The Stigmatization of Clarity (Homeworker Helper)
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This impression was supported by the experts who thought the story was unrepresentative of many presentations in Lebanon and should be toned down to respond to a wider scope of mild-to-moderate depression or higher functioning. In Lebanon, people tend to have severe anxiety and usually say: I'm angry, I'm furious, I'm sad, I'm bored, I'm scared rather than I'm helpless, I'm tired, I'm miserable; they keep active but are anxious.
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Additional recommendations about the context and local understanding of mood problems were raised by the participants of the different nationalities. They suggested to add financial problems, stressful work conditions and violence as prominent community problems that might lead to people being depressed. Recommendations were also given at the level of the text whereby participants suggested different wording translations and metaphors that would appeal better and depict distress and recovery.
The study team was very aware of the heterogeneity of populations across Lebanon and globally who may use this intervention e. In the illustrations brief, it was important to specify that illustrations should not include cues targeting one group over another as possible. For example, for depicting adversity and distress, the distressing situation is left interpretable see Fig. Example illustrations of distressing situations.
Images reproduced with permission from WHO. All participants accepted the illustrations but suggested amendments to the facial expressions of the characters in the story to make them more realistic. One comment concerned a particular hand gesture of the main character, along with the background colour bright orange. Participants stated that the gesture in combination with the colour referred to a certain political sign and colour used by a Lebanese political party see Fig. Example of how the colours and hand gesture were changed after adaptation. As part of the behavioural activation component of the intervention, activities are suggested with the main character in the story carrying out activities that will improve his or her mood.
Gender specialists at the WHO reviewed the story and highlighted areas where activities were particularly gendered, e. Some changes were made in reaction to this review e. However, the local team and participants of FGDs highlighted that gendered activities listed above were the reality in Lebanon and that the story should remain realistic to local norms for people to be able to relate to it.
The final story was seen to broadly achieve a balance between removing unhelpful gender stereotypes while remaining realistic to the local situation. Community participants, as well as health professionals recommended to start with the enjoyable self-care activities first, before doing necessary life activities, which are sometimes a stress factor for people in their community. They also highlighted the fact that people living in Lebanon needed to stop and pause for a while, and think about themselves. Most participants embraced the idea of encouraging people to gain social support and take some rest without feeling guilty about it as being very busy was very often discussed see Fig.
The new version shows the main character not in a state of inactivity, but continuing with normal activities but in a depressed mood. Participants reviewed the story and a table of activities and commented on each of them.
Strong opinions were held in support or against certain activities. An important point was highlighted by the Syrian women and men, who clarified that most Syrian women did not enjoy a high level of independence to go out of their houses alone, thus the example of the woman going out for a walk alone was not perceived as feasible to them. Participants suggested simple indoor self-care activities in sessions 1 and 2, like changing one's appearance and clothes from time to time, personal hygiene, praying, gardening for both genders, reorganizing or tidying the house for women, playing football or exercising for men.
Outdoor more complex activities suggestions included going out with friends, spending time in nature, shopping, exercising, fishing, swimming, organizing a family trip, etc. A renowned topic for addition in all FGDs was that religion was an important component in people's lives and could be added as a solution to help against distress.
Table 2 in Appendix 3 has examples of how activities were changed after cognitive interviewing. You should stress a lot on religion and advice people to listen to prayers, talk about the importance of faith across all religions, faith gives strength. Lebanese Women. The examples below show how illustrations were changed based on the feedback generated, whereas other aspects of the intervention that were changed, are shown in Table 3 in Appendix 4. In this section, participants were asked to discuss the feasibility of Step-by-Step delivered via technology; thus, the feasibility, the length of sessions, the pace of the intervention, the setting preferences, privacy concerns and the support methods were discussed.
Despite the perceived relevance of the intervention, the feasibility of delivering Step-by-Step via e-platform was debatable. When asked whether it would be practical to use the intervention, answers varied among the different groups. Also, the wide availability of mobile phones and Internet coverage in all households, even the most vulnerable ones, and the time and place flexibility associated with it, were considered as encouraging factors.
Nevertheless, all Lebanese men noted that despite the friendliness of such an intervention and its flexibility, the slow and low quality of Internet connection might be a huge challenge for usage of such an intervention, whereas the majority of Lebanese women were more concerned about their very busy lifestyle and the length of sessions.
A big proportion of the Syrian women and men had different concerns though; they mentioned that the main barrier for using an e-intervention was their illiteracy or electronic device illiteracy especially older adults , and the majority of Syrian women stressed the fact that they did not have access to a phone most of the time as it is shared with their husband. These factors were also foreseen by the majority of the front-line workers. Lebanese, Male. With few exceptions, most participants had the impression that the sessions were too long and repetitive, and that there was more focus on symptoms and unnecessary details of the story rather than on solutions.
