-class area showed greater improvements in mental health than their counterparts who moved to a low-income area Evans et al, ; Truong and Mai, Interventions typically take the form of community renewal or regeneration, targeting various aspects of the built and social environments of disadvantaged neighbourhoods.

Evaluations of these interventions tend to be in the form of before-and-after studies, which have consistently shown improvements in mental health Howden-Chapman, ; Thomson et al, ; VicHealth, Other reported benefits include: a reduced sense of isolation and fear of crime; an increased sense of belonging; increased community involvement; greater recognition of neighbours; and an improved view of the area as a place to live Thomson et al, An example is provided by the Neighbourhood Renewal Project, run by the Victorian Health Promotion Foundation VicHealth , in which the most disadvantaged communities in Victoria were allocated resources for improving housing, jobs, health and services, and towards reducing levels of crime.

The programme utilises a community-development approach, whereby communities collaborate with government and business to achieve the aims of the project. For further details, see VicHealth, The other type of intervention that has been mentioned is relocation. Those in the intervention group were relocated from poor areas into geographies of greater opportunities, while controls remained in the poor areas both groups having similar housing in the different settings.

The findings indicated an improved quality of life; greater mental and physical health; less use of harsh parenting techniques; and increased employment in the intervention groups. Data from non-experimental studies have also indicated what other factors at the neighbourhood level may be important as summarised in Table 9 below. The accumulation of multiple stressors over long periods of time results in greater psychological and physiological effects Saegert and Evans, It has also been found that those who have poorer health have greater difficulty accessing good housing Smith et al ; Thomson et al , and as such the vicious cycle comes into play.

Community housing and Micro-credit Several interventions target poverty alleviation at a community level as a means of reducing mental illness and thereby encouraging economic empowerment. Given the varied uses of this terminology, it is important to have clear definitions of what we mean by community development and economic empowerment.

Community members identify and prioritise local problems together, which are then addressed by collaboration among community members, Government, Non-Governmental Organisations and private business.

The effect of community development on mental health is presented in Figure 7 on page 38 below. Economic empowerment encompasses access to adequate income and employment; employment equity; increased opportunities for control in employment; and possession of the necessary life skills for negotiating the labour market VicHealth, There are very few good quantitative studies in this area, since many of the study designs are before-and-after studies, which make it impossible to exclude secular trends in accounting for observed differences.

For example, mental-health improvements may be due to other changes in the environment that occurred during the study period, such as new government feeding schemes, and so on. This review aims to highlight the best research in the area, while also acknowledging interventions which might still require further, empirical evidence. Activities of the VO members include awareness and advocacy for human rights, and the initiation of a compulsory savings programme.

BRAC staff train members of the VO in different trades such as village health worker, poultry vaccinator, and so on , who then provide for the members of the VO and sell their services to other villagers for a small fee. After a month of membership, VO members may apply to BRAC for an individual loan, which is granted for use in income-generating activities, or for housing.

BRAC families also had lower rates of malnutrition, improved child survival rates, and improved mental health. The authors argue that the increased emotional stress was due to the challenging of traditional gender norms, which in turn resulted in increased domestic violence as above.

In this instance, more attention should be paid to involving men in the project such that a forum to ameliorate potential gender tension is created.

The other significant effect of providing credit without training is the stress that can result from the lack of skills to effectively manage the loan, hence the importance of providing training and support to loan recipients is highlighted. The village health worker then shares this knowledge with the community groups. The outcomes cited by the World Health Organisation include: improved physical health; nutrition; gender equity; social support; skills acquisition; financial autonomy; and social empowerment Arole et al, The evaluations are clearly of a pre-post nature but how the outcomes have been assessed is not clear.

Accessed 22 January A randomised, controlled trial compared outcomes two years after the initiation of the programme and found statistically significant improvements in household assets Adjusted RR: 1. No significant differences were found in terms of perceived social capital among this cohort. One of the main limitations of the study is that — owing to the nature of the intervention — it is not possible to know whether reductions in partner violence were as a result of the gender-equity training or the micro-finance provision.

FED-UP, discussed above, is another example of how micro- finance and social capital can be utilised to reduce poverty housing deprivation, in this instance. Opponents to the provision of micro-finance alert us to possible pitfalls of this approach. In his critique of micro-finance solutions for development in Africa, Buckley argues that providing credit to those who cannot access credit through conventional channels disrupts self-selection such that those with insufficient business acumen and credit-management will inevitably be the recipients of these loans.

Employment interventions These interventions seek to increase employment of vulnerable groups either directly or indirectly through increasing job-seeking abilities. The latter ably addresses the loss of motivation to seek employment that can arise in the context of high unemployment rates. The intervention consists of five half-day workshops over a week delivered by two trainers to small groups of unemployed people.

