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Costa et al. BMC Health Services Research 2014, 14:49 RESEARCH ARTICLE Factors associated with quality of services for marginalized groups with mental health problems in 14 European countries Open Access
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Costa et al. BMC Health Services Research 2014, 14:49 RESEARCH ARTICLE Factors associated with quality of services for marginalized groups with mental health problems in 14 European countries Open Access Diogo Costa 1,2*, Aleksandra Matanov 3, Reamonn Canavan 4, Edina Gabor 5, Tim Greacen 6, Petra Vondráčková 7, Ulrike Kluge 8, Pablo Nicaise 9, Jacek Moskalewicz 10, José Manuel Díaz Olalla 11, Christa Straßmayr 12, Martijn Kikkert 13, Joaquim JF Soares 14, Andrea Gaddini 15, Henrique Barros 1,2 and Stefan Priebe 3 Abstract Background: Different service characteristics are known to influence mental health care delivery. Much less is known about the impact of contextual factors, such as the socioeconomic circumstances, on the provision of care to socially marginalized groups. The objectives of this work were to assess the organisational characteristics of services providing mental health care for marginalized groups in 14 European capital cities and to explore the associations between organisational quality, service features and country-level characteristics. Methods: 617 services were assessed in two highly deprived areas in 14 European capital cities. A Quality Index of Service Organisation (QISO) was developed and applied across all sites. Service characteristics and country level socioeconomic indicators were tested and related with the Index using linear regressions and random intercept linear models. Results: The mean (standard deviation) of the QISO score (minimum = 0; maximum = 15) varied from 8.63 (2.23) in Ireland to (2.07) in Hungary. The number of different programmes provided was the only service characteristic significantly correlated with the QISO (p 0.05). The national Gross Domestic Product (GDP) was inversely associated with the QISO. Nearly 15% of the variance of the QISO was attributed to country-level variables, with GDP explaining 12% of this variance. Conclusions: Socioeconomic contextual factors, in particular the national GDP are likely to influence the organisational quality of services providing mental health care for marginalized groups. Such factors should be considered in international comparative studies. Their significance for different types of services should be explored in further research. Keywords: Mental health services, Quality index of service organization, Socially marginalized groups, Multi-level analysis * Correspondence: 1 Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Alameda Prof Hernani Monteiro, Porto, Portugal 2 Institute of Public Health, University of Porto, Rua das Taipas, 135, Porto, Portugal Full list of author information is available at the end of the article 2014 Costa et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. Costa et al. BMC Health Services Research 2014, 14:49 Page 2 of 12 Background Risk factors for poor mental health, including social marginalisation, are particularly common in large capital cities [1,2] and these environments deserve more focus in comparative studies on the provision of care for marginalized groups [3]. It has been suggested that comprehensive services addressing a range of different needs might be more efficient in delivering care to marginalized groups with high prevalence of mental disorders, such as the homeless, refugees and asylum seekers, Roma populations, sex workers and the long-term unemployed [4-9]. However, variation in the provision of health services, especially for vulnerable groups, can be attributed not only to the type of clients the units serve but also to the environment or broader context in which service is provided, as reflected in countries socioeconomic characteristics [10,11]. The current paper aims to: describe an Index developed to measure services organisation in the context of mental health care provided to socially marginalized people in Europe the Quality Index of Service Organisation (QISO); test how the characteristics of services are associated with this created Index; test how country socioeconomic indicators impact on the Index when comparing European capitals. Methods Good practices in mental health care for socially marginalized groups in Europe were identified through the PROMO project - Best Practice in Promoting Mental Health in Socially Marginalized People in Europe [12]. PROMO was designed to assess programmes and systems of services in 14 European countries providing mental health care to socially marginalized groups. Services were assessed in terms of their organisational characteristics, type of clients, components of care and funding arrangements, and how these services interconnect to form systems [12]. The study focused on the following six social groups: the long-term