Write the background/ introduction? TOPIC: ?hospital readmission after being discharged to homecare services? 1. Background knowledge-brief summary of current knowledge of problem being

Musculoskeletal Health Related to Mental Health in Developing Countries

Capstone Project Submitted to

Denver College of Nursing

Abstract

This Quality Improvement (QI) project will consist of researching the diagnosis of mental health conditions on individuals with a diagnosis of chronic pain as well. It will also consist of research on best practices for cross-cultural education. This project will be divided into two sections; Phase I and Phase II. Phase I will include a review of the literature, development of a power point presentation for students, and development of a psychosocial yoga graphic handout that Global Health Prospective (GHP) can take on medical mission trips abroad to teach individual yoga to assist in alleviating chronic pain and helping with the management of mental health disorders. The objective of this psychosocial yoga graphic handout is to see if alleviating chronic pain improves an individual's overall mental health status. Implementation will occur in Phase II.

Since this is a Quality Improvement project, the author will consult with GHP leadership to get approval for use. Once approved, the Global Health Program (GHP) students will participate as subjects in a cross over design Quality Improvement Project. First, as part of their own control group, they will take a pre-test before receiving a power-point lecture about best cross-cultural education methods, chronic pain, and mental health in developing countries. A post-test will be given. The GHP students will then cross over and be their own intervention group, where they participate in a simulation educational venue reinforcing the psychosocial Yoga Graphic handout and also appropriate stretches and exercises to use when teaching a patient. A second post-test will then be taken prior to embarking on a GHP Mission. Cognitive social learning will be used to teach this psychosocial yoga graphic handout in the environment in which the population lives. GHP staff will be able to evaluate the effectiveness of the psychosocial graphic handout by observing the students and population using a teach-back method and having patients demonstrate the skills they have learned. When the GHP students return from the mission, a third post-test will be administered. A statistician will be consulted.

Keywords: "demonstration, effectiveness, evaluate, objective, evaluating"

Table of Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 1: INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Summary of Scholarly Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Intended Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11 Study Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 2: LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Search Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Chapter 3: PROPOSED INTERVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Theoretical Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Chapter 4: METRIC AND OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Preliminary Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Potential Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Use of Pre-Test/Post-Test Crossover Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Chapter 5: DISCUSSION/CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Evaluation of Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Anticipated Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Recommendations for Further Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Musculoskeletal Health Related to Mental Health in Developing Countries

Chapter 1: Introduction

Chronic pain is recognized as a major public health problem worldwide and can cause a significant economic and social burden on an individual. Not only does chronic pain affect an individual; it severely impacts their family and life. Chronic pain impacts both a patient's mental and physical health. Treating and diagnosing chronic pain can be difficult to do in a developing country, as pain is a subjective experience and there is no test to measure and locate it exactly. With that said, mental health resources are limited in developing countries as well, and can be difficult to diagnose and treat. It is the assumption that the results of this scholarly paper and proposal for a universal psychosocial yoga graphic handout for assisting in the treatment of chronic pain will help improve mental health. This paper will use the research found for best practices for cross-cultural education.

Summary of Scholarly Work

Chronic musculoskeletal pain is a common problem worldwide, being among the top ten most prevalent diseases (Sá et al., 2019). Musculoskeletal conditions include more than 150 different diagnoses that affect one's body (Briggs et al., 2018). Current reports on its prevalence in developing countries are diverse (Sá et al., 2019). Chronic musculoskeletal pain is mainly associated with headaches, migraines, lower back pain, and neck pain. Lower back pain and migraines ranked in the top five causes of people living with a disability in middle- and high-income countries (Sá et al., 2019). Maintaining musculoskeletal health is critical for normal human function, mobility, dexterity, and ability to work and participate in daily life (Briggs et al., 2018). With that said, musculoskeletal health and chronic pain often lead to a decline in one’s mental health (Briggs et al., 2018). More specifically, chronic pain and musculoskeletal pain are a common problem that has a profound impact on an individual’s life and society as a whole (Mills, Nicolson, & Smith, 2019).