This programme has been evaluated by large-scale randomised controlled trials, where programme participants were compared to a control group of unemployed people. The results indicate that, up to two years after the programme, participants were more likely than members of the control group to be employed, working more frequently and earning a higher monthly income Vinokur et al The intervention also had a beneficial impact on mental health outcomes.

The successful implementation of this programme in diverse settings suggests that this intervention is successful in different economic contexts; the differences in outcomes observed in the dissimilar settings were mainly related to who benefits most from the intervention Vuori et al , I A cost-benefit analysis of the programme demonstrated large net benefits for the programme Vinokur et al VicHealth has instituted many economic empowerment interventions in a range of settings in Australia.

African communities in Australia were given training and support to start up financial projects in different parts of Australia e. Another programme funded the evaluation of mental health outcomes of existing youth employment programmes run by other organisations VicHealth Economic assistance Limited evidence was found on the mental health impacts of social assistance provision. A South African cross-sectional study Case, in the Langeberg District evaluated the health impact of old-age pensions on household health.

They were also more likely to report better overall health, have a flush toilet, and were less likely to have skipped a meal. Pensioners themselves enjoyed these same benefits as the other household members and in addition were less likely to report deteriorations in health status due to limitations on activities of daily living. Similar associations were not found in households with elderly people not receiving a pension.

As such, social assistance programmes should, where possible, aim to empower social assistance recipients to return to work.

Child-care programmes Doherty et al define child care as care for preschoolers through to underage year-olds outside of school hours by people who are not family members. The Guidelines for Early Childhood Development Services Department of Social Development, , consider child-care services for children aged years. Both ecological and cross-sectional studies have demonstrated that access to child care is associated with increased maternal employment and enrolment in educational activities Ficano et al, For example, in the USA, data from 4, American women with children under the age of 13 Hofferth and Collins, showed that not having access to a formal, non-parental child- care arrangement, distance longer than 10 minutes from home to a child-care centre, and high cost of child care were associated with a higher probability of job exit.

Child care has also been shown to assist mothers on social-assistance grants in re-entering the labour force. This effect was found to be strongest among the poorest of the population.

With regard to this evidence, Doherty et al argue that the provision of high-quality child care is fundamental in enabling parents to enter and remain in employment. While none of these studies evaluated mental health outcomes, there is some evidence of the association between child care and mental health.

In a cross-sectional study of low-income working mothers living in poor urban neighbourhoods in Philadelphia USA , Press et al found that mothers who had problems with child care were significantly more likely to report depressive symptoms after adjusting for confounders. No studies were found that evaluate the mental health impact of child care on children older than 5 years.

One would have to consider the mental health impacts of separation of children from their parents. The quality of child care services should be such that child care is psychologically and cognitively beneficial to the child as discussed in pre-school education.

Differences in what constitutes literacy are therefore related changes in the core skills required to engage effectively in basic activities in different societies over time. Literacy is known to be associated with overall health and mental health, which occur by means of both direct and indirect mechanisms, as illustrated in Figure 8 below. Indirect mechanisms are seen to relate to the effects of low literacy on socio-economic status with literacy linked to lower incomes, higher unemployment and lower wages Rootman and Ronson, While there are no rigorous studies on the mental health effects of literacy interventions, improving literacy should plausibly improve both health general and mental and employment outcomes Rootman and Ronson, Although the literature tends to focus on the mental and physical health effects of preventing malnutrition in children Patel et al, , this work ignores the effects of food insecurity on the family as a whole, and mothers in particular see Risk Review.

A serial cross-sectional study was found which evaluated food insufficiency status and depressive status at three points in time over three years Heflin et al, The findings indicated that changes in food security are significantly associated with changes in depressive status.

Yet empirical data on the mental health outcomes of interventions targeting food insecurity at the household level were not found. Given the strong evidence of preventing malnutrition in children, however, it is highly plausible that interventions targeting food security will improve the overall mental health of communties.

It is nevertheless highly plausible that such programmes would improve mental health. Others have suggested that increasing the minimum wage and instituting progressive tax policies which are pro-poor would in all likelihood improved the mental health of the poor Vichealth This is interesting in the context of the introduction of wage subsidies in South Africa which, if we follow this line of argument, will plausibly improve the mental health of its recipients.

No studies researching the impact of such policies on mental health were found. Existing Interventions in the Western Cape Province 1. Some of the criticisms that have been made about housing delivery are illustrative of the gaps between the vision of the Housing Act and its successful realization or implementation. These problems can be expected to increase with increased urbanisation and poverty Oldfield It has resulted in the purchase of 10 homes in five years.

