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Testing the WHO responsiveness concept in the Iranian mental healthcare system: a qualitative study of service users
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Social Determinants of Health Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
Umeå University, Faculty of Social Sciences, Department of Social Work.
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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. Vol. 11, no 1, 325
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-51864DOI: 10.1186/1472-6963-11-325ISI: 000300431800001PubMedID: 22115499OAI: oai:DiVA.org:umu-51864DiVA: diva2:489575
Available from: 2012-02-03 Created: 2012-02-03 Last updated: 2017-12-08Bibliographically approved
In thesis
1. Assessing responsiveness in the mental health care system: the case of Tehran
Open this publication in new window or tab >>Assessing responsiveness in the mental health care system: the case of Tehran
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Bedömning av lyhördhet i det psykiatriska vårdsystemet : en fallstudie från Teheran
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
Mental health care, responsiveness, health system, Iran
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-109499 (URN)978-91-7601-344-1 (ISBN)
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

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