unemployed, the homeless, street sex workers, asylum seekers and refugees, irregular migrants and travelling communities. Data collection was conducted within highly deprived areas of the capital cities of the following 14 European countries: Austria, Belgium, Czech Republic, France, Italy, Germany, Hungary, Ireland, Netherlands, Poland, Portugal, Spain, Sweden and United Kingdom. A total of 28 highly deprived geographical areas, two in each participating capital city, were identified using local indices of public health and social deprivation. The population size of each area was intended to be between 80,000 and 150,000 inhabitants, with some flexibility to accommodate different local contexts. If chosen areas were too small, they were combined to achieve the target size. The selected areas were: Vienna: District 16 and District 20; Brussels: Schaerbeek & St Josse and Molenbeek; Prague: Prague 3 & 7 and Prague 8; Paris: Secteur Flandre in the 19th arrondissement of Paris and La Courneuve & Aubervilliers in Seine-Saint-Denis; Berlin: Wedding and Kreuzberg; Budapest: District 8 and District 7 & 9; Rome: District 7 and District 15; Dublin: Dublin North Central and Dublin West; Amsterdam: Bos en Lommer & De Baarsjes & Geuzenveld-Slotermeer and Amsterdam Zuid Oost; Warsaw: Praga Polnoc and Wola; Lisbon: Marvila & Santa Maria dos Oliváis and a group of smaller areas (Anjos, Castelo, Encarnação, Graça, Madalena, Mercês, Pena, Penha de França, Santa Catarina, Santa Engrácia, Santa Justa, Santiago, Santo Estêvão, Santos-o- Velho, São Cristóvão e São Lourenço, São José, São Miguel, São Nicolau, São Paulo, São Vicente de Fora, Sé, Socorro); Madrid: Villaverde and Centro; Stockholm: Rinkeby-Kysta & Spånga-Tensta & Skarpnäk and Sodermalm; London: Hackney and Tower Hamlets [13]. The aim was to assess all mental health, social care and general health services that potentially serve marginalized groups with mental health problems. Their organisational characteristics and components, including the type of provider, funding, accessibility, routine data collection, characteristics of staff and programmes provided to people with mental disorders from the marginalized groups were assessed using the PROMO Tool for Assessment of Services (available online) [14]. This structured questionnaire was developed through a Delphi process involving experts from the 14 countries. An online platform was developed to facilitate exchange of information amongst participants involved in this process. The final version of the instrument was translated into the languages of participating countries and three pilot interviews were conducted in each capital to assess applicability and suitability. Data collection was focused on the two identified deprived areas, however, services located outside these areas were also assessed if they were used by clients from the target areas. Available directories and lists were used to identify relevant services, as well as information from local clinicians and experts. Service managers or a member of the staff with relevant knowledge were then contacted via , telephone or post, and invited to participate after a detailed explanation of the purpose of the study and its implications. They were assessed through face to face or telephone interviews. Ethical approval was not required for this study, as no patient data were collected. The services were classified on the basis of their primary focus of care (mental health, general health or social care services) and with regard to the population Costa et al. BMC Health Services Research 2014, 14:49 Page 3 of 12 groups they were serving (either specific to one or more of the PROMO groups or generic, i.e. not focussing on a particular population group). Out of 617 services assessed, 350 were generic services (221 mental health care, 84 social care and 45 general health) and 267 were group-specific services (51 mental health care, 187 social care and 29 general health), (Table 1). Despite the existence of a common protocol for conducting assessments with managers or relevant staff, including numerous reminders for gathering information, some missing information still persisted for variables from all capital cities. The Quality Index of Service Organisation score (QISO) The QISO was developed to facilitate identification of organisational good practice in the context of providing mental health care for socially marginalized people. Its components were defined by the multidisciplinary team of experts involved in the PROMO consortium. The experts professional backgrounds were in mental health and social care, public health and social sciences, encompassing both clinical and research expertise. The team of experts discussed and refined each potential quality indicator and its contribution to the overall index score until a consensus was reached on a final set. Evidence generated within the scope of this and other projects in which participating experts were involved was taken into