Communities learn the skills necessary to oversee the construction of their homes and to manage their finances from other communities. The project is regarded as highly successful and is supported by an extremely favourable cost-benefit analysis, which found a net benefit of R million.

Additional benefits of this programme include empowerment, economic participation and enhanced social and human capital. In terms of mental health, these benefits accrue to health capital. Urban Renewal The Urban Renewal Strategy was approved by the National Cabinet in October and eight urban renewal pilot areas were identified nation wide. The audit of the Programme in in Khayalitsha indicated that a comprehensive range of activities have been undertaken, including: skills development and employment programmes for vulnerable groups; the provision of child care; improvements of the built environment streetlights, roads, infrastructure, sports facilities ; and the establishment of community police forums and safe schools to name a few measures.

Clear outcome measurement is not evident in the audit of the programmes, and no health outcomes were mentioned. Although funding in general has increased from to , funding for certain projects was discontinued, and the reasons for this event were unclear. Despite the apparent successes of this programme, moreover, it does not appear to have been expanded to include equally, and more deprived, areas. An audit of these programmes does not indicate the measurement of outcomes.

If successful, these programmes should be expanded to cover other townships. The authors of the strategy review a range of large-scale poverty alleviation projects administered by various Departments Education, Social Development, Public Works and Local Government and highlight the need to address the following imperatives in order to achieve greater success.

See the Integrated Poverty Reduction Strategy. From this review, the IPRS proposes that Local Government must be the primary driver and facilitator of programmes and programmes should build on existing knowledge and skills within communities such that communities have the capacity to contribute to solutions. This approach bears a striking resemblance to the community development approaches discussed in the evidence above.

In line with findings on vulnerable groups, the IPRS focuses on programmes that target the development of disadvantaged women and the youth in general. The IPRS also proposes investment in rural areas with potential growth in an attempt to discourage migration to the cities and urban areas. The main problems appear to be in putting these interventions into practice. Social assistance Provision of social assistance is viewed by the Department of Social Development as the largest poverty alleviation measure undertaken by government Western Cape Department of Social Development , and it has been shown to have been highly beneficial for recipients as discussed above.

Despite its successes, it is not without its failures. Among those eligible for social security under the current system there is a large gap between who is eligible and who receives the grant. Statistics from the National Department of Social Development, for example, show that of the 3.

Accessing child support grants is particularly difficult in rural areas. Despite the successes of this programme, there are many problems: 1 the primary caregiver is required to show proof of identity, employment income and other means of child-support. These problems highlight some of the difficulties associated with accessing social security in South Africa. A further problem is the exclusion of many South Africans who need social security but are not eligible for it under the current system.

Frustration with the social security system has led to the campaign for a Basic Income Grant which has yet to be approved by government Naidoo et al The document details strategies to increase the movement of social assistance recipients to employment which include creating employment for disabled people and single mothers, particularly in civil service.

NGO poverty-alleviation programmes There are a range of projects run by non-governmental organisations which alleviate poverty and can assist with this objective for example, Men on the Side of the Road, Ikamva Labantu and The Big Issue.

No empirical evidence on the mental health outcomes of this programme or others was found. Recommendations Although these recommendations are discussed separately, the interventions that occur in any geographic area or electoral ward should address the multiple components of deprivation in that specific area, as identified by communities. Overall, a community development approach is recommended. Again, where cost is a consideration, such areas could be shared e.

Overcrowding in multi-dwelling units should be strongly discouraged. Review current employment programmes: incorporate methods of the JOBS programme as described above 9.

Experts in the field should be consulted in this regard. World Development. Ahrentzen, S. Double Indemnity or Double Delight? Journal of Social Issues.

Baumann, T. Small Enterprise Development. Buckley, G. Microfinance in Africa: is it either the problem or the solution?

Catalano, R. Comment: Housing Policy and Health. Do poverty alleviation programmes reduce inequities in health? The Bangladesh experience. In: Leon D, Walt G, eds. Poverty, inequality and health. Oxford, Oxford University Press: — Crawford, A.

Review of Policy Research. Department of Social Development. Guidelines for Early Childhood Development Services. Pretoria: Government of South Africa. Department of the Premier. Ficano, C. Frumkin, H. Health Places: Exploring the Evidence. American Journal of Public Health. Galea, S. Urban Health: Evidence, Challenges and Directions. Annual Review of Public Health. Heflin, C. Social Science and Medicine.

Hofferth, S. Collins Howden-Chapna, P. Housing standards: a glossary of housing and health. Journal of Epidemiology and Community Health. What makes Mental Health Promotion effective?. In: International Journal of health promotion and education. Supplement: the evidence of mental health promotion effectiveness: strategies for action. Mental Health Promotion works: a review.

