Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Benefit or burden: introducing paraprofessional support staff to health visiting teams: the case of Starting Well

With increased public-sector funding to expand and improve frontline services, pre-existing skill shortages within key professional workforces have become more acute. One response to this has been to encourage the development of skill-mix approaches which allow tasks previously undertaken by professional staff groupings to be assumed by new paraprofessional employees. Within the UK National Health Service, one group of professionals who are being challenged to change their way of working in this way are health visitors. Starting Well, one of Scotland's four health demonstration projects, which was established in 2000 to bring about a step-change in child health within deprived communities in Glasgow, operated as a pilot for such a skill-mix model of health visiting. The project was evaluated using a multimethod approach that encompassed the study of both processes and outcomes. The present paper reports on a process evaluation of the project's implementation that addressed the rationale underlying the development of Starting Well's skill-mix approach and the challenges which this model faced in practice. The perceptions of both managerial staff (n=18) and those working in practice (n=33) were gathered using semistructured interviews which sought to elicit and test Starting Well's theory of change in relation to the use of paraprofessional staff. Two sets of interviews were conducted with each group of staff between 2001 and 2003. Two main types of challenge were identified: deploying potentially vulnerable members of staff; and co-management of paraprofessionals by the health service and a voluntary-sector organisation. A potential challenge identified from the literature, i.e. that of implementing a new role within an existing team, proved to be less problematic within Starting Well. These issues are discussed in relation to current policy and practice debates.     

Mental health literacy in religious leaders: a qualitative study of Korean American Clergy

Although religious leaders in ethnic minority communities are often the first point of contact for mental health needs, little is known about their mental health literacy. The aim of the current study was to explore the knowledge and beliefs about depression held by Korean American clergy, using a qualitative approach. The Gateway Provider Model (GPM) and Jorm's conceptualisation of mental health literacy served as a framework for the enquiry. Seventeen clergy members serving in Korean communities in two U.S. metropolitan cities participated in an individual in‐depth interview during the spring of 2013. Using the constant comparison method, the research team coded the data independently, compared and modified codes, and derived major categories and themes in consensus approach. Eight themes emerged from the interviews, and they were grouped into five categories: (i) the ability to identify the problem; (ii) knowledge about causes and risk factors; (iii) knowledge and beliefs about treatment; (iv) knowledge about resources and services; and (v) contextual factors. Despite some variations, a majority of the participants acknowledged that depression is an important issue in the Korean American community and felt a sense of responsibility for the well‐being of their community members. The findings highlight the need for mental health education and training for religious leaders in ethnic minority communities to help them properly respond to community mental health needs.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

Mental health promotion and non-profit health organisations

Health related non-profit organisations (NPOs) provide a potentially important but largely untapped role in mental health promotion in communities. This paper reports on a study investigating the activities and contributions made by NPOs to mental health and well-being. One hundred and eight NPOs based in the metropolitan area of Brisbane, Queensland, Australia, participated in a survey exploring agency activities that contribute to promoting mental well-being; factors that helped or hindered the organisation in engaging in mental health promotion activities and evaluation methods and processes. An index of key themes was developed and frequencies derived from categorical data. NPOs undertook five key types of activities to promote mental health and well-being: support provision (81%); service provision (59%); information sharing (52%); activities to promote well-being (24%); and advocacy (6%). Systematic evaluation of longer-term outcomes was rare, with most NPOs (72%) relying on informal feedback from clients. Human resources in the form of paid or volunteer workers were most frequently (58%) identified as contributing to the capacity of agencies to carry out mental health promotion activities. Training and education emerged as a substantive need (34%). NPOs are well placed to enhance resiliency in the context of ongoing health problems, disability or other adverse psychosocial circumstances that place people at risk of mental health problems. As such they constitute a significant resource for advancing mental health promotion goals. What is needed to extend the practice and evidence base in this area is training and skill development for NPO workers, along with larger-scale research conducted in collaboration with NPOs to assess the contributions and cost-effectiveness of the sector.     

A qualitative study exploring the benefits of involving young people in mental health research

Introduction

It is increasingly accepted that young people need to be centrally involved in research on issues that affect them. The aim of this study was to explore young people's perceptions of the benefits for them of being involved in mental health research and the processes that enabled these benefits.

