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PubMed2003

'Follow the Fish': involving young people in primary care in Midlothian.

OBJECTIVES: The project aims were to enable young people to contribute their views about health services, to encourage professionals and policy makers to listen to the young people and to stimulate action to address the issues raised. DESIGN: Peer interviews were undertaken by a team of five young people to identify the experience and views of young people of various ages about health services. Drama workshop sessions were conducted with 10-15 young people, encompassing initial issue-identifying activities and group discussion about their own experience of, and views about health services, followed by role-play and improvisation to construct drama scenarios about the issues gathered from the interviews and discussions. SETTING AND PARTICIPANTS: Twenty young people aged 12-16 years from the Mayfield and Gorebridge areas of Midlothian were recruited from Newbattle Community High school. The project was conducted as a voluntary after-school activity for 12 weeks. RESULTS: A drama was constructed from research conducted by young people into the experiences and views of their peer group about health services. A cast of young people performed the drama to an invited audience of 30 health and education professionals and held a post-performance question and answer session with the audience to explore the issues raised. The drama engendered a number of practical outcomes related to improving the usage and experience of health services of young people. CONCLUSIONS: Drama can offer a means to encourage participation, facilitate participants' self-expression and explore health/health service themes and issues. In conjunction with conventional techniques such as interviews and group discussions, a drama project can also be used to communicate the experience, views and needs of the wider client group to service providers and planners. Such initiatives can generate outcomes to improve service users' experience of health services.

Adolescent↗
PubMed1999

Integrated clinical service for sexual assault victims in a genitourinary setting.

BACKGROUND: Reported sexual assault is increasing, and the diverse immediate and longer term needs of the victim are usually met by exposure to a number of healthcare professionals often in different locations, involving delays and travel, increasing the trauma for the victim. OBJECTIVES: To set up a centre to address the immediate and longer term needs of the sexual assault victim and review issues arising during the development of the service. METHODS: Description of setting up the service in the genitourinary medicine department of Kings College Hospital, south London, and the aspects of care offered. RESULTS: The number of victims referred by police increased from 15 in 1992 to 58 in 1996. In 1996, 55 female and three male victims were seen. 23 different police stations brought victims for examination; mean age of the victim was 27 years (range 14-60), median time between assault and examination was 22 hours (range 3 hours-3 months); 23% had genital injuries, 59% had other physical injury, and 11% needed further hospital care. 71% accepted screening for sexually transmitted infection (STI), 21% had an STI diagnosed, 16% of the women required emergency contraception, 26% received prophylactic antibiotics, and 58% saw a health adviser. 70% had a follow up appointment arranged of which 50% attended. CONCLUSION: The high uptake of STI screening, emergency contraception, health adviser consultation, and follow up supports the concept of a comprehensive integrated system to meet the disparate needs of the victim while still obtaining the necessary forensic evidence. The wide catchment area of service users indicates gaps in services available for the assault victim. Earlier genitourinary involvement after sexual assault is becoming increasingly pertinent in relation to HIV prophylaxis.

Adolescent↗
PubMed1993

Characteristics of youths identified from a psychiatric case register as first-time users of services.

OBJECTIVE: The study examined associations between sociodemographic factors and first-time use of mental health services by children and adolescents, including whether the patterns differ by age at first treatment contact. METHODS: The authors examined sociodemographic characteristics of 4,949 youths listed on a psychiatric case register in Monroe County, New York, who were under age 19 when first seen for public mental health treatment between 1987 and 1989. Data on race and type of insurance for patients in the county's four catchment areas were compared with 1980 census data. Insurance was categorized as public (such as Medicaid) or private and was used as a proxy for socioeconomic status. RESULTS: Both minority and publicly insured youths of low socio-economic status were overrepresented in the treatment population in relation to their numbers in the county, although publicly insured youths from the poorest catchment area were underrepresented in the treatment population. Among children (ages five to 12) in the treatment population, males outnumbered females by 2 to 1, but among adolescents (ages 13 to 18), the numbers were similar. Among minority groups, children receiving first-time mental health services were more likely to have public insurance. Minority adolescents were somewhat more likely to be privately than publicly insured.

Adolescent↗
PubMed2001

Utilization of dental services in Southern China.