Kaplan, R. Physical and Psychological Factors in Sense of Community. Environment and Behaviour. Lund, H. Pedestrian Environment and Sense of Community.

Journal of Planning Education and Research. Noble, M. UK: University of Oxford. Northridge, M. Sorting out the connections between the built environment and health: a conceptual framework for navigating pathways and planning healthy cities. Oldfield, S. The Housing Crisis in the Western Cape. Patel, V. Chapter Petticrew, M.

Evidence: The Way Forward. Press, J. Journal of Family Issues. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet, Rootman, I. Canadian Journal of Public Health. Saegert, S. Smith, S. Thomson, H. Health effects of housing improvement: systematic review of intervention studies. British Medical Journal. Health impact assessment of housing improvements: incorporating research evidence. Townsend, P.

Journal of Social Policy. In: Noble, M. Truong, K. A systematic review of relations between Neighborhoods and Mental Health. Journal of Mental Health Policy and Economics. Vic Health Journal of Applied Psychology, 76 2 : Journal of Occupational Health Psychology, 5 1 : Journal of Occupational Health Psychology, 7 1 : 5- Weich, S. Prevention of the common mental disorders: a public health perspective. Psychological Medicine. Western Cape Department of Social Development. Prevention of mental disorders: Effective interventions and policy options, Summary Report.

Geneva: World health Organization. Events that would qualify as traumatic stressors include violent crimes, acts of war, road accidents, and family violence National Collaborating Centre for Mental Health, A worrying observation from this study was that none of the traumatic incidents or mental-health symptoms had been identified by day-hospital clinicians.

It is therefore crucial that the health-care system recognises and treats the effects of trauma exposure on patients. Moreover, the need to recognise the effects of trauma goes beyond the health-care system, and within the health-care system; beyond even the primary care and mental health systems. The first point of contact for many survivors of violence or of natural disasters is not the health-care system, but other agencies, such as the police or disaster-management bodies.

An individual female who has been raped, for instance, may well go first to the police, before undergoing the necessary physical examinations to collect forensic evidence, and may then have to appear in court to face the perpetrator. Each agency involved in such a case needs to be sensitive to the effects of such trauma exposure, because the inappropriate handling of survivors may exacerbate their symptoms Herman, ; Campbell et al.

Re-traumatisation, in other words, does not describe exposure to a new trauma, but the activation or exacerbation of mental- health symptoms related to the original trauma that brought the survivor into contact with the relevant system. In the field of trauma, ultimate prevention includes preventing exposure to traumatic incidents. People who are not exposed to traumatic incidents cannot develop post- traumatic stress disorder, and while they may be at risk for anxiety, depression or substance abuse for other reasons, they are less likely to develop these disorders.

Reductions in crime and violence including family violence thus provide clear evidence of successful mental-health promotion outcomes. In order to further understand this level of prevention, readers of this volume are referred to the report of the Injuries Workgroup. Health promotion in the mental health field also includes the development of adequate coping skills for dealing with stressors.

Thus the interventions proposed by the Cardiovascular Disease Workgroup are also likely to affect mental health. Since social support is equally important in recovery from exposure to traumatic stressors Mollica et al, , interventions that build social support are likely to be preventive, and the Major Infectious Diseases Workgroup includes recommendations with regard to this matter in their report.

It follows that the recommendations of other workgroups are also likely to assist in either preventing exposure to traumatic stressors, or in improving the skills and the environment to assist in coping with such stressors.

This report therefore deals primarily with the two remaining areas in terms of improving mental health: treating disease; and preventing disease, impairment and disability. Recommendations will be made with regard to ensuring that post-traumatic mental-health states are adequately recognised and treated within the health system. Prevention will be dealt with in terms of the prevention or amelioration of mental-health symptoms after trauma exposure, and the prevention of re-traumatisation.

Recommendations will therefore be made for addressing secondary traumatisation, as it is an essential part of reducing the burden of mental illness among care providers. Nature of the evidence There is strong evidence from randomised controlled trials and from systematic reviews that demands evidence-based, efficacious interventions for treatment of PTSD. There is also some evidence to suggest that early intervention reduces symptoms in those at risk of developing chronic PTSD.

This report also draws on guidelines for clinical practice derived from reviews of the literature and often developed by expert panels, which address the prevention and amelioration of mental health symptoms after trauma exposure.

In some cases, literature reviews have been used. Retraumatisation and secondary traumatisation have been relatively under- studied. In other words, while there may be very little hard evidence on which these recommendations are based, the lack of evidence is more about the lack of studies in the field rather than any contradictory evidence, and these recommendations are offered in the light of everyday clinical experience in the Western Cape Province and elsewhere in South Africa.

