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Sapag JC, Rush B. Evaluation of collaborative mental health services in Latin America: Theoretical and methodological basis. Int J Health Plann Manage 2024; 39:83-99. [PMID: 37865953 DOI: 10.1002/hpm.3719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/17/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVES Approaches to collaborative mental health care (CMHC) have been implemented in many countries to strengthen the accessibility and delivery of mental health services in primary care. However, there are not well-defined frameworks to evaluate CMHC models. The purpose of this article is to identify, contextualize and discuss relevant health services research approaches, theory, and evaluation models for the development of an appropriate evaluation framework in order to foster effective CMHC in Latin America. METHODS A comprehensive literature review informed a critical analysis of relevant theories and alternative methods to be considered in the development of the framework. RESULTS Specific health services research frameworks are discussed in the context of evaluating CMHC. Two theoretical perspectives - collaboration theory and systems theory - and three evaluation models- realistic, developmental and collaborative - are analyzed in terms of their relevance. Methodological implications are identified. CONCLUSION An appropriate evaluation framework for CMHC in Latin America needs to reflect theoretical and contextual considerations and relevant evaluation approaches and methods, including key dimensions and attributes/variables, core indicators, and recommendations for implementation.
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Affiliation(s)
- Jaime C Sapag
- Departments of Public Health and Family Medicine, Division of Public Health and Family Medicine, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brian Rush
- Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Gumz A, Reuter L, Löwe B, Voderholzer U, Schwennen B, Fehrs H, Wünsch-Leiteritz W, Brunner R, Kästner D, Zapf A, Weigel A. Factors influencing the duration of untreated illness among patients with anorexia nervosa: A multicenter and multi-informant study. Int J Eat Disord 2023; 56:2315-2327. [PMID: 37814447 DOI: 10.1002/eat.24069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION The duration of untreated illness (DUI), that is, the interval between the onset of anorexia nervosa (AN) symptoms and start of specialized treatments, has a strong influence on the prognosis. OBJECTIVE To quantify modifiable predictors of the DUI and to derive recommendations for secondary prevention strategies. METHODS Within a multicenter, multi-informant study, DUI was assessed in interviews with patients undergoing first specialized AN treatment. Modifiable factors were assessed perspectives of AN-patients, their relatives, and primary care practitioners [PCPs]) with the FABIANA-checklist (Facilitators and barriers in anorexia nervosa treatment initiation). The effect of FABIANA-items on the DUI for each perspective was calculated using Cox Regression (control variables: age, eating disorder pathology, health care status, migration background, body mass index [BMI]). RESULTS We included data from N = 125 female patients with AN (72 adults, 53 adolescents, Mage = 19.2 years, SD = 4.2, MBMI = 15.7 kg/m2 , SD = 1.9), N = 89 relatives (81.8% female, 18.2% male, Mage = 46.0 years, SD = 11.0) and N = 40 PCPs (Mage = 49.7 years, SD = 9.0). Average DUI was 12.0 months. Watching or reading articles about the successful treatment of other individuals with AN (patients' perspective) and regular appointments with a PCP (PCPs' perspective) were related to a shorter DUI (HR = 0.145, p = .046/ HR = 0.395, p = .018). Patients whose relatives rated that PCPs trivialized patients' difficulties had a longer DUI (HR = -0.147, p = .037). PCPs and relatives rated PCPs' competence higher than patients did. DISCUSSION It is recommended (a) to incorporate treatment success stories in prevention strategies, (b) to inform PCPs about potential benefits of regular appointments during the transition to specialized care, and (c) to train PCPs in dealing with patients' complaints. PUBLIC SIGNIFICANCE Many individuals with AN seek treatment very late. Our study shows that a promising approach to facilitate earlier AN treatment is to inform patients about successful treatments of affected peers, to foster regular appointments with a PCP and, to motivate these PCPs to take individuals' with AN difficulties seriously. Thus, our study provides important suggestions for interventions that aim to improve early treatment in AN.