account when developing the QISO [15,16]. This, in turn, resulted in different weightings of each component as a reflection of their importance to the provision of care to marginalised groups. An emphasis was put on self-referrals as the overall service accessibility and networking were highlighted in other PROMO data and in the findings of previous studies on the provision of care in the context of marginalisation. Clinicians working in deprived areas struggle to find adequate services to provide relevant care to the individuals from marginalised groups, with service coordination often being insufficient [13,15]. Amongst the four components of good practice identified in 154 interviews with experts from the 14 capital cities, three directly relate to access and referrals, specifically, facilitating access to services that provide different aspects of health care (reducing the need for further referrals), strengthening the collaboration and co-ordination between different services, and disseminating information on services both to marginalised groups and to practitioners in the area [13]. Therefore, information concerning service organisation comprised indicators covering six domains, with final organisation scores ranging from 0 to a possible maximum score of 15. Quality provision domains and their contribution to the overall score were: accessibility (8), supervision (1), multidisciplinary team (1), programmes provided (2), coordination (1) and evaluation (2). Quality indicators within each domain correspond to specific service characteristics and account for up to two Table 1 Typology of services assessed Target population Primary focus of care Generic Group-specific Mental health Social care General health Austria 18 (5.1) 28 (10.5) 9 (3.3) 32 (11.8) 5 (6.8) France 41 (11.7) 21 (7.9) 31 (11.4) 11 (4.1) 20 (27.0) Hungary 4 (1.1) 1 (0.4) 1 (0.4) 1 (0.4) 3 (4.1) Poland 26 (7.4) 16 (6.0) 17 (6.3) 19 (7.0) 6 (8.1) Czech Republic 11 (3.1) 8 (3.0) 6 (2.2) 12 (4.4) 1 (1.4) Germany 79 (22.6) 50 (18.7) 53 (19.5) 66 (24.4) 10 (13.5) Italy 15 (4.3) 19 (7.1) 14 (5.1) 12 (4.4) 8 (10.8) Netherlands 24 (6.9) 13 (4.9) 23 (8.5) 14 (5.2) 0 Sweden 0 5 (1.9) 2 (0.7) 0 3 (4.1) Belgium 34 (9.7) 20 (7.5) 21 (7.7) 24 (8.9) 9 (12.2) UK 38 (10.9) 28 (10.5) 40 (14.7) 21 (7.7) 5 (6.8) Spain 6 (1.7) 11 (4.1) 6 (2.2) 11 (4.1) 0 Portugal 17 (4.9) 4 (1.5) 13 (4.8) 7 (2.6) 1 (1.4) Ireland 37 (10.6) 43 (16.1) 36 (13.2) 41 (15.1) 3 (4.1) Total Figures are n (%). Services were classified as either generic or group-specific, based on their target users: if more than 50% of the people using a service were from one of the marginalised group, the service was classified as specific for that group. Social care, mental health or general health service classification was based on service self-definition. In cases where it was not clear whether a service was mental health specific or generic, if 50% of clients were estimated to have a mental health problem the service was classified as a mental health service. Costa et al. BMC Health Services Research 2014, 14:49 Page 4 of 12 points of the score as detailed in Table 2. Accessibility includes indicators on service opening hours, the existence of exclusion criteria for clients, and accepting selfreferrals. Supervision refers to the provision of internal or external staff supervision of any type. Multidisciplinary team is defined as having staff with both mental health and social care professional backgrounds. Programmes provided refers to active outreach programmes and/or home visits to clients as well as case-finding. Coordination refers to services having routine meetings with other services. Finally, Evaluation includes indicators on recording data on input and attendance, as well as data on client satisfaction. Service-level variables In addition to service characteristics, which correspond to the indicators of quality of service organisation, a number of other service features were recorded during the PROMO assessments. In the current analysis, the total number of staff (measured in whole time equivalents, with the number of hours per week defined by each respondent according to his/her national norm) and the number of care programmes provided were used as service-level covariates, due to their importance to the quality of health provision, as asserted in the relevant literature [17], including mental health care studies [18]. Programmes were defined as specific health care or social interventions that each service potentially provides to their clients. Each service was assessed using a specific list of programmes: active outreach, casefinding, home visits, counselling, individual psychotherapy, group psychotherapy, self-help groups, occupational therapy, medication, detoxification and acute withdrawal treatment, drug addiction treatment, alcohol addiction treatment, direct practical help in clients homes, befriending, leisure activities support, mental health advocacy, social welfare support, housing/accommodation