Methods

Qualitative interviews were conducted by co-researchers (young people with lived experience and/or interest in mental health) with 13 young people (aged 13–24 years) who had experience of being involved in mental health research when they were between 11 and 16 years of age. Reflective thematic analysis was used to identify important aspects of young people's experiences.

Results

Four main themes were identified: (1) opportunity to have a meaningful impact, (2) opportunity to be part of a supportive community, (3) opportunity to learn and grow and (4) increasing opportunities for young people.

Conclusion

This study highlights young people's experiences of being involved in mental health research and identifies ways in which researchers can ensure that involvement opportunities bring benefits to both the young people and the research.

Patient or Public Contribution

This research was a response to issues raised by young people involved in research. The project was supported by co-researchers throughout, including design, data collection, analysis and write-up.     

Reflective supervision: A qualitative program evaluation of a training program for infant and early childhood mental health supervisors

Reflective supervision has been promoted as essential to the practice of infant and early childhood mental health. The authors employed a qualitative program evaluation of a four-month reflective supervision training, using focus groups with 34 supervisors from 26 publicly funded infant and early childhood mental health programs. Participants reported the training to be effective and impactful, particularly experiential components. Barriers to implementation included lack of buy-in from administrators, isolation when others in the agency were not familiar with the model, and job demands. Recommendations include adding a collective participation approach to training within agencies to support dissemination and sustainability.     

Case management in mental health services:the role of community mental health support teams

The progressive reduction in the numbers of hospital places available for people with mental health problems has led to an increasing demand on community support services. One response has been the development within social services departments of community mental health support teams, which employ largely unqualified staff who offer support to people with longer term mental health needs. The paper examines to what extent the practice of one authority's support teams reflects an appropriate ‘case management’ style of service, as developed in the USA to address the needs of long-term community patients. Key features of this approach are identified, and used as the basis of analysis of the support teams' practice in relation to 214 cases. It is concluded that a ‘case management’ model can be appropriate for work involving unqualified staff, provided that the service structure as a whole enables access to other skills as appropriate. Two specific risks are identified: firstly that the service is developed because of cost rather than appropriateness; and secondly that the service can rapidly become silted up with increasing numbers of people who need service of indefinite duration.     

'It's been really, really hard': a qualitative study of the health problems of people receiving emergency relief in Australia

The aim of the research reported in this paper was to explore the perspectives and insights of emergency relief recipients in relation to their complex health problems, which had contributed to their position of needing to seek emergency relief. The sample consisted of 20 adults aged between 19 and 51 years who had received emergency relief in a regional city in Victoria, Australia. Non-probability sampling was used, employing the convenience sampling procedure. A qualitative, exploratory research approach utilising in-depth interviews was selected to obtain data from the respondents. The method of data analysis used involved open, axial and selective coding. The main findings were that the participants experienced abuse and neglect in childhood, the effects of mental health problems, going without food, lack of access to and the high cost of health care, and the interactive aspects of health problems and poverty. Implications for policy and service delivery are outlined.     

Mental health problems and acculturative issues among married immigrant women in Korea: A qualitative study

ABSTRACT

Through this research the author explored immigrant women’s mental health problems with the goal of deepening understanding to develop a framework for preventing mental disorders and improving their mental health. A qualitative research design was used to examine the women’s lived experiences. The data were collected from February 2014 to October 2014. Twenty women were recruited from multicultural community service centers. Inclusion criteria were the ability to communicate and the absence of acute physical or psychological problems; participants were excluded if they were under 18 years old or separated. Individual in-depth interviews were conducted with participants regarding their experiences of living in Korean society. The data were analyzed using the grounded theory approach. A conceptual framework—Embracing Cultural Conflict Model—was constructed based on the personal–family–community context as well as the paradigm of the immigrant woman using eleven concepts. The conceptual framework suggests that multicultural programs and services should take into account a historical understanding of Korean society and family, address problem-solving strategies including improving mental health literacy, build support from both the Korean family and family of origin, and offer multicultural activities to satisfy homeland-related cultural needs.     