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Affiliation(s)
- Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychosomatics and Psychotherapy, Psychologische Hochschule Berlin, Berlin, Germany
| | - Laurence Reuter
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychosomatics and Psychotherapy, Psychologische Hochschule Berlin, Berlin, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Voderholzer
- Schön Clinic Roseneck, Prien am Chiemsee, Germany
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany
| | | | - Helge Fehrs
- Department of Psychosomatic Medicine and Psychotherapy, Asklepios Westklinikum Hamburg, Hamburg, Germany
| | | | - Romuald Brunner
- Department for Paediatric and Adolescent Medicine, Medical University Center Regensburg, Hamburg, Germany
| | - Denise Kästner
- Department of Psychosomatics and Psychotherapy, Psychologische Hochschule Berlin, Berlin, Germany
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Reuter L, Kästner D, Schmidt J, Weigel A, Voderholzer U, Seidel M, Schwennen B, Fehrs H, Löwe B, Gumz A. The development and psychometric evaluation of FABIANA-checklist: a scale to assess factors influencing treatment initiation in anorexia nervosa. J Eat Disord 2021; 9:144. [PMID: 34732246 PMCID: PMC8565008 DOI: 10.1186/s40337-021-00490-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A long duration of untreated illness (DUI) is an unfavorable prognostic factor in anorexia nervosa (AN) and is associated with chronic illness progression. Although previous preventive measures aimed at reducing DUI and thus improving short- and long-term treatment outcomes have been partially successful, a better understanding of the factors involved in the sensitive phase prior to treatment initiation is needed. To date, there is no validated instrument available to assess these factors specifically for patients with AN. The FABIANA-project (Facilitators and barriers in anorexia nervosa treatment initiation) aims at identifying predictors of the DUI in order to target preventive measures better in the future. As part of this project, the FABIANA-checklist was developed, based on a multi-informant perspective and a multimodal bottom-up approach. The present study focusses on the process of item generation, item selection and psychometric validation of the checklist. METHODS Based upon a previous qualitative study, an initial set of 73 items was generated for the most frequently mentioned facilitators and barriers of treatment initiation in AN. After a process of consensual rating and cognitive pre-testing, the resulting 25-item version of the FABIANA-checklist was provided to a sample of female patients (N = 75), aged ≥ 14 years with AN that underwent their first psychotherapeutic treatment in the last 12 months. After item analysis, dimensionality of the final version of the FABIANA-checklist was tested by Principal Component Analysis (PCA). We evaluated construct validity assuming correlations with related constructs, such as perceived social support (F-SozU), support in the health care system (PACIC-5A), illness perception and coping (BIPQ). RESULTS We included 54 adult and 21 adolescent patients with AN, aged on average 21.4 years. Average BMI was 15.5 kg/m2, age of onset was 19.2 years and average DUI was 2.25 years. After item analysis, 7 items were excluded. The PCA of the 18-item-FABIANA-checklist yielded six components explaining 62.64% of the total variance. Overall internal consistency was acceptable (Cronbach's α = .76) and construct validity was satisfactory for 14 out of 18 items. Two consistent components emerged: "primary care perceived as supportive and competent" (23.33%) and "emotional and practical support from relatives" (9.98%). With regard to the other components, the heterogeneity of the items led to unsatisfactory internal consistency, single item loading and in part ambiguous interpretability. CONCLUSIONS The FABIANA-checklist is a valid instrument to assess factors involved in the process of treatment initiation of patients with AN. Psychometrics and dimensionality testing suggests that experienced emotional and practical support from the primary health care system and close relatives are main components. The results indicate that a differentiated assessment at item level is appropriate. In order to quantify the relative importance of the factors and to derive recommendations on early-intervention approaches, the predictive effect of the FABIANA-items on the DUI will be determined in a subsequent study which will further include the perspective of relatives and primary caregivers. Trial registration Clinical Trials.gov Identifier: NCT03713541: https://clinicaltrials.gov/ct2/show/NCT03713541 .
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Affiliation(s)
- Laurence Reuter
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany.
| | - Denise Kästner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Justine Schmidt
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Ulrich Voderholzer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.,Schön Clinic Roseneck, Prien am Chiemsee, Germany.,Department of Psychiatry and Psychotherapy, University Hospital of Freiburg, Freiburg, Germany
| | - Marion Seidel
- Schön Clinic for Psychosomatic Medicine and Psychotherapy, Bad Arolsen, Germany
| | - Bianca Schwennen
- Medclin Seepark Clinic for Acute Psychosomatic Care, Bad Bodenteich, Germany
| | - Helge Fehrs
- Department of Psychosomatic Medicine and Psychotherapy, Asklepios Westklinikum Hamburg, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
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Kästner D, Weigel A, Buchholz I, Voderholzer U, Löwe B, Gumz A. Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals. J Eat Disord 2021; 9:28. [PMID: 33640028 PMCID: PMC7913310 DOI: 10.1186/s40337-021-00381-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND An early psychotherapeutic treatment of anorexia nervosa (AN) is crucial for a good prognosis. In order to improve treatment initiation, knowledge about facilitators and barriers to treatment is needed. OBJECTIVE Against this background, we aimed to identify facilitators and barriers from the perspectives of patients, carers and professionals using a qualitative approach. METHOD To this end, semi-structured interviews were conducted in triads of female patients with AN aged 14 years and older at the beginning of their first psychotherapeutic treatment, their carers, and referring health care professionals. A modified Grounded Theory approach was used for analysis. RESULTS In total, 22 interviews were conducted (n = 6 adults, n = 4 adolescents, 4 full triads). The duration of untreated AN ranged between 30 days and 25.85 years (M = 3.06 ± 8.01 years). A wide spectrum of facilitators and barriers within the patient, the social environment, the health care system and the society were identified. Most prominent factors were 'recognizing and addressing' by close others, 'waiting times and availability' and 'recommendations and referrals' by health care professionals. 'Positive role models for treatment' were perceived as a specific facilitative social influence. Facilitators were more frequently mentioned than barriers and most of the factors seem to hold potential for modifiability. CONCLUSION Overall, the findings suggest that early intervention approaches for AN should not only address patients and the health care system, but may also involve carers and successfully treated former patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03713541 .
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Affiliation(s)
- Denise Kästner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany.
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Ines Buchholz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Ulrich Voderholzer
- Schön Clinic Roseneck, Prien am Chiemsee, Germany.,Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, University of Munich (LMU), Munich, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
| | - Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Centre, Hamburg-Eppendorf, Martinistr. 52, W37, 20246, Hamburg, Germany
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