Needs and Appropriateness of Help According to Types of Professionals and Their Users



Marie-Josée Fleury, PhD
Assistant Professor, Department of Psychiatry, McGill University
Douglas Hospital Research Centre, Montreal, Canada

Guy Grenier, PhD
Research Associate, Douglas Hospital Research Centre, Montreal, Canada




Fleury M.J. & Grenier G. (2007). Needs and Appropriateness of Help According to Types of Professionals
 and Their Users.  International Journal of Psychosocial Rehabilitation. 12 (1), 5-22

Contact:
Marie-Josée Fleury, Ph.D.
Douglas Hospital Research Centre
6875 LaSalle Blvd.
Montreal, Quebec, Canada H4H 1R3
E-mail: flemar@douglas.mcgill.ca

Acknowledgements :
The Canadian Health Services Research Foundation (CHSRF), the Conseil québécois de la recherche sociale (CQRS), Fonds de recherche sur la société et la culture (FRSC), the Quebec department of health and social services, the Institut national de santé publique du Québec and the regional agencies of Quebec City, Bas-St-Laurent, Chaudière-Appalaches, Montréal-Centre and Outaouais all provided grant support for this study. We also express our thanks to Youcef Ouadahi for his help in collecting and analysing the data for the purposes of this article, and to Dr. Alain Lesage for his review of our article.

Abstract
The discrepancies in needs-identification and the appropriateness of help according to patients’ profiles, types of healthcare professionals, and users are examined based on 159 pairs of professionals and users. The Camberwell Assessment of Need (CAN) was used to assess: the number, severity and diversity of needs according to professionals and users, their degree of agreement and the appropriateness of help in meeting needs. The results show that patients tend to select as their primary healthcare provider a type of professional in accordance with their profile. Types of professionals tend to prioritize or neglect various needs in accordance with their background. The user/professional pairs with the highest agreement were those that obtained the most appropriate help. No type of professional can then identify all of its patients’ needs. More cross-vocational training programs as well as interdisciplinary needs-evaluation and diversified care, which include systematically the patient’s perspective, are thus necessary.

Keywords: needs-assessment; agreement between professionals and users; appropriateness of help; mental health types of professionals; patient profiles

Introduction
In the past several years, considerable consensus has emerged in the field of mental health on the necessity of considering the patient’s needs as a starting point for service planning. Evaluating patients’ needs has become a key component of the rehabilitation process (Andresen, Caputi, & Oades, 2000). Numerous evaluation tools have been devised to support this development; of these, the Camberwell Assessment of Need (CAN) is the most frequently used (Phelan, Slade, Thornicroft, Dunn, Holloway, Wykes et al., 1995).  Most studies using the CAN instrument have demonstrated moderate agreement between users and professionals in needs identification (Slade, Phelan, & Thornicroft, 1998; Slade, Leese, Ruggeri, Kuipers, Tansella, & Thornicroft, 2004). Other instruments have produced similar results (Comtois, Morin, Lesage, Lalonde, Likavëanova, & L’Écuyer, 1998; Gibbons, Bédard, & Mack, 2005). Authors explain the divergence in needs-perception by pointing to the different factors that affect users and professionals. In their view, socio-cultural environment, education, and past experiences play a primary role in users’ identification of their needs, whereas professionals are more influenced by training and professional values (Nielsen, Middleboe, Werdelin, Petersen, Mackeprang, Mortensen et al. 1999; Slade, 1996). Chaplain and Perkins (1999) state that the perceptions of people in the same profession are more closely aligned than with those of professionals from other disciplines. For instance, two nurses will tend to think alike more than, say, a nurse and a psychiatrist or a nurse and a psychologist. The same observation has been made of other health professionals (Meredith, Wells, & Camp, 1994; Shao, Williams, Lee, Badgette, Aaronson, & Cornell, 1997), even when they come from different countries (e.g. Australia and Singapore) (Parker, Chen, Jua, Loh, & Jorm, 2000).  However, no study has attempted to explain the divergence in the perceptions of types of professionals in relation to their patients’ clinical and socio-demographic profile and service-utilization. Correlations between needs-identification and the adequacy of services have also been neglected. This paper, drawn from a larger study on integrated service networks in Quebec, Canada (Fleury, Mercier,  Lesage, Ouadahi, Grenier, Aubé et al., 2004), aims to: (1) examine patients’ clinical and socio-demographic profile and service-utilization according to the profession or occupation of their most significant professional or mental healthcare provider; (2) assess the level of agreement in the number, severity and diversity of the needs identified by professionals in accordance with their occupation and their respective patients; and (3) evaluate the appropriateness of the help provided by services according to types of professionals and users.

Method
Data collection
Needs-analysis was performed with the French-language version of the Camberwell Assessment of Need (CAN) instrument (Bonsack & Lesage, 1998), whose reliability has been tested in several countries (Slade, Phelan, Thornicroft, & Parkman, 1996; Arvidsson, 2003).  An important characteristic of the CAN is its capacity to encompass patients’ needs and the types of care provided by relatives and established services. The CAN includes five categories of needs and 22 domains. The categories of needs are: (1) Basic (accommodation, food, daytime activities); (2) Health (physical health, psychotic symptoms, psychological distress, safety to self, safety to others, alcohol, drugs); (3) Functioning (self-care, looking after the home, childcare, basic education, money); (4) Social (company, intimate relationships, sexual expression); and (5) Services (information on disorder and treatment, transportation, telephone and benefits). There are five sections in the CAN. In the first, for each of the 22 domains, the patient indicates their perceived need severity on a three-point scale (no problem=0, moderate problem due to help given=1, serious problem whether or not help is received=2). When a moderate or serious problem is reported, the patient must complete the other sections of the questionnaire pertaining to the level of help received from relatives or services (none=0, low=1, moderate=2, high=3); the level of perceived need for help from services (none=0, low=1, moderate=2, high=3); and finally, adequacy of that help (right type of help provided –  1=yes or 0=no) and satisfaction (related to the amount of help provided – 1=yes or 0=no). In every section, patients can also answer “I don’t know”, which is considered as missing information. The CAN is based on a semi-directed interview which takes 30 to 45 minutes, and can be administered at the patients’ residence or elsewhere to their convenience.

Additional data were drawn from patients’ records, related to their socio-demographic (gender, age, income, education and current type of residence) and clinical profile (principal and secondary diagnosis, and life span: number of suicide attempts, criminal record, drug and alcohol abuse, and history of violence), and their use of health services (number and length of hospital stays between January 2002 to May 2004, number and type of resources used during the last year). In a brief complementary interview, patients and professionals were also asked to answer a question on their perception of the patients’ mental health state. Users also had to provide information on their service trajectory in the past year, such as the type and number of professionals involved in their care and the duration of their follow-up. The data collection has involved research assistants with a professional clinical background and trained for the purpose of the study.

Study design and cohort description
The study had a cross-sectional design based on patients living in six districts of the province of Quebec, Canada, chosen by convenience as most representative of semi-urban (areas 1, 2 and 3), rural (area 4) and urban (areas 5 and 6) settings. Population size ranged from 20,000 in area 4 to 128,000 in area 6 (Fleury, Grenier, & Lesage, 2006).  Targeted patients, aged 18 to 65 years, had to have been hospitalized in the last year and diagnosed with severe mental illness according to ICD-9 code 295 (Schizophrenia) or 297 (Delusional Disorder). Subjects were randomly selected from a list of 937 patients provided by hospital archives in the different districts. Sampling size was set at 30 patients per district, except for one rural district, set at 10, and an urban district at 60. From the list of eligible patients, we selected the first who agreed to participate in the study, for a global objective of 190. That number could not be reached in only one district. The final sampling was 186 patients, or 97.8% of the objective. It was representative of Quebec’ hospitalized population at the time of the data collection in terms of gender (χ2=3.97, df=1, p≤0.01), and age, with the exception of one urban territory (49.4; SD 10.3 versus 41.2; SD 12.6 for Quebec; χ2=29.52, df=4, p>0.05 – MED-ECHO, 2003-2004). Each participant signed a consent form approved by the relevant ethics boards.

The 186 patients selected were then asked to identify the professional whom they perceived as most significant and considered as their main mental healthcare provider; professionals identified in this manner were judged to be in the best position to answer the CAN. One hundred sixty-five professionals were identified. Professionals chosen by users included: 72 nurses (43.6%); 28 social workers (16.9%); 20 psychiatrists (12.1%); 22 educators (special or psycho-educators) (13.3%); 7 human relations officers (4.2%); 6 community workers (3.6%); 4 social agents (2.4%); 4 psychologists (2.4%); and 2 occupational therapists (1.2%). Nurses, social workers and community workers were present in the six districts covered by the study. Nurses were found mainly in urban district 6, where they constituted 64.4% of the significant professionals and in semi-urban district 1 (53.3%). Social workers were very few in number in districts 3, 5 and 6, and particularly present in the surrounding regions (1, 2 and 4). In district 2, they represented 40% of professionals chosen by users. Psychiatrists were more concentrated in district 5, where they made up 50% of the significant professionals. Most of the educators were found in district 3, while the community workers were found mostly in district 6. Finally, professionals’ profile in district 4 was heterogeneous, with no category of professional standing out. Community workers, human relations officers, and social agents have a university education in related social sciences branches (psychology, psycho-education, social work, communication, and criminology, etc.) and provide community follow-up. The difference in their appellations seems to be related principally to the organization with which they are affiliated (local community health centre, hospital or community resources). In this study, we refer to those professionals as “community workers.” Considering their small number, psychologists and occupational therapists have been excluded. Therefore, this study centres on 159 user/professional pairs.

A majority of the 159 patients were men (102 or 64.2%), whose mean age was 49.8 years (SD 11.8), single (109 or 68.6%), had a high-school education (85 or 53.5%), and were living autonomously in an apartment (86 or 54.1%). A diagnosis of schizophrenia was nearly the rule (155 or 97.5%). Nearly half of the cohort (79 or 49.7%) had a chronic syndrome such as mental retardation or personality disorder (as per DSM-IV). A history of family psychiatric problems was also reported for 72 patients (45.3%). Moreover, 49 patients (30.8%) had a history of problems with alcohol, 48 (29.1%) with drugs, 48 (30.2%) a history of violence, and 40 (25.2%) problems with the law. Fifty (31.4%) had tried to take their own life, averaging 1.80 lifetime suicide attempts (SD = 1.23). Users perceived their mental health state more positively (Figure 1) than professionals did (Figure 2). Only 16 users (10.1%) considered it to be bad, whereas 32 (20.1%) very good or excellent, compared to 39 professionals (24.5%) who estimated it to be bad and 13 (8.3%) very good. The average number of patient hospitalizations between January 2002 and May 2004 was 1.92 (SD = 1.47). The length of stay was less than 7 days for 53 users (33.3%) and between 1 and 2 weeks for 44 users (27.7%). On average, patients used 2.0 mental health resources in the past year (SD = 1.01), mainly outpatient clinics (111 or 69.8%), community resources (34 or 17.9%), local community health centres (28 or 17.6%), and specialized clinics (28 or 17.6%). Fifty-two (32.7%) mentioned being followed by a psychiatrist and a general practitioner. Twenty-nine (18.2%) had been seen by the same psychiatrist and 28 (17.6%) by the same general practitioner for more than ten years. Sixty (37.7%) reported consulting another professional as well, mainly a social worker (24 or 15.1%).





Statistical analyses of the data were conducted, using SPSS software (version 11.5). To measure the agreement between patients and professionals on overall needs-identification, the Kappa coefficient was used. Kappa measures the amount of agreement obtained between two raters beyond that which would be expected by chance alone (Spitznagel, & Helfzer, 1985; Crewson, 2005). Agreement is considered almost perfect when k ≥ 0.80; substantial if k is between 0.61 and 0.80; moderate, between 0.41 and 0.61; fair, between 0.21 and 0.40; and slight, between 0 and 0.20 (Middelboe, Mackeprang, Hansson, Werdelin, Karlsson,  Bjarnason et al., 2001).

Results
Users’ profile according to type of professionals (of the primary healthcare provider)
Patients who identified nurses as their most significant professionals had a socio-demographic profile similar to the patients’ general profile. Most of them were diagnosed with paranoid schizophrenia (34 out of 72 or 47.2%), and many had antecedents of violence (28 or 38.9%). The number of suicide attempts was rather high (28 or 38.9%). Of all the types of professionals, nurses’ perception of their patients’ mental health state was the most positive, with 78% rating it average to very good. Their users ranked second compared to patients of the other types of professionals, with 88.8% perceiving their mental health state from average to excellent. These patients were the main users of community follow-up. Twenty-nine out of 72 (40.2%) mentioned being followed by a psychiatrist and a general practitioner, 17 of them (23.6%) by the same general practitioner, and 16 (22.2%) by the same psychiatrist for more than ten years. Twenty-eight out of 72 (38.9%) reported consulting another professional as well, mainly a social worker (14 or 19.5%).

The social workers’ patients came mainly from rural or semi-urban settings (24 out of 28 or 85.7%). They were the only group with an almost equal number of women and men (12 patients out of 28 women or 42.9%). They also had the lowest rate of bachelors (15 out of 28 or 53.6%). They had mainly schizo-affective problems (13 out of 28 or 46.4%); a minority (4 out of 28 or 14.3%) also had another diagnosis. Psychiatric family antecedents (16 out of 28 or 57.1%) and suicide attempts (10 or 35.7%) were especially high. The social workers were also confronted with more cases of alcohol abuse than other professionals (13 out of 28 or 46.4%). Antecedents of violence were scarce (5 or 17.9%). The social workers’ perception of their patients’ mental health state was within the norm compared to overall professionals, with 68% considering it to be average to very good. Their patients’ perception was the second-highest of the user cohort, 92.8% evaluating it from average to excellent. These patients constituted the main users of resources (2.6 resources per user). Eighteen patients (64.3%) reported being followed by another professional, nine (32.1%) by a psychiatrist and a general practitioner – seven (25%) for more than ten years.

The psychiatrists’ patients were by far the most autonomous. Except for one, they lived in apartments, mostly in urban settings (13 or 65%), were rather young (averaging 42.6 years of age, SD 13.0), educated (12 out of 20 or 60% had completed junior college or university), and more than any other, single (16 out of 20 or 80%). They had fewer legal antecedents (3 or 15%), suicide attempts (also 3 or 15%) and chronic syndromes (7 or 35%). But, many had family psychiatric antecedents (15 or 75%), and a history of drug use (10 or 50%) and violence (7 or 35%). Psychiatrists perceived their patients’ mental state the most negatively, with 80% considering it average or bad. Conversely, 85% of their users judged it from average to very good; however, nobody in that group rated it excellent. The psychiatrists’ patients made scarce use of resources (1.8 per user), merely visiting outpatient clinics occasionally. Three users (15%) mentioned being followed by another professional as well as by a psychiatrist for the past ten years.

The educators’ patients differed from those of other professionals in many aspects. They were older (on average, 50.6, SD 7.7), a significant number were separated, divorced or widowed (7 out of 22 or 31.8%, against 33 out of 165 or 20% for the cohort). Many lived in intermediary resources (8 or 36.4%), and most in semi-urban settings (17 or 77.3%). The main diagnosis for these patients was schizo-affective disorder (13 or 59.1%), and a high number also had a chronic syndrome (17 or 77.3%). The rate of suicide attempts was the highest (8 or 36.4%). But, few patients had legal antecedents (4 or 18.2%), problems of violence (4 or 18.2%), and drug (3 or 13.6%) or alcohol abuse (2 or 9.1%). The educators’ perception of their patients’ mental health state was the second-lowest among all professionals, 77.2% judging it to be from average to bad. Conversely, 90.9% of their users evaluated it from average to excellent. The educators’ patients were the main users of specialized clinics. Nine (40.9%) reported being followed by another professional, mainly a social worker (6 or 27.3%). All were followed by a psychiatrist, and 7 (31.8%) by a psychiatrist and a general practitioner – two (9%) for more than ten years.

Finally, the patients who chose community workers were the youngest (averaging 39.3 years, SD 13.5), the most urban (13 out of 17 or 76.5%) and the least-educated (6 or 35.3% had completed elementary school only). These patients’ main diagnosis was paranoid schizophrenia (7 or 41.7%). They had few antecedents of violence (4 or 23.5%), legal problems (3 or 17.6%), or alcoholism (3 or 17.6%). Community workers ranked third in the perception of their patients’ mental health state, 64.7% evaluating it from average to very good. Community workers’ patients were the most numerous to judge it very good or excellent (47.0%), with only patient (5.9%) considering it bad. Community workers’ patients were among the most infrequent users of resources (1.8 per user), preferring services unrelated to mental health. Six patients (35.3%) were followed by another professional as well, generally a social worker (4 or 23.5%), and five (29.4%) by a psychiatrist and a general practitioner. One patient had been consulting the same general practitioner for more than ten years, and another, the same psychiatrist for as long.

Number, severity and diversity of needs according to professionals and users
Table 1 shows the number of problems – overall (total of moderate and serious) and serious – identified by professionals and users. Professionals reported that more than 40% of users had overall needs in the following areas: psychotic symptoms (126 or 79.2%); company (95 or 59.7%); daytime activities (84 or 52.8%); money (71 or 44.7%); psychological distress (69 or 43.4%); and looking after the home (66 or 41.5%). In needs-identification, self-care was the area where professionals and users most disagreed (44 versus 13 for users). More than 40% of users perceived problems in psychotic symptoms (124 or 78.0%), company (86 or 54.1%), food (77 or 48.4%), daytime activities (75 or 47.2%), money (72 or 45.3%), and psychological distress (71 or 44.7%). Information on disorder and treatment stood out as the area where users perceived the most problems as compared to professionals (62 versus 38 for professionals). As for serious problems, professionals and users agreed that they occurred more frequently in company, daytime activities, psychotic symptoms, intimate relationships, money, transportation, sexual expression, and psychological distress. In the 14 remaining areas, the proportion of users with serious problems was less than 10%. Professionals identified more serious problems in self-care (12 vs. 0) and basic education (10 vs. 4), whereas users identified them in information (15 vs. 3) and benefits (5 vs. 1).