Using qualitative methodology to inform an Indigenous-owned oral health promotion initiative in Australia

Indigenous Australians experience poor oral health. Oral health perceptions among a group of rural-dwelling Indigenous Australians were explored so that a culturally appropriate, community-owned oral health promotion initiative might be developed. Focus group methodology was used, with prompt questions including oral health knowledge, oral health's role in general health, how community oral health had changed in recent times, the causes of poor oral health and ways to prevent poor oral health at a community level. Some 34 participants took part; age range 21-72 years. A core category emerged from the data and was labelled 'cultural adaptation'. Five sub-categories were also identified; 'lifestyle changes', 'oral health behaviours', 'barriers to dental care', 'impact of poor oral health' and 'oral health literacy'. Participants felt that historical legacy impacted on the oral health of community members, through continued practices of being told what to do, where to live and what oral health services were available to them. Participants perceived they had little power over their oral health or oral health care decisions. Findings from the focus group discussions were used in the development of a context-specific, oral health promotion initiative, which involved construction of an audiovisual tool in Phase I and a series of interactive, context-specific seminars focused on key issues raised in the focus groups in Phase II. Oral health promotion initiatives among rural-dwelling Indigenous Australians may be more successful if perceptions of the anticipated audience are considered in the design stage of such strategies.     

Young people's views of mental health education in secondary schools: a Scottish study

Background   This exploratory study used mixed methods to investigate young people's preferences in the delivery of mental health education and to investigate possible age and gender differences.
Method   Information was gathered about the delivery of mental health education in three secondary schools. Nine pupil focus groups were carried out to identify key themes which were then further developed and administered through questionnaires to a larger sample of 773 pupils.
Results   Gender and age differences were found in young people's preferences about who should deliver mental health education, and what, when, where and how this should be delivered.
Conclusion   Mental health education should reflect the needs of young people. Age and gender preferences should be considered when designing these programmes.     

Young people supporting parents with mental health problems: experiences of assessment and support

The explosion of interest in young people as carers over the last decade and a half conceals the fact that there are still no reliable estimates of the number of young people with caregiving responsibilities. This is even more problematic in circumstances where the 'looked after' person has a mental health problem. In this study, we reflect on what can be done to identify, assess and support young people in these circumstances. We draw on selected findings from a study that has been examining the constituents of good assessment practice in work with family carers supporting relatives with mental health problems. The study embraces different carer groups but this paper concentrates on the experiences of young carers at one study site where Barnardo's and partner organisations had developed a joint initiative targeting young people who are looking after parents and relatives with mental health problems. Following a review of the literature about young people as carers, the paper describes how Barnardo's worked to support them through its young carers projects. Based on face-to-face interviews with the young people (N = 10) caring for a mother with mental health problems, the main part of the paper provides an account of how they talk about, make sense of and evaluate the support they have received through this combined initiative. The findings underscore the value of one particular young carers project, and provide clues about what lessons may be transferable to other similar projects.     

Understanding adolescent mental health: the influence of social processes, doing gender and gendered power relations

Despite a well-documented gender pattern in adolescent mental health, research investigating possible explanatory factors from a gender-theoretical approach is scarce. This paper reports a grounded theory study based on 29 focus groups. The aim was to explore 16- to 19-year-old students' perceptions of what is significant for mental health, and to apply a gender analysis to the findings in order to advance understanding of the gender pattern in adolescent mental health. Significant factors were identified in three social processes categories, including both positive and negative aspects: (1) social interactions, (2) performance and (3) responsibility. Girls more often experienced negative aspects of these processes, placing them at greater risk for mental health problems. Boys' more positive mental health appeared to be associated with their low degree of responsibility-taking and beneficial positions relative to girls. Negotiating cultural norms of femininity and masculinity seemed to be more strenuous for girls, which could place them at a disadvantage with regard to mental health. Social factors and processes (particularly responsibility), gendered power relations and constructions of masculinities and femininities should be acknowledged as important for adolescent mental health.     

Mental health issues and resources in rural and regional communities: an exploration of perceptions of service providers

OBJECTIVE: To identify service providers' and community organisations' perceptions of the resources available to support people with mental illness and the unmet needs of this client group in rural Queensland. DESIGN: An exploratory study was undertaken involving focus group interviews across the study sites. SETTING: Five regional towns in rural Queensland. PARTICIPANTS: Ten to 14 members were recruited for each of the five focus groups. The groups represented a diverse mix of participants including health and community service providers and representatives from community organisations. Results: Participants identified gaps in services in relation to health, employment and education, housing and accommodation, transport and social inclusion and health promotion. Inter-service communication and inappropriate funding models were themes affecting service delivery. CONCLUSIONS: Specific service issues of housing and transport were identified to be particularly problematic for people with mental illness across all towns. Intersectoral communication and funding models require further research.