A population's utilization of dental services is an important parameter in oral health care planning, which has rarely been studied in China. The objectives of this report were to describe the dental service utilization pattern of middle-aged and elderly Chinese and to analyze the influence of selected variables on the use of dental services. A Guangdong Province population of 1,573 35- to 44-year-olds and 1,515 65- to 74-year-olds recruited from urban and rural communities was interviewed in their local dialect. It was found that 23% of the middle-aged and 24% of the elderly subjects had visited a dentist within the preceding year. The two most commonly cited reasons for not having seen a dentist for at least 3 years were: no perceived need, and no serious dental problems. Among subjects who had visited a dentist within 3 years, the 3 most commonly received treatments were: fillings, extractions, and dental prostheses. Furthermore, a logistic regression analysis showed that women, subjects who lived in urban areas, were better educated, were wealthier, and had better oral health knowledge were more likely to be a recent dental service user. In conclusion, dental service utilization among the adult Southern Chinese was found to be low, problem-driven, and influenced by some socio-economic factors.

Adult↗
PubMed1998

Psychiatry and the burden of mental illness.

OBJECTIVE: To examine the morbidity produced by mental disorders, to project changes in morbidity likely to be produced by demographic and economic change, and to review the possible role of psychiatry in the health care system. METHODS: Using prevalence data for psychiatric disorders and population projections, this paper presents the likely changes in morbidity over the next 20 years. A review of social and economic information indicates changes in social attitudes and their effects on mental health. This paper examines the determinants of health and how they are likely to change and explores some possible directions for changes in health care delivery. RESULTS: Psychiatric disorders have been greatly underestimated as a cause of disability but account for 5 of the 10 leading causes of disability and 47.2% of all years lived with a disability (YLD) in developed countries. By 2016, there will be significant changes in the distribution and type of psychiatric disorders seen in the population, with cases of dementia almost doubling. Most of the population growth will be in the older age-groups, who will be well informed and will demand high standards of service. The gap between rich and poor will increase, and the results of childhood poverty and abuse will become more apparent. The disadvantaged, including many mentally ill, will suffer deprivation as disability payments decline, but youth unemployment will improve, possibly reducing crime rates. Forced early retirements will decline. Alternative medicine will make inroads into health care. A crisis in subsidized accommodation for the elderly can be anticipated, which perhaps will lead to reopening institutions that are currently being closed or to developing new forms of care. As the baby boomers pass 50 years of age and begin consuming health care services, governments will revise plans and eligibility for services; users will pay for services more directly. CONCLUSIONS: Psychiatry is very vulnerable to minor changes in health care schemes and will increasingly be called on to show economic arguments to justify its services. Pressure to support a primary care model by changing practice styles, developing new skills, and training practitioners will probably occur. The major growth area likely will be geriatric psychiatry.

Adolescent↗
PubMed1996

Drug and alcohol user treatment/intervention services in Russia--a Western perspective.

This paper reviews the state of drug and alcohol treatment/intervention services in Russia. The background and the development of addiction services in Russia is described, and the current problems of alcohol and particularly drug misuse are discussed. Current methods of treatment are considered, in the context of a description of the addiction services in St. Petersburg. Some of the issues facing the authorities are discussed: poor training in addiction, the low status of the speciality, overmedicalization of treatment, and the absence of any community-based services. The lack of any harm reduction policies or practice is noted.

Alcoholism↗
PubMed1999

A natural response to drug misuse problems: a review of drug-user treatment services of Bangladesh.

This paper reviews and describes the natural processes through which the people of a Third World country, Bangladesh, have been trying to provide treatment to drug misusers. As the demand for medical help increases, different organizations develop to cater to the needs. Bangladesh has followed the age-old ashram model and the contemporary medical hospital model to provide services to its addicts. In reality the drug misuse treatment providers are still evolving through different learning stages about the biopsychosocial manifestations of addiction. According to the authors, the stages of learning can be divided into three phases: 1) the early period of confusion and enthusiasm, 2) the period of truism, and 3) the period of pragmatism. The people who have gained experience in running treatment centers in the last decade need to form alliances to share their experiences in order to develop rational models for drug treatment programs in Bangladesh. It is also important that they develop methods to monitor providers' activities and to protect clients' safety and interests.

Attitude of Health Personnel↗
PubMed1996

Human-microcomputer relations in an integrated laboratory service: the users' perspective.

The Motala Clinical Chemical Laboratory includes both central (hospital) and peripheral primary health care units. A laboratory computer system has been developed that is shared by all units. In order to illuminate the crucial human-computer interaction, the authors did a questionnaire study of the attitudes and experiences of the whole laboratory staff. The null hypothesis of the study-that computerizing is a threat to the users-was rejected. The quality of the laboratory work and reports was also felt to be improved.

Adult↗
PubMed1995

A review of studies of heavy users of psychiatric services.

OBJECTIVES: This paper reviews studies of patients who are heavy users of psychiatric services and identifies areas in which further research and evaluation are indicated. METHODS: Extensive searches were conducted of the English language psychiatric and psychological literature before 1994. Important references from initially identified studies were followed up. More than 200 articles were reviewed, 72 of which are described in this review. The 72 papers were selected because they dealt with three questions: What is heavy service use? What patient characteristics contribute to it? What service delivery characteristics contribute to it? RESULTS AND CONCLUSIONS: Criteria for identifying and defining heavy users of psychiatric services vary among studies. Few studies of heavy service users have attempted to examine use of all psychiatric services, both inpatient and community based. In most studies, 10 to 30 percent of patients are identified as heavy users, those who utilize between 50 and 80 percent of service resources. This group consists of a constantly changing cohort of patients who generally have psychotic illnesses as well as comorbid personality disorders and high levels of drug and alcohol misuse. Few studies have examined social issues such as isolation, homelessness, and social support, although these factors appear to contribute significantly to heavy service use. Few attempts have been made to define heavy-user groups in fiscal terms. More research on heavy users of psychiatric services is clearly needed to improve providers' ability to plan appropriately targeted mental health services for this disabled group of patients who use expensive resources.

Community Mental Health Services↗
PubMed2005

Sharing stories: complex intervention for diabetes education in minority ethnic groups who do not speak English.

OBJECTIVE: To develop and refine a complex intervention for diabetes support and education in minority ethnic groups, delivered through bilingual health advocates. DESIGN: Action research framework-a variety of methods used in an emergent and developmental manner, in partnership with clinicians, managers, and service users, drawing especially but not exclusively on narrative methods. SETTING: Deprived inner London district. INTERVENTIONS: Development and evaluation of three components of the complex intervention: a group based learning set for bilingual health advocates, in which stories about clients with diabetes formed the basis for action learning; advocate led support and education groups for people with diabetes, which used personal stories as the raw material for learning and action; organisational support to help to develop these new models and embed them within existing services. RESULTS: Both advocate groups and user groups were popular and well evaluated. Through storytelling, advocates identified and met their own educational needs in relation to diabetes and the unmet needs of service users. In the advocate led user groups, story fragments were exchanged in a seemingly chaotic way that the research team initially found difficult to facilitate or follow. Stories were not so much told as enacted and were often centred on discussion of "what to do." Whereas some organisations welcomed, successfully implemented, and sustained the advocate led groups, others failed to do so. A key component of the complex intervention was organisational support. CONCLUSIONS: An action research approach allowed engagement with an underserved group of health service staff and with hard to reach service users. The study produced subjective benefits to these groups locally as well as a worked-up complex intervention that will now be formally tested in a randomised controlled trial.

Attitude to Health↗
PubMed2006

Stakeholders' views on measuring outcomes for people with learning disabilities.

What works and how do we know? These are recurring questions for health and social care professionals, although mediated through differing philosophies and historical perspectives. The aims of the study reported here were to discover views of managers and commissioners of services for people with learning disabilities in Scotland regarding (a) current approaches to service evaluation (as an indication of what is to be measured) and (b) healthcare outcome measurement (as an indication of preferences regarding how this should be measured). A postal questionnaire was used to survey 94 stakeholders from the NHS, Local Authorities, and non-statutory organisations across Scotland. Respondents' views were sought on current approaches to service evaluation within learning disabilities; outcome measurement; appropriateness of specified methods of measuring health outcomes; desired future methods of outcome measurement within learning disabilities; and service user involvement in care. A 77% (73/94) response rate to the questionnaire was achieved. Different methods of service evaluation were used by different stakeholders. Staff appraisal was the most frequently identified method (used by 85% of respondents). Specific outcome measures were used by 32% of respondents although there were differences of opinion as to what constitutes specific outcome measures. Overall there was strong support for goal-setting and reviewing (83%) and individualised outcome measures (75%) as appropriate methods for use with people with learning disabilities. The hypothetical question asking what outcome measures should be introduced for this client group had by far the lowest response rate (51/73). The overwhelming majority of all respondents, 68 (92%), reported user involvement in their service. Staff ambivalence to outcome measurement was evident in the research and respondents highlighted the complexity and multidimensional nature of outcomes for this service user group. Managers recognised that outcome measurement was expected but were uncertain how to go about it.

Humans↗
PubMed2004

An evaluation of a multidisciplinary team for intermediate care at home.

BACKGROUND: The implementation of the National Health Service Plan for the UK will see an expansion of services for intermediate care. Such services are usually targeted at older people and aim to: prevent 'avoidable' admissions to acute inpatient care; facilitate the timely discharge of patients from acute inpatient care; promote patient rehabilitation. A range of services might fall under the banner of intermediate care. They are usually delivered in patients' homes or in non-acute institutions. This paper describes an evaluation of a multidisciplinary Rapid Response Team (RRT). This service aimed to provide a home based alternative to care previously provided in an acute hospital bed which was acceptable to patients and carers and which maintained clinical care standards. The service was provided for the population of Hereford, a rural town in the middle of England. METHODS: A mixed-method descriptive design using quantitative and qualitative techniques was used to monitor: the characteristics of service users, the types and amounts of care received, any 'adverse' events arising from that care, and the acceptability of the service to patients and carers. A collaborative approach involving key stakeholders allowed appropriate data to be gathered from patient case notes, RRT staff, local health and social care providers, and patients and their carers. A suite of self-completed questionnaires was, therefore, designed to capture study data on patients and activities of care, and workshops and semi-structured interview schedules used to obtain feedback from users and stakeholders. RESULTS: Service users (231) were elderly (mean age 75.9), from three main diagnostic categories (respiratory conditions 19.0%, heart/stroke 16.2%, falls 13.4%), with the majority (57.0%) having both medical and social care needs. All patients received care at home (mean duration 5.6 days) with only 5.7% of patients having to be re-admitted to acute care. Overall, patients and carers had positive attitudes to the new service but some expressed concerns about their ability to influence the choice of care option (24.1% and 25.0% of patients and carers, respectively), whilst 22.7% of carers were concerned about the quality of information about care. CONCLUSIONS: Both the nature of schemes for intermediate care, and the policy context in which they are introduced, mean that pragmatic methodologies are often required to evaluate their impacts. Unfortunately, this need for pragmatism can then mean that it is difficult to reach definitive conclusions about the merits of schemes. However, the findings of this evaluation suggest that the Rapid Response Team provided an 'acceptable' alternative to an extended period of care in an acute setting. Such schemes may have relevance beyond the NHS of the UK as a means of providing a more appropriate and cost efficient match between patients' needs for care, the types of care provided, and the place in which care is provided.

Journal Article↗
PubMed1998

Developing user involvement in mental health services.

This paper describes the user consultation component of a corporate approach to the mental health needs assessment of a local population. The context of the paper is established by presenting the views of users and user representatives on current mental health services. This is followed by the development of participants' views of an 'ideal' mental health service within the boundaries of technical feasibility. Three focus groups were held with current service users, and one group with user representatives. The users have extensive experience of a range of mental health services. The findings suggest that user representatives tend to represent their own needs rather than those of users. It would also seem that service users are not a homogeneous group, different groups having different priorities. Overall, users' views of current services generally reflect previous studies, but the 'ideal' approach seems to broaden the discussion and identify an agenda for change. This agenda is framed within categories of service delivery, service providers, labelling, advocacy, future research, leaving services, involvement, co-ordination, information, choice and accessibility. There is no clear role specifically identified for mental health nurses by users, but many opportunities are highlighted. Exploration of the utility of co-operative inquiry between mental health nurses and service users is recommended.

Female↗
PubMed1992

A voucher system that enables persons with severe mental illness to purchase community support services.

Fragmentation in the delivery of community support services is often identified as a major barrier to persons with severe mental illness, preventing them from living productive lives in the community. In Nassau County, New York, in 1989 a voucher process was created to allow service users to develop individualized support networks by purchasing services directly and by pooling funds to start new services. The voucher process is part of an intensive case management program. Goals set in the individual service plans of users guide voucher purchases. The local Mental Health Association manages funds based on a bank credit card model. The user, the case manager, and a staff member from an agency designated by the user review expenditures quarterly. The first year of operation is described, and suggestions for developing a voucher process, such as the need for extensive retraining of users and providers, are offered.

Community Mental Health Services↗
PubMed2006

User involvement in the provision of HIV services: some lessons learned from a user group in an HIV treatment centre in London.

In recent years attention has been focused on the greater participation of health service users in the identification of health service need, service design and delivery and service evaluation. This approach attempts to improve communication between health professionals and the health communities they serve in order to deliver more effective services. The establishment of user groups in HIV services has been one approach by which clinicians have attempted to establish ways that service users could help in the improvement of clinical services. This research article describes the process in the involvement of a user group in an east London HIV service. It describes the challenges that faced both the service users and the clinical staff and it analyses the factors that led to the discontinuation of the user group. The article discusses factors and challenges that must be addressed before meaningful user involvement in HIV services can be established.

HIV Infections↗
PubMed2006

Strategies for integrating primary health services in middle- and low-income countries at the point of delivery.

BACKGROUND: Strategies to integrate primary health care aim to bring together inputs, organisation, management and delivery of particular service functions to make them more efficient, and accessible to the service user. In some middle and low income countries, services have been fragmented by separate vertical programmes established to ensure delivery of particular technologies. We examined the effectiveness of integration strategies at the point of delivery. OBJECTIVES: To assess the effects of strategies to integrate primary health care services on producing a more coherent product and improving health care delivery and health status. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (August 2005), MEDLINE (1966 to September 2005), EMBASE (1988 to 2005), Socio Files (1974 to September 2005), Popline (1970 to September 2005), HealthStar (1975 to September 2005), Cinahl (1982 to September 2005); Cab Health (1972 to 1999), International Bibliography of the Social Sciences (1970 to 1999), and reference lists of articles. We also searched the Internet and World Health Organization (WHO) library database, hand searched relevant WHO publications and contacted experts in the field. SELECTION CRITERIA: Randomised trials, controlled before and after studies, and interrupted time series analyses of integration strategies in primary health care services. Health services in high-income countries were excluded. The primary outcomes were indicators of health care delivery, user views on any measure of service coherence, and health status. We also sought information on comparative costs. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed study quality. MAIN RESULTS: Three cluster randomised trials and two controlled before and after studies were included, with three types of comparison: integration by adding on an additional component to an existing service (family planning); integrated services versus single special services (for sex workers); integrated delivery systems versus a vertical service (for family planning); and packages of enhanced primary child care services (integrated management of childhood illnesses) vs. routine child care. Interventions were complex and in some studies inputs varied substantially between comparison arms. Overall, no consistent pattern emerged. Only one study attempted to assess the user's view of the service provided. AUTHORS' CONCLUSIONS: Few studies of good quality, large and with rigorous study design have been carried out to investigate strategies to promote service integration in low and middle income countries. All describe the service supply side, and none examine or measure aspects of the demand side. Future studies must also assess the client's view, as this will influence uptake of integration strategies and their effectiveness on community health.

Child↗
PubMed2002

Community mental healthcare in England: associations between service organisation and quality of life.

The present authors set out to explore the relationship between different forms of service organisation and quality of life (QoL) for service users. Four mental health trusts and their corresponding social services departments were recruited to exemplify: (1). high and low levels of integration between health and social services; and (2). high and low levels of targeting at users with severe mental health problems. The authors used the Lancashire Quality of Life Profile, and chose their sample size to be able to detect a difference of 0.5 in subjective satisfaction scales. Analysis of covariance was used to investigate the simultaneous impact of variables representing user characteristics, objective and subjective QoL, and service organisation. Two hundred and sixty users selected at random from the active caseloads of mental health services in the four districts were interviewed at time 1 and 232 people were interviewed 6 months later (time 2). No bias was detected in the non-respondents at time 2. The authors found few differences between districts. As in other similar studies, QoL seemed to be stable for the whole sample over time. In 6 months, general satisfaction with leisure increased and the number of people who had been in hospital fell. Negative affect score was the only variable found to be associated with subjective QoL, and no predictors of objective QoL were identified. There was some evidence of better objective outcomes for people in receipt of integrated mental health services. They socialised more, and seemed to have less difficulty accessing police and legal services. The results also suggest that interventions targeted at negative affect could have benefits for subjective QoL.

Adult↗