Evidence of interventions Early interventions immediately after a traumatic experience can either prevent the development of later symptoms, or prevent existing symptoms from becoming chronic National Collaborating Centre for Mental Health, Since many patients present to the health-care system with physical injuries after experiencing a traumatic event, those involved in injury care for instance, in emergency rooms and orthopaedic and plastic-surgery clinics should be equipped to screen patients for post-traumatic mental- health symptoms, and to make appropriate referrals as necessary National Collaborating Centre for Mental Health, ; Katon et al, Furthermore, health-care providers should also be made aware that patients presenting with adverse mental-health symptoms or unexplained physical symptoms may have experienced a trauma.

Essentially, therefore, all health-care providers should be competent to assess for trauma exposure and for related adverse mental-health symptoms, and to refer appropriately. This implies the development of protocols for screening and referral, and the training of all health-care providers to be competent to use such screenings and referrals. Protocols should also include guidelines for age-appropriate screening, since symptoms manifest differently in children and in adults National Collaborating Centre for Mental Health, Currently, the evidence suggests that knowledge about evidence-based approaches to treatment requires sustained dissemination efforts by those organisations seeking to implement such approaches Katon et al.

Early referral of patients with severe symptoms in the immediate aftermath of the traumatic incident, or whose symptoms persist beyond one to three months, has been shown to reduce the development of more chronic states of PTSD in some cases, and the evidence appears to favour this as more cost- effective than treating only established cases Katon et al. Treating PTSD is also likely to address co-morbid mental-health problems where present, which commonly include anxiety and depression National Collaborating Centre for Mental Health, More chronic states of PTSD increase the burden on both the mental- and physical-health systems, as patients are likely to need longer- term mental-health treatment and to experience higher rates of physical symptoms Katon et al.

For individuals, an appropriate intervention immediately after injury is to enquire whether this injury was caused by a traumatic event; to assess for symptoms; and to educate patient and family about symptoms that may follow.

Referrals should always be made to a mental-health professional who is competent in dealing with the special instance of trauma, rather than a generalist. Patients whose symptoms are less severe should be invited to return if symptoms become more prominent, and a follow-up appointment should be scheduled after the passage of one month. It is then crucial that there be continuity of care, and that the assessment and follow-up appointment s be carried out by the same health-care practitioner.

Such a step makes it possible to follow up patients who may have missed an appointment which in itself may be an indication of increasing symptom severity and further avoids re-traumatisating clients by inadvertently forcing them to tell their trauma stories many times over to different people.

Thus the health-care system should include sufficient mental-health professionals who are competent in trauma-focused psychotherapy, and ought to make provision for the continuity of care with regard to assessments and follow-up appointments.

Early intervention is likely to reduce the development of more chronic mental- health symptoms, and is also likely to be more treatable with brief psychological interventions five sessions within the first month after the event; sessions where symptoms occur within the first three months offered on an out-patient basis National Collaborating Centre for Mental Health, , thus reducing the overall burden on the health-care system. Early detection and treatment are thus also cost-effective.

This approach is suitable for groups who usually work together and who regularly deal with critical incidents, such as emergency services. The literature thus suggests that programmes using Critical Incident Stress Management techniques are likely to be efficacious in groups such as emergency services, rescue teams, the staff of psychiatric hospitals, police services, and among soldiers.

Since this is a relatively new area in the literature, evaluation should be built into the design of any such new programmes, to ensure that they do in fact reduce symptoms. Disaster management offers another arena for preventing the development of long-term post-traumatic mental health problems. Disaster plans should include provision for a fully co-ordinated psycho-social response to the disaster, including provision for immediate practical help, supporting the affected communities in caring for those involved, and the provision of specialist, evidence-based assessment and treatment of adverse mental- health symptoms National Collaborating Centre for Mental Health, ; National Institute of Mental Health, Details of what should be included in such a plan are available from The Sphere Project, a project of humanitarian NGOs and the Red Cross and Red Crescent Societies, which has designed a set of minimum standards for disaster response.

All healthcare providers, therefore, should be competent to screen for post-traumatic mental health problems, and to make appropriate referrals to mental health practitioners. Re-traumatisation There is very little data on interventions to reduce re-traumatisation.

The area that has been most studied is that of women who have been raped, and authors in this area suggest that it is important to continue efforts to educate those who deal with rape survivors about post-traumatic reactions and how to handle them during such necessary procedures as forensic examinations Campbell et al, ; Stenius et al, There is every reason to expect that the same principles will apply to those who deal with survivors of other forms of traumatic incidents, such as child-abuse survivors.