advice and support, legal advice and support, job coaching/finding, mental health promotion measures and any other programmes specified by the service being assessed. Country-level variables Three Eurostat country-level socioeconomic indicators were included and tested: the country Gross Domestic Product (GDP), the Material Deprivation rate and the Gini coefficient. The GDP is a commonly used measure for assessing a country s wealth or socioeconomic status, while the Gini coefficient is a measure of income inequality which has been correlated with the prevalence of poor health outcomes and mental disorders [19]. The Material deprivation rate was also chosen because of its direct relevance to the marginalized groups studied, and is considered as an ecological measure of country s burden of social marginalization [20-22]. The Gross Domestic Product per capita in Purchasing Power Standards (PPS) (2008) has been defined by Eurostat as the value of all goods and services produced Table 2 Quality Index of Service Organisation domains, constituting indicators, definition of indicators and their value to the overall score Domain Indicator Definition Value Accessibility Days open Open everyday Mon-Fri 1 Opening hours: a. Open outside Open anytime outside normal office hours (Mon-Fri) 1 normal office hours Opening hours: b. Open at Open at weekend (anytime) 1 weekend Exclusion criteria: a. Lack of No to lack of motivation 1 motivation Exclusion criteria: b. Command of No to command of language of the host country 1 language Exclusion criteria: c. Addictions No to addictions 1 Self-referrals Yes to self-referrals 2 Staff supervision Any supervision internal/external Yes to any supervision (internal/external) 1 Multidisciplinary team Programmes provided Coordination Evaluation Presence of multidisciplinary team Yes to any combination of mental health and social care professionals (at least one mental health and one social care professional) Active outreach/home visits Yes to active outreach or home visits 1 Case finding Yes to case finding 1 Routine meetings with other services Recording data on input, attendance and satisfaction Yes to routine meetings 1 Yes to recording data on input and attendance 1 Yes to recording outcome data on satisfaction and experience 1 1 Costa et al. BMC Health Services Research 2014, 14:49 Page 5 of 12 less the value of any goods or services used in their creation. The volume index of GDP per capita in Purchasing Power Standards is expressed in relation to the European Union (EU-27) average set to equal 100. A country index higher than 100 corresponds to GDP per capita higher than the EU average. Basic figures are expressed in PPS, a common currency that eliminates differences in price levels between countries, thus allowing meaningful volume comparisons of GDP between countries. This index is intended for cross-country rather than for temporal comparisons. The Gini coefficient (2008) as a measure of income inequality is conceptualised as the relationship of cumulative shares of the population arranged according to the level of equalized disposable income, to the cumulative share of the equalized total disposable income received by them. The highertheginicoefficient,themoreinequalityexists. The Material Deprivation rate by poverty status (2008) is the percentage of the population with an enforced lack of at least three out of nine material deprivation items depicting material living conditions, such as housing conditions, possession of durables, and capacity to afford basic requirements [23]. The term enforced lack refers to people wishing to possess items, but not being able to afford them and the items in question are part of a predefined economic strain and durables dimension. Economic strain refers to people not being able to afford to do things they would like to do, such as taking a week s annualholidayawayfrom home, paying a mortgage, rent, utility bills or hire purchase instalments, having a meal with meat, chicken or fish every second day, keeping their home adequately warm, or being able to face unexpected expenses. The durables dimension corresponds to enforced lack of items such as a colour TV, a telephone, a personal car or a washing machine [24]. Statistical analysis Quality index of service organisation distribution Descriptive statistics were computed for the QISO distribution across countries. T-tests and ANOVAs were computed to compare and relate types of services with the QISO. An exploratory factor analysis was also performed to test the QISO components and reliability and is presented in Additional file 1. Exploring factors associated with QISO Correlations between the QISO and the service and country level variables were computed. Unifactorial and multifactorial linear regression analyses were used to examine the association between services characteristics and the QISO. Exploring country differences in QISO With the li
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