Recent data shows that one in two adults in America lives with a musculoskeletal condition, and this is equal to the rate of cardiovascular and chronic respiratory disease, which cost the United States 213 billion dollars in 2011 (Briggs et al., 2018). There have been a relatively small number of studies done to assess the prevalence of chronic pain in developing countries. Sá et al., (2019) did twelve studies which included 29,902 individuals, and 7,263 individuals were identified to have chronic pain. Out of these studies, the percentage of individuals with chronic pain in developing countries ended up being 18%, according to the study (Sá et al., 2019). Being able to measure the prevalence of chronic pain in developing countries has clear advantages, as this provides supporting information for the guidance of healthcare, where there are limited resources.

Mental health is a leading cause of the global burden of disease, and the resources for mental health services in developing countries remain very limited (Gilbert, Patel, Farmer, & Lu, 2015). Mental health disorders account for about 8% of the global burden of diseases, affecting as many as 700 million people worldwide (Gilbert, Patel, Farmer, & Lu, 2015). It is common for a patient to feel sad or depressed after a big life change or if they are trying to manage a chronic condition like pain (National Institute of Mental Health, n.d).

Yifeng et al., (2020) did an investigation concerning mental and physical comorbidity with chronic back or neck pain in the Chinese population. The investigation assessed the prevalence of chronic neck and back pain with the onset of mental disorders. Chronic physical conditions were addressed by self-report. Mental disorders were assessed by the Composite International Diagnostic Interview (CIDI). Role disability during the past 30 days was assessed with the World Health Organization Disability Assessment Schedule. The 12-month prevalence of chronic back or neck pain was 10.8%. Most people with chronic back or neck pain reported at least one other comorbid condition, including other chronic pain conditions (53.4%), chronic physical conditions (37.9%), and mental disorders (23.9%) (Yifeng et al., 2020). It was found that there is a strong association between chronic back or neck pain and anxiety disorders. Chronic back or neck pain and physical-mental comorbidity is very common in China and chronic back or neck pain may increase the likelihood of other physical and mental diseases. This presents a great challenge for both clinical treatment and public health education (Yifeng et al., 2020).

Pharmacological and physical interventions are typically the first line of treatment for managing pain, however, in developing countries, this is not always an option. Psychosocial interventions have commonly been used in developed countries for treating pain. They have been incorporated alongside medical treatment and play a big role in helping patients adjust to the pain, cope with feelings of distress, sadness, or depression, and ensure adherence to medication (Portelli,2018). The most commonly used psychological interventions are behavioral treatments, cognitive therapies, cognitive behavior therapy, hypnosis, biofeedback, relationship and distraction, and emotional freedom techniques (Portelli, 2018). Using these techniques can help instill a sense of control and empowerment in a person, making them more likely to continue treatment (Portelli, 2018).

Problem

There are many barriers identified to the lack of treatment for chronic pain and mental health in developing countries. Kprinak (2015) notes that "According to the World Health Organization (WHO), mental health is a state of well-being in which every individual can realize his/her potential, and can cope with the normal stressors of life, work, and make a contribution to their family and community”. Mayo Clinic (2019) notes “Mental illness refers to a wide range of mental health disorders that affect mood, thinking, and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors”. There is a large treatment gap for mental health care in low- and middle-income countries, where most people with a mental, neurological, and substance abuse diagnosis receive little or no care (Thornicroft & Sermrau, 2019). A countries’ healthcare system plays a crucial role in determining the countries are overstretched due to the higher burden of disease in their population and lower availability of human and financial resources (Thornicroft & Sermrau, 2019). Three-quarters of the global disease burden is due to mental health disorders, and 8.9% of the disease burden in low- and middle-income countries is due to mental health disorders (Thornicroft & Sermarau, 2019). An average of 1.9% of the healthcare budget in low- and middle-income countries is allocated to the treatment and prevention of mental health disorders (Thornicroft & Sermarau, 2019). Thornicroft & Sermarau (2019) stated "A large multi-country survey showed that 76%- 85% of people with a mental health disorder in low-income countries had not received treatment in the previous 12 months, this lack of treatment increases the rate of disability and suicide".

There has been a long-term disagreement on the exact causes of mental illness, which has led to a variety of treatments being used. There has been an increase in global health aid agencies to encourage and support national governments to move toward strengthening mental health care in developing countries (Kopinak, 2015). One organization that has recently been developed is called Emerald. Emerald is an international program that aims to improve mental health outcomes in six low -and -middle-income countries by generating evidence and capacity to enhance health system performance, thereby improving mental health services (Thornicroft & Sermarau, 2019). Emerald is working in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. These countries all are facing mental health challenges, such as weak government, low resources, and poor information systems (Thornicroft & Sermarau, 2019). Some challenges Emerald is facing are inadequate resources, limited financing, poorly trained staff, lack of understanding about the education of mental health, low level of empowerment, and the marginalization of service users and caregivers (Thornicroft & Sermarau, 2019).

Not only are there challenges being faced with the treatment of mental illness, but there is also a stigma around it. Studies have suggested that developing countries exhibit a fear, shame, and stigma directed toward mental disorders (Seeman, Tang, Brown, & Ing, 2016). Shame and fear will lead to social distancing, which can result in isolation, lack of employment, avoidance of seeking help, poor adherence to treatment and poor health.

While mental health faces some significant barriers, we are also facing barriers regarding the treatment and diagnosis of chronic pain. Chronic pain is the leading cause of disability globally (Kohrt, Griffith, & Patel, 2018). In low- and middle-income countries people have greater exposure to road injuries, interpersonal and political violence, unregulated manual labor, and limited access to healthcare (Kohrt, Griffith, & Patel, 2018). Unfortunately, health care services to address pain are inadequate in low- and middle-income countries where the majority of people with chronic pain reside. However, improving access to medication is vital, and multidisciplinary, and multidimensional approaches demonstrate a better outcome (Kohrt, Griffith, & Patel, 2018). This is why it is important to consider the role of psychosocial interventions because psychological distress is one of the prime mediators for the relationship between chronic pain and disability (Kohrt, Griffith, & Patel, 2018).

Intended Improvement

This research study will evaluate the relationship of mental health in association with chronic musculoskeletal pain in developing countries. It will consist of two phases. Phase I is a proposal of a psychosocial yoga graphic handout that can be used to help with managing chronic musculoskeletal pain and mental health in developing countries. Phase I will also include the development of a power point presentation for students and faculty regarding best practices for cross cultural education, chronic pain, mental health, and development of a pre and post-test for students on the topic. Phase II is the implementation of the psychosocial yoga graphic handout. In phase II the students of GHP will receive a PowerPoint presentation, which will be about chronic pain, mental health, and treatment in developing countries. Students will also be given a pre-test before this presentation to determine their knowledge of these issues. Students will be trained on how to use the psychosocial yoga graphic handout on all future GHP trips, and this training will entail a simulation lab on how to properly perform these exercises and stretches.

On the trip, students will be expected to provide education to local patients on how to perform these exercises and be able to evaluate the effectiveness of the exercises. Students and faculty will be using a teach-back method with the developing countries’ population. Upon return, students will be given a post-test to evaluate their experience and determine if their knowledge base has grown based on their experience.

Through the review of the literature for this study, barriers to success will be identified as well as strategies recommended to overcome these barriers. During Phase II, training for students and faculty will be implemented. Both chronic pain and mental health education will be provided for faculty and students. Faculty and students should be aware of chronic pain and mental health and the prevalence within the culture they are traveling to. Requirements for this program and toll will include student evaluation, time requirements, and expectations will be set for students and faculty. During Phase II, this education will be implemented for all future occurring GHP trips. The effectiveness of knowledge gained from students will be evaluated after every trip.

Study Question:

1. What is the relationship between mental health and chronic pain in developing countries?

2. What is the relationship in pre-test/post-test scores between a traditional lecture vs. simulation venue of understanding basic Yoga Knowledge and Application by Global Health Students at Denver College of Nursing (DCN)?

3. What is the knowledge of faculty going on the mission with the GHP students regarding Yoga in relation to chronic pain and mental health?

Chapter 2: Literature Review

A literature review was conducted using the search terms of "mental health, developing countries, low-income countries, chronic pain, middle-income countries”, and “lower back pain". The publication date searched was from 2015 to 2020. The online databases used were Pubmed, Medline, and Google Scholar. Approximately 200 articles were located. Inclusion criteria were peer-reviewed, scholarly journals. The articles had to discuss chronic pain rates, mental health rates, correlation of mental health and chronic pain, treatment of chronic pain, or mental health. Twelve articles were chosen that met these criteria. See the reference list for the full citation of the scholarly articles utilized.