Where service delivery is not trauma-informed, it may be re-traumatising or less than optimally effective Harris et al. These treatments are normally provided on an outpatient basis, and should be provided weekly by the same person.

There is no evidence about the effectiveness of other psychotherapy modalities, such as brief psychodynamic approaches which may be more widely available in health systems, when treating patients who have experienced traumatic incidents. The lack of evidence should not be read as implying that they are ineffective; they simply have not been investigated in the same way that trauma-focused cognitive-behavioural therapy and eye movement desensitisation and reprocessing have been investigated.

If these approaches are used, they should ideally be evaluated. As a front-line treatment for trauma i. It should also be noted that other guidelines oppose the use of medication in the immediate aftermath of trauma exposure National Collaborating Centre for Mental Health, In more complicated cases, where initial treatment fails, or where the PTSD is comorbid with severe depression, antidepressants should be considered, and consideration should be given to augmenting these with antipsychotic medication if there is no response Baldwin et al.

Decisions about medication are complex and are best made by psychiatrists. Secondary traumatisation Those who work with trauma victims are vulnerable to secondary traumatic stress and who are experiencing such stress are more likely to make poor professional judgements than those who are not so affected Collins and Long, Much of the literature on self-care focuses on mental health professionals.

These professions, too, should receive appropriate training and support. Conclusion Those who work with trauma survivors are vulnerable to secondary traumatic stress. Training in self-care and other support structures should be developed for those who work with trauma survivors, and evaluated in terms of their ability to prevent the development of post-traumatic symptoms.

Despite their best intentions, however, it is unlikely that these sources are sufficient to address the needs for treatment. Despite the important role of medication, most of these NGOs do not get help from doctors or nurses. Recommendations 1. Health department interventions 1. Most mental health care professionals employed by the province deal with inpatient psychotic disorders; there is much less emphasis on outpatients with mood anxiety disorders such as PTSD.

Attention should thus be given to staffing outpatient clinics with mental health professionals who are competent to deal with trauma. Then, in her third term, she continued that work by serving as a member of the Farm Bill Conference Committee where she helped lead efforts to pass a bipartisan Farm Bill that provided farmers with the support they need to continue putting food on the plates of Americans across our nation. While working on this key piece of legislation, she conducted a 21st Century Heartland Tour to better understand the needs of our family farmers.

Sitting around kitchen tables, in barns and garages across the 17th Congressional District, she asked hundreds of our farmers and agricultural producers what worked for them in the last Farm Bill and what they needed from a new one.

While no agreement is ever perfect, the USMCA will serve all Illinoisans — it has the toughest enforcement mechanisms our country has ever seen, expands access to markets for our producers, and has broad support among stakeholders. As we tackle the climate crisis, Cheri has sought to give family farmers and rural America — including families in Northwest and Central Illinois — a seat at the table. That motto was most recently reflected when she was selected as one of the two recipients of the Democracy Award for Exceptional Constituent Services from the Congressional Management Foundation.

Cheri knows that if we want to put hardworking families first once again, we need Washington to spend a lot more time listening to the Heartland. Born in Springfield, Illinois, Cheri Callahan Bustos comes from a long line of farmers and teachers and grew up in a family that loved sports and their community.

The granddaughter of a hog farmer and a nurse and the daughter of a social worker and a newsman, Cheri was the youngest of three children. Her dad would go on to work in public service and Major League Baseball. Her mom would go on to be a preschool teacher. She is proud of her agricultural roots. She followed her dad into the news business. While covering the police beat as a reporter in the Quad-Cities, Cheri met a rookie cop named Gerry Bustos who she fell in love with and married.

With Gerry, who now serves as the Sheriff of Rock Island County, they raised three sons and they now have three grandchildren, all of whom proudly call Illinois home.

Throughout her career in journalism, Cheri used her pen to help her community. She uncovered numerous stories of corruption and greed in government, winning awards for her work on behalf of the public interest.

There, she helped families access affordable coverage and worked to improve the quality of health care available in the community. Cheri was elected to serve on the City Council in East Moline for two terms and made her top priority economic development. She led the removal of downtown blight and the development of the largest construction project in downtown East Moline in generations: a nonprofit health clinic.

In , she was sworn into her first term in Congress, representing the hardworking families of the 17 th Congressional District. She also attended Illinois College in Jacksonville, where both her parents and son graduated. An accomplished basketball and volleyball player, Cheri was inducted into the Illinois College Sports Hall of Fame in Richard brings to this role two decades of experience at the community, state, and federal levels building collaboration between the housing, health care, social services, and criminal justice sectors to address the housing and services needs of vulnerable Americans.

He has a Ph. Melissa E. There she determines strategy for working with health care organizations to improve population health, build equitable value-based networks and enhance clinical quality.