Syrian, Male. Some participants expressed that users might need more than a week to transition from one session to another and might need reminders to complete the sessions. It's very difficult to get out of the sad phase in 1 or 2 weeks, this needs more time. Preferred place of usage e. Most participants preferred to use Step-by-Step on their own phones instead of using tablets provided in the PHCCs for convenience and privacy and due to lack of time.
I don't have time to come to the center to user it, especially that I can use it on my phone at home, on my convenience. Lebanese, Female. Lebanese and Palestinian participants reported that they did not have any problem using Step-by-Step and providing their contact information, while Syrian men and women and some Lebanese participants in the North area were more sceptical about it and declared that they might put fake numbers as they feared being spied on by certain agencies.
Participants recommended the project to be disseminated through the local PHCCs because they are trusted, and to put the MoPH logo so that it adds credibility to the intervention. This is reflected in the following statement:. Some people might not like to enter their number, especially that there is an unknown organization involved and our information would be stored there.
We would trust the MoPH better. Lebanese women in the North. When asked about the e-helper support, participants preferred to get an introductory call instead of an email, to get a notification before the call from the e-helper, and to get the number of the e-helper who would call them in advance.
This finding was stressed particularly when phones were shared with spouses mainly for Syrians.
Male and female participants reported being less desirable husbands or wives if their partner should find out they had emotional problems. But trying to keep the identity of the caller from their partner could raise questions about their fidelity and even put them at risk of gender-based violence. Syrians preferred to get phone calls and talk to the e-helper, while some of the Lebanese preferred messages only. Through carrying out in-depth cognitive interviewing with community members, mental health professionals and front-line primary health care staff, valuable information about the content, implementation and the prospective use of the WHO Step-by-Step programme was gathered and used to adapt the intervention to enhance cultural acceptability among different groups in Lebanon.
The methods used for the adaptation of Step-by-Step are not dissimilar to other methods used for gathering data to inform adaptation of psychological interventions in low- and middle-income countries. In a paper providing an overview of the procedures adopted by three such studies, the wider Step-by-Step project somewhat parallels the methods of these research teams in drawing upon the UK Medical Research Council framework for the design and development of complex interventions Patel et al.
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This is by using a multi-phase approach exploratory or formative work on context, feasibility and piloting with process evaluation before definitive testing , of which this study entails part of the first phase. We have used a systematic and documented approach to gathering data for adapting the intervention, engaging a broad range of stakeholders including health workers and community members and previous to this research phase, a number of Lebanese mental health service providers and public mental health academics for their inputs on intervention development and project planning Patel et al.
During the adaptation workshop based on the qualitative data, the team made decisions about what characteristics and content to revise while maintaining the fidelity of the intervention. One very important adaptation referred to how symptoms of depression were explained in the intervention.
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From our results, we cannot conclude whether this presentation of symptoms corresponds to an emic cultural concept of distress Kohrt et al. It may also be that due to the low socio-economic status of many people in a middle-income country such as Lebanon, inactivity is not an option because people have to secure their livelihoods. Ethnographic research on cultural concepts of distress would be required to better understand this concept. Similarly to the content, decisions pertaining to the delivery method of Step-by-Step were made and are detailed in Table 3 of Appendix 4.
Given the range of views on acceptability of the support element of Step-by-Step, one main decision was to give the choice to the participants to choose their preferred method of contact phone, email, chat , their preferred day and time. This is to prevent any breach of privacy, confidentiality and any intrusiveness of the support.
We did not find a preference for traditional methods of healing as some studies suggest: Karam et al. However, our findings parallel results from a systematic review which identified a preference for directive and authoritarian approaches to care, mirrored in our focus groups by the preference of a doctor figure who is prescriptive and directive Gearing et al.
Our findings also dovetail with the barriers identified in this systematic review, such as lack of awareness around mental health, gender issues and stigmatization of people with mental health problems. Using community members from the cultural group 1 is adapting to, as was done for this adaptation, is said to be the best way to arrive at the most contextually appropriate revisions of psychological interventions Hall et al. A recent and large meta-analysis found that most cultural adaptation methodologies take a top-down methodology to adapt interventions, with just four out of 78 studies adapted interventions using a bottom-up, or community-driven approach Hall et al.
A strength of the present study is that it adds to the literature in a context of a lack of published accounts of bottom-up cultural adaptation practices in the region.
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Furthermore, we ensured that the three main cultural groups in Lebanon were involved, that is Lebanese, Syrian and Palestinian men and women. This cognitive interviewing had several limitations. First, we recruited participants through primary health care services, which may have biased our results towards opinions that are compatible with medical health care seeking and therefore not including people more inclined to seek traditional forms of care.
Second, the final decision makers as to adaptations did not include Palestinians nor Syrians. Third, though we did engage target community members, for ethical reasons, we did not use target community members who had common mental disorders, so we could have gone one step further with our ecological validity.
We did however try to include the local mental health perspective by getting feedback from local mental health experts and from PHCC staff.