Most of the articles discussed the impact of chronic pain in developed and underdeveloped countries and their relationship to mental health. Chronic pain is the leading cause of years lived with disability globally (Kohrt, Griffith, & Patel, 2018). Populations in low- and middle-income countries have a higher rate of chronic pain due to greater exposure of road injuries, interpersonal and political violence, unregulated manual labor, and limited access to health care (Kohrt, Griffith, & Patel, 2018). Mental disorders are a leading cause of the global burden of disease (Gilbert, Patel, Farmer, & Lu, 2015). Mental health and substance use disorders account for approximately 8% of the global burden of disease, which accounts for about 700 million people worldwide (Gilbert, Patel, Farmer, & Lu, 2015). There are many barriers identified in the low treatment of chronic pain and mental health.

The main barriers are identified in the literature. Social factors such as poverty, urbanization, internal migration, and lifestyle changes all have an impact on mental and physical health. There are also demographic impacts such as age, sex, and family history that play a role. Developing countries also face the lack of available health care, the stigma behind mental health, poor governance, and greater exposure risk to hard physical labor and accidents. Not only are resources slim in developing countries, but cultural and religious attributes of illness and belief systems influence treatment behaviors and complicate access to services and outcomes for mental health (Rathod et al., 2017).

There is a significant treatment gap for mental health in developing countries, the majority of people with a mental health or substance abuse diagnosis receive little to no care (Thornicroft & Sermrau, 2019). A countries’ healthcare system plays a big role in the coverage their country provides for mental health and how effective it will be. More common than not, developing countries are overstretched due to the high burden of disease in their population and lower availability of human and financial resources (Thornicroft & Sermrau, 2019).

Not only does mental health face significant barriers, but there are also barriers to treatment and diagnosis of chronic pain. Chronic pain is the leading cause of disability globally (Kohrt, Griffith, & Patel, 2018). As mentioned above, in developing countries, people have greater exposure to road injuries, interpersonal and political violence, unregulated manual labor, and limited access to healthcare (Kohrt, Griffith, & Patel, 2018). In developing countries, health care services to address and treat pain are inadequate.

Kohrt, Griffith, & Patel (2018) discussed the relationship between chronic pain and mental health as a global problem. This author identifies that pain is the leading cause of disability globally. The review focuses on the burden of chronic pain in developing countries and why populations in developing countries are at a higher risk of developing chronic pain. The author talks about how using psychosocial interventions for the treatment of chronic pain should be used. Not only would psychosocial interventions help in the treatment of chronic pain, but also at improving one's mental health (Kohrt, Griffith, & Patel, 2018). Using psychosocial interventions would help with the burden of chronic pain, which will reduce the risk of over-utilization of opioid medications globally (Kohrt, Griffith, & Patel, 2018).

Yifeng et al., (2020) did an investigational study concerning mental and physical comorbidity in relation to chronic back or neck pain in the Chinese population. The investigation assessed the prevalence of chronic neck and back pain with the onset of mental disorders. Chronic physical conditions were addressed by self-report from patients (Yifeng et al., 2020). Mental disorders were assessed by the Composite International Diagnostic Interview (CIDI) (Yifeng et al., 2020). Role disability during the past 30 days was assessed with the World Health Organization Disability Assessment Schedule. The 12-month prevalence of chronic back or neck pain was 10.8%. Most people with chronic back or neck pain reported at least one other comorbid condition, including other chronic pain conditions (53.4%), chronic physical conditions (37.9%), and mental disorders (23.9%) (Yifeng et al., 2020). Yifeng et al., (2020) found that there is a strong association between chronic back or neck pain and anxiety disorders. Chronic back or neck pain and physical-mental comorbidity is very common in China and may increase the likelihood of other physical and mental diseases. This presents a great challenge for both clinical treatment and public health education (Yifeng et al., 2020). Ultimately, this study showed that the need for awareness and education around chronic pain and mental health conditions is needed in both developed and underdeveloped countries.

