Carol Harvey

Understanding and evaluating qualitative research.

Qualitative research aims to address questions concerned with developing an understanding of the meaning and experience dimensions of humans’ lives and social worlds. Central to good qualitative research is whether the research participants’ subjective meanings, actions and social contexts, as understood by them, are illuminated. This paper aims to provide beginning researchers, and those unfamiliar with qualitative research, with an orientation to the principles that inform the evaluation of the design, conduct, findings and interpretation of qualitative research. It orients the reader to two philosophical perspectives, the interpretive and critical research paradigms, which underpin both the qualitative research methodologies most often used in mental health research, and how qualitative research is evaluated. Criteria for evaluating quality are interconnected with standards for ethics in qualitative research. They include principles for good practice in the conduct of qualitative research, and for trustworthiness in the interpretation of qualitative data. The paper reviews these criteria, and discusses how they may be used to evaluate qualitative research presented in research reports. These principles also offer some guidance about the conduct of sound qualitative research for the beginner qualitative researcher.

Psychotic disorders in urban areas: an overview of the study on low prevalence disorders

Objective: This paper reports on a study designed within the framework of the National Survey of Mental Health and Wellbeing to: estimate the prevalence of psychoses in urban areas of Australia; identify profiles of symptomatology, impairments and disabilities; collect information on services received and needed; and explore quality of life issues in a broadly representative sample of people with psychotic illnesses. Method: The study was conducted over four areas in the Australian Capital Territory, Queensland, Victoria and Western Australia, as a two-phase survey: (i) a census and screening for psychosis of all individuals who made contacts with mental health services during a period of 1 month in 1997; and (ii) interviews with a stratified random sample (n = 980) of the screen-positive individuals (n = 3800) using a standardised instrument. Results: The point prevalence (1 month) of psychotic disorders in the urban population aged 18–64 is in the range of 4–7 per 1000 with a weighted mean of 4.7 per 1000. People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance-use comorbidity and frequent side effects of medication. Although the utilisation of hospital-based and community mental health services, as well as of public and non-governmental helping agencies, is high, the majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent. Conclusions: The so-called ‘low-prevalence’ psychotic disorders represent a major and complex public health problem, associated with heavy personal and social costs. There is a need for a broad programmatic approach, involving various sectors of the community, to tackle the multiple dimensions of clinical disorder, personal functioning and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention.

People living with psychotic illness in 2010: the second Australian national survey of psychosis.

Objective: The 2010 Survey of High Impact Psychosis (SHIP) is Australia’s second national psychosis survey. This paper provides an overview of its findings, including comparisons with the first psychosis survey and general population data. Methods: The survey covered 1.5 million people aged 18–64 years, approximately 10% of Australians in this age group. A two-phase design was used. In phase 1, screening for psychosis took place in public mental health services and non-government organizations supporting people with mental illness. In phase 2, 1825 of those screen-positive for psychosis were randomly selected and interviewed. Data collected included symptomatology, substance use, functioning, service utilization, medication use, education, employment, housing, and physical health including fasting blood samples. Results: The estimated 1-month treated prevalence of psychotic disorders in public treatment services was 3.1 people per 1000 population; the 12-month treated prevalence was 4.5 people per 1000. The majority (63.0%) of participants met ICD-10 criteria for schizophrenia/schizoaffective disorder. One-half (49.5%) reported attempting suicide in their lifetime and two-thirds (63.2%) were rated as impaired in their ability to socialize. Over half (54.8%) had metabolic syndrome. The proportion currently smoking was 66.1%. Educational achievement was low. Only 21.5% were currently employed. Key changes in the 12 years since the first survey included: a marked drop in psychiatric inpatient admissions; a large increase in the proportion attending community mental health clinics; increased use of rehabilitation services and non-government organizations supporting people with mental illness; a major shift from typical to atypical antipsychotics; and large increases in the proportions with lifetime alcohol or drug abuse/dependence. Conclusion: People with psychotic illness face multiple challenges. An integrated approach to service provision is needed to ensure that their living requirements and needs for social participation are met, in addition to their very considerable mental and physical health needs.

Psychosis prevalence and physical, metabolic and cognitive co-morbidity: data from the second Australian national survey of psychosis

Background There are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities. Method The 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18–64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants. Results The 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18–64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence. Conclusions Our findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.

Factors associated with length of stay and the risk of readmission in an acute psychiatric inpatient facility: a retrospective study

Objective: This study was to investigate factors influencing the length of stay and predictors for the risk of readmission at an acute psychiatric inpatient unit. Method: Two comparