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Assessing responsiveness in the mental health care system: the case of Tehran
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Bedömning av lyhördhet i det psykiatriska vårdsystemet : en fallstudie från Teheran (Swedish)
Abstract [en]

Introduction: Understanding health service user perceptions of the quality of care is critical to developing measures to increase the utilisation of healthcare services. To relate patient experiences to a common set of standards, the World Health Organization (WHO) developed the concept of health system responsiveness. This measures what happens during user’s interactions with the system, using a common scale, and requires that the user has had a specified encounter, which they evaluate. The concept of responsiveness has only been used in a very few studies previously to evaluate healthcare sub-systems, such as mental healthcare. Since the concept of responsiveness had not been previously applied to a middle income country, such as Iran, there is a need to investigate its applicability and to develop a valid instrument for evaluating health system performance. The aim of this study is to assess the responsiveness of the mental healthcare system in Tehran, the capital of Iran, in accordance with the WHO responsiveness concept.

Methods: This thesis is a health system research, based on qualitative and quantitative methods. During the qualitative phase of the study, six focus group discussions were carried out in Tehran, from June to August 2010. In total, 74 participants, comprising 21 health providers and 53 users of the mental healthcare system, were interviewed. Interviews were analysed through content analysis. The coding was synchronised between the researchers through two discussion sessions to ensure the credibility of the findings. The results were then discussed with two senior researchers to strengthen plausibility. Responses were examined in relation to the eight domains of the WHO’s responsiveness model.

In accordance with the WHO health system responsiveness questionnaire and the findings of the qualitative studies, a Farsi version of the Mental Health System Responsiveness Questionnaire (MHSRQ) was tailored to suit the mental healthcare system in Iran. This version was tested in a cross-sectional study at nine public mental health clinics in Tehran. A sample of 500 mental health services patients was recruited and subsequently completed the questionnaire. The item missing rate was used to check the feasibility, while the reliability of the scale was determined by assessing the Cronbach’s alpha and item total correlations. The factor structure of the questionnaire was investigated by performing confirmatory factor analysis (CFA).

To assess how the domains of responsiveness were performing in the mental healthcare system, I used the data collected during the second phase of the study. Utilising the same method used by the WHO for its responsiveness survey, we evaluated the responsiveness of outpatient mental healthcare, using a validated Farsi questionnaire.

Results: There were many commonalities between the findings of my study and the eight domains of the WHO responsiveness model, although some variations were found. Effective care was a new domain generated from my findings. In addition, the domain of prompt attention was included in two newly labelled domains: attention and access to care. Participants could not differentiate autonomy from choice of healthcare provider, believing that free choice is part of autonomy. Therefore these domains were unified under the name of autonomy. The domains of quality of basic amenities, access to social support, dignity, and confidentiality were considered important for the responsiveness concept. Some differences regarding how these domains should be defined were observed, however.

The results of the qualitative study were used to tailor a Farsi version of the MHSRQ. A satisfactory feasibility, as the item missing value was lower than 5.2%, was found. With the exception of the access domain, the reliability of the different domains in the questionnaire was within a desirable range. The factor loading showed an acceptable uni-dimensionality of the scale, despite the fact that the three items related to access did not perform well. The CFA also indicated good fit indices for the model (CFI = 0.99, GFI = 0.97, IFI = 0.99, AGFI = 0.97).

The results of the mental healthcare system responsiveness survey showed that, on average, 47% of participants reported experiencing poor responsiveness. Among the responsiveness domains, confidentiality and dignity were the best performing factors, while autonomy, access to care and quality of basic amenities were the worst performing. Respondents who reported their social status as low were more likely to experience poor responsiveness overall. Autonomy, quality of basic amenities and clear communication were dimensions that performed poorly but were considered to be highly important by the study participants.

Conclusion and implications: This is the first time that mental healthcare system responsiveness has been measured in Iran. Our results showed that the concept of responsiveness developed by the WHO is applicable to mental health services in this country. Dignity and confidentiality were domains which performed well, while the domains of autonomy, quality of basic amenities and access performed poorly. Any improvement in these poorly performing domains is dependent on resources. In addition, attention and access to care, which were rated high in importance and poor in performance, should be priority areas for intervention and the reengineering of referral systems and admission processes. The role of subjective social status in responsiveness should be further studied. These findings might help policymakers to better understand what is required for the improvement of mental health services.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 60 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1752
Keyword [en]
Mental health care, responsiveness, health system, Iran
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-109499ISBN: 978-91-7601-344-1 (print)OAI: oai:DiVA.org:umu-109499DiVA: diva2:857459
Public defence
2015-10-23, Sal 135, Byggnad 9A, Allmänmedicin, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2015-10-02 Created: 2015-09-29 Last updated: 2015-10-01Bibliographically approved
List of papers
1. Testing the WHO responsiveness concept in the Iranian mental healthcare system: a qualitative study of service users
Open this publication in new window or tab >>Testing the WHO responsiveness concept in the Iranian mental healthcare system: a qualitative study of service users
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2011 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 1, 325Article in journal (Refereed) Published
Abstract [en]

Background Individuals' experience of interacting with the healthcare system has significant impact on their overall health and well-being. To relate patients' experiences to a common set of standards, the World Health Organization (WHO) developed the concept of health system responsiveness. This study aimed to assess if the WHO responsiveness concept reflected the non-medical expectations of mental healthcare users in Teheran.

Methods In this qualitative study, four mixed focus group discussions were formed, comprising 53 mental health service users in Tehran, Iran, in 2010. Content analysis was performed for data analysis. Responses were examined in relation to the eight domains of the WHO's responsiveness model.

Results There were many commonalities between the findings of this study and the eight domains of the WHO responsiveness model, although some variations were found. Effective care was a new domain generated from our findings. In addition, the domain of prompt attention was included in two new labelled domains: attention and access to care. Participants could not differentiate autonomy from choice of healthcare provider, believing that free choice is part of autonomy. Therefore these domains were unified under the name of autonomy. The domains of quality of basic amenities, access to social support, dignity and confidentiality were considered to be important for the responsiveness concept. Some differences regarding how these domains should be defined were observed, however.

Conclusions The results showed that the concept of responsiveness developed by the WHO is applicable to mental health services in Iran. These findings might help policy-makers' better understanding of what is useful for the improvement of mental health services.

Place, publisher, year, edition, pages
BioMed Central, 2011
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-51864 (URN)10.1186/1472-6963-11-325 (DOI)000300431800001 ()22115499 (PubMedID)
Available from: 2012-02-03 Created: 2012-02-03 Last updated: 2017-12-08Bibliographically approved
2. Service Users and Providers Expectations of Mental Health Care in Iran: A Qualitative Study
Open this publication in new window or tab >>Service Users and Providers Expectations of Mental Health Care in Iran: A Qualitative Study
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2013 (English)In: Iranian Journal of Public Health, ISSN 2251-6085, Vol. 42, no 10, 1106-1116 p.Article in journal (Refereed) Published
Abstract [en]

Background: Mental disorders are known to be an important cause of disabilities worldwide. Despite their importance, about two thirds of mentally ill people do not seek treatment, probably because of the mental health system's inability to decrease the negative side effects of the interaction with the mental health services. The World Health Organization has suggested the concept of responsiveness as a way to better understand the active interaction between the health system and the population. This study aimed to explore the expectations of mental health service users and providers. Methods: Six focus group discussions were carried in Tehran, the capital of Iran. In total, seventy-four participants comprising twenty-one health providers and fifty-three users of mental health system were interviewed. Interviews were analyzed through content analysis. The coding was synchronized between the researchers through two discussion sessions to ensure the credibility of the findings. The results were then discussed with two senior researchers to strengthen plausibility. Results: Five common domains among all groups were identified: accessibility, quality of interpersonal relationships, adequate infrastructure, participation in decisions, and continuity of care. The importance of cultural appropriateness of care was only raised by service users as an expectation of an ideal mental health service. Conclusions: Both users and providers identified the most relevant expectations from the mental health care system in Iran. More flexible community mental health services which are responsive to users? experiences may contribute to improving the process of care for mental health patients.

Keyword
Responsiveness, Mental health, Iran
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-83639 (URN)000326245200005 ()
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2006-1512
Available from: 2013-12-05 Created: 2013-12-03 Last updated: 2017-12-06Bibliographically approved
3. Reliability and validity of a Mental Health System Responsiveness Questionnaire in Iran
Open this publication in new window or tab >>Reliability and validity of a Mental Health System Responsiveness Questionnaire in Iran
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2014 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, 1-10 p.Article in journal (Refereed) Published
Abstract [en]

Background:

The Health System Responsiveness Questionnaire is an instrument designed by the World Health Organization (WHO) in 2000 to assess the experience of patients when interacting with the health care system. This investigation aimed to adapt a Mental Health System Responsiveness Questionnaire (MHSRQ) based on the WHO concept and evaluate its validity and reliability to the mental health care system in Iran.

Design: In accordance with the WHO health system responsiveness questionnaire and the findings of a qualitative study, a Farsi version of the MHSRQ was tailored to suit the mental health system in Iran. This version was tested in a cross-sectional study at nine public mental health clinics in Tehran. A sample of 500 mental health services patients was recruited and subsequently completed the questionnaire. Item missing rate was used to check the feasibility while the reliability of the scale was determined by assessing the Cronbach's alpha and item total correlations. The factor structure of the questionnaire was investigated by performing confirmatory factor analysis (CFA).

Results: The results showed a satisfactory feasibility since the item missing value was lower than 5.2%. With the exception of access domain, reliability of different domains of the questionnaire was within a desirable range. The factor loading showed an acceptable unidimentionality of the scale despite the fact that three items related to access did not perform well. The CFA also indicated good fit indices for the model (CFI = 0.99, GFI = 0.97, IFI = 0.99, AGFI = 0.97).

Conclusions: In general, the findings suggest that the Farsi version of the MHSRQ is a feasible, reliable, and valid measure of the mental health system responsiveness in Iran. Changes to the questions related to the access domain should be considered in order to improve the psychometric properties of the measure.

Keyword
Mental Health System, Responsiveness, Reliability, Validity, Questionnaire, Iran
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-92691 (URN)10.3402/gha.v7.24748 (DOI)000339655900001 ()25079288 (PubMedID)
Available from: 2014-09-01 Created: 2014-09-01 Last updated: 2017-12-05Bibliographically approved
4. Measuring the mental health care system responsiveness: results of an outpatient survey in Tehran
Open this publication in new window or tab >>Measuring the mental health care system responsiveness: results of an outpatient survey in Tehran
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-109428 (URN)
Available from: 2015-09-28 Created: 2015-09-28 Last updated: 2015-10-01

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