Seeman, Tang, Brown, & Ing (2016) proposed strategies for strengthening the mental health systems in developing countries that have arisen out of the work of the Emerald research program in in low- middle-income countries. This 5- year program was aimed to improve mental health outcomes in six developing countries in Africa and Asia. It helped with building capacity and generating evidence to enhance health system strengthening. The ultimate goal of this program was to assist in reducing the mental health treatment gap. Approximately 75% of people in developing countries do not receive any form of treatment or care for their mental health disorder, and approximately 95% receive inadequate? treatment in general (Seeman, Tang, Brown, & Ing, 2016). This study showed that there is a continued need for advocacy to enhance mental health services in developing countries.

Gilbert, Patel, Farmer, & Lu (2015) assessed the need for investment in global mental health. Mental illness and substance abuse account for approximately 8% of the global burden of disease, impacting as many as 700 million people worldwide. This study showed that mental health and substance abuse disorders are the third leading cause of disability, which is more than cardiovascular disease and cancer. The WHO reports that 75% of people with mental disorders live in low- or middle-income countries, and most don't have access to any kind of care, despite cost-effective pharmacological, psychological, and social interventions (Gilbert, Patel, Farmer, & Lu, 2015). This study reported that in 2011, on average, low-income countries devote 0.5% of their health budget to mental health (Gilbert, Patel, Farmer, & Lu, 2015). According to this study, a growing body of evidence shows that effective interventions could be integrated into the existing health systems in low-income countries to improve the mental health care (Gilbert, Patel, Farmer, & Lu, 2015).

Briggs et al., (2018) show the burden of musculoskeletal conditions globally. Musculoskeletal conditions include more than 150 different diagnoses that affect the locomotor system. These conditions are characterized by pain and reduced physical function, which can lead to a decrease in mental health. Musculoskeletal conditions account for the greatest number of persistent pains with all ages and geographies. Musculoskeletal health accounted for 61.4% of the global disability-adjusted life years (DALYs) in 2016, compared to 43.9% in 1990 (Briggs et al., 2018). The majority of this rise was witnessed in developing countries. This shift shows the importance of focusing on healthcare from curative to promotive, preventive, and rehabilitative health care in low- and middle-income countries. This study showed that musculoskeletal conditions were ranked second highest for years lived with a disability in 2016 (Briggs et al., 2018). Ultimately, there is likely an underestimate of the true burden of musculoskeletal health conditions. Most importantly, this study noted that it is important to address health concerns as a whole, this includes mind and body.

Koyanagi, Stubbs, & Vancampfort (2018) review the correlation of low physical activity across low- and middle-income countries, in a cross-sectional analysis of community-based data. Physical inactivity accounts for 5.5% of all avoidable global deaths (Koyanagi, Stubbs, & Vancampfort, 2018). This study utilized an International Physical Activity Questionnaire (IPAQ) and participants were split into those who do and do not comply with physical activity recommendations. The study found that physical co-morbidities might be direct barriers to physical activity or associations that might be mediated by feelings of depression, cognitive problems, and sleep/energy problems (Koyanagi, Stubbs, & Vancampfort, 2018). The data also showed that depression is an important factor that is negatively associated with physical activity participation amongst males 18-64 years of age (Koyanagi, Stubbs, & Vancampfort, 2018). However, being able to help people that suffer from depression become active is important because it has been demonstrated that physical activity can reduce symptoms of mild, moderate, and severe depression (Koyanagi, Stubbs, & Vancampfort, 2018).

Mills, Nicolson, & Smith (2019) did a review of chronic pain and its epidemiology and associated factors in population-based studies. Chronic pain is a complex and distressing problem that can have a significant impact on one's life. Chronic pain frequently occurs as a result of disease or an injury. Chronic pain is its condition with its medical definition. This study looked at the distribution and determinants of chronic pain and allowed understanding and treatment of the problem. The prevalence and incidence of chronic pain were looked at. The research suggested that chronic pain affects 13-50% of adults in the UK (Mills, Nicolson, & Smith, 2019). Out of this number, 10.4-14.3% were found to have moderate to severely disabling chronic pain (Mills, Nicolson, & Smith, 2019). This review looked at multiple factors that are associated with chronic pain, such as physi