She also leads the 3M HIS division strategy on social risk in the context of 3Ms population health products and supports the division government relations team. Clarke previously worked as the vice president for population health at an integrated clinical network where she negotiated managed care contracts and pioneered innovative care strategies to improve health outcomes for medically underserved patients.

Previous to that, she was a senior medical director at Aetna-owned Active Health Management, a population health management company, which managed more than 18 million covered lives. Clarke helped to steer the organization as it transitioned into adopting a patient-centered, population health and value-based care approach to health care services.

As Deputy Administrator of the Center for Innovation and Partnership CIP , Kelly Cronin leads the administration of programs and initiatives that serve both older adults and people with disabilities, including consumer access and protection programs.

She also directs efforts to develop and integrate networks of state and community-based organizations to address social determinants of health and to advance the integration of medical and social care to improve health outcomes of older adults and people with disabilities. Before joining HHS in , Ms. Cronin was a health services researcher and coordinated clinical trials in pharmaceutical and medical technology industries. She holds a master of public health with a concentration in epidemiology and biostatistics and a master of science in health policy from the School of Public Health and Health Services at George Washington University.

Senator Patty Murray. Elizabeth has spent more than a decade in federal government roles, including as the health policy lead for U.

Department of Health and Human Services. She previously managed federal government relations for NewYork-Presbyterian, a large academic medical center across New York City. This body of work analyzed opportunities to integrate novel services and supports into health care delivery and financing and explored legal barriers to scaling innovation within the health care system.

Sandra Elizabeth Ford, M. In this role, which she began in May of , Dr. Her primary areas of focus are the socials determinants of health SDOH , health equity, and biopreparedness, including COVID response, monkeypox, Ebolavirus, and other biological threats. Prior to assuming this role, Dr. In this role, Dr. Her Maternal and Child Health initiative, M.

While Dr. Her knowledge and expertise were essential when facing the COVID crisis, and she was instrumental in ensuring the safety of the citizens of DeKalb and Fulton Counties simultaneously while still overseeing core public health services in both counties.

From May July , Dr. There, she also led the development of policy and legislation pertaining to public health and enforcing related laws and regulations.

A board-certified pediatrician, Dr. Evelyn is a trusted advisor in helping her clients bridge the gap between health information technology policy and standards and business requirements.

She has a strong ability to work across and build consensus with diverse stakeholder groups to include multidisciplinary providers, policymakers, healthcare payers, researchers, system vendors and implementers, and standard development organizations.

Gallego provides specialized expertise in digital health interoperability and health policy with a focus on alignment of regulatory, technical, and process improvement requirements to enable the effective adoption and use of technology.

She is a thought leader in the areas of care coordination, social determinants of health SDOH , health IT policy analysis and development, health information exchange and interoperability, and health IT standards development. Daniella and her team forge relationships with a politically diverse congressional delegation across four states, as well as national organizations, to promote policies that support the healthiest generations of children and the providers who care for them. Key strategies include a combination of direct advocacy, major events with congressional and Administration officials, thought leadership, publications, social media and relationship-building.

She and her team have successfully engaged their delegation to champion legislation related to pediatric mental health, Medicaid, social determinants of health, the pediatric workforce, telehealth, pediatric payment innovation, biomedical research and early childhood health. At TFAH, she advocated for a health system that promotes integration of clinical and community-based prevention.

Previously, she worked first as the Legislative Correspondent and then as a Legislative Assistant for the late Congresswoman Julia Carson, advising the Congresswoman on environmental, agriculture and telecommunications policy and handling Transportation and Infrastructure Committee work. From to , Dr. Under her leadership, the Department achieved national public health accreditation in Hacker also launched the Live Well Allegheny initiative, aimed at reducing cigarette smoking, obesity, and physical inactivity.

Previously, Dr. Between and , she held a variety of leadership roles at the Cambridge Public Health Department and the Institute for Community Health both part of the Cambridge Health Alliance.

She also spent several years working for the Boston Public Health Commission, with a focus on adolescent health, serving as Division Director for Child and Adolescent Health to , Director of Adolescent and School Services to , and Director of Adolescent Services to She wrote Community-Based Participatory Action Research , a widely used academic text, and taught a course on the topic at the Harvard T. Chan School of Public Health. As the Executive Director of the Institute for Community Health, she designed, led, and published on numerous community participatory health projects.

She has published 67 peer-reviewed articles on a wide variety of topics, including adolescent health and school-based health centers, obesity, substance use, and health policy. She is board-certified in internal medicine and has served as an Associate Professor at Harvard Medical School to and at Harvard School of Public Health to Previously, Ali served as policy lead on child nutrition and other public health and human services programs for the House Committee on Education and Labor Democrats, where she led the authorization of the Pandemic EBT program and other child nutrition policies.

She is a Registered Dietitian Nutritionist with an M. In that role, he oversees data analysis and research, software development, strategic planning, and new program incubation for the department.

Prior to Amazon, he was an Associate Director at Social Finance, a Boston-based non-profit organization dedicated to scaling high quality, evidence-based non-profit service providers, and he worked for the Federal Reserve Board in Washington, D. Additionally, Jenn spearheads the Member Insights function using qualitative and advanced analytic approaches to understand the gaps in care and unmet needs of populations. Jenn has helped companies articulate and achieve success across several aspects of the healthcare space.

As a military veteran, Jenn brings leadership and vision to diverse audiences, and offers a unique perspective within start-ups and high-growth stage companies. With a passion for organizational mission and values, as well as the unique competitive advantage of establishing a strong culture, Jenn works with all departments to streamline processes and programs that integrate the member experience into every aspect of the business.

Formerly, she was selected for the David. During her studies, Nadia worked as a project coordinator at the Feinberg School of Medicine Center for Child Trauma Assessment, Services, and Interventions supporting projects that focused on training frontline providers in trauma-informed care, building and enhancing trauma-informed and strengths-based practices for Transition Age Youth, and the intersection of race and trauma.

Nadia was also the founder and CEO of Cocoa Queens, a social enterprise whose goal was to use hair extensions and products as an unconventional avenue of exposure for breast health information to create breast health awareness and access to health information for African American women. Marcella Maguire, Ph. Her work nationally focuses on the intersection of the housing and healthcare sectors in the financing, policy and implementation of systems and programs.

Prior to joining CSH, Marcella worked for 17 years for the City of Philadelphia leading efforts to integrate behavioral health, managed care and affordable and supportive housing systems.

In addition, she oversees staff and operations of the Primary Care Office. Kelly has led the department in achieving national reaccreditation status by the Public Health Accreditation Board while going through a merger with the Department of Human Services. She also led the development of an innovative framework and data sharing dashboard for the state health assessment and improvement plan processes that focuses on identifying and addressing the social determinants of health.

Len M. In all three capacities he continues to expand his recent work on financing social determinants of health. Since that time he has testified frequently before Congress and state legislatures, published widely and spoken to a large number of hospital associations, physician groups, boards of directors, and health policy forums around the country.

Len is often asked to provide technical expertise to members of Congress, governors, state legislators, local policy officials, and private health-related organizations. He has consistently sought to add moral arguments to the technical health policy debate.

Len got his B. Through the implementation of the GHHI comprehensive housing intervention model and its best practices Toolbox that she helped develop, cities are improving the ability of children to arrive in the classroom healthy and ready to learn and to stay in school through reduced asthma related absences.

Norton has developed over 45 pieces of successful healthy housing legislation that focus on reducing health disparities.

Through its current feasibility and development work with healthcare partners and jurisdictions nationally, she heads a GHHI technical assistance team that is creating sustainable models for Medicaid reimbursement for preventive asthma and household injury services. A founding member of the NEWHAB Advisory Board, she provides a leading voice to articulate the significant health and social benefits of weatherization investments through her advisory role with Energy Efficiency for All EEFA and has authored research publications on the non-energy benefits of energy efficiency.

Since in , the Center has been supporting and operating a variety of programs. Examples include:. In this time he worked on the establishment of quality and program benchmarking, the Office of Long-Term Living, rebalancing efforts, and the passage of assisted living and regulation development.

Rachel also oversees behavioral health issues and strategy across all eleven of the HHS family of agencies. In her role, she is the senior executive appointee responsible for working with HHS agencies and the White House to develop strategic direction and advance operational implementation of high priority policy in the areas of coverage, child wellbeing and behavioral health issues.

Previously, Rachel was Deputy Director for Administration of the Virginia Department of Medical Assistance Services, the agency that administers the Medicaid program in Virginia for more than 2 million individuals. In her role, Rachel also oversaw all policy, legal and regulatory functions for the agency. For her efforts with Medicaid expansion, she was recognized for her service by Governor Ralph Northam in January Prior to her time on Capitol Hill, Rachel worked with Ascension Health, the largest not-for-profit health care system in the nation.

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WebThe changes have enhanced the individual and provider experience. There will be new individual and provider portals that will look and act differently. Providers can get help by . WebTalent Network | CareSource Talent Network Please specify a Career Area and/or Location and then click Add. Opt In for Additional Communications Your privacy is important to us. . WebThe Ohio Home Care Waiver Program case managed by CareSource has moved to a new system platform on April 1, The changes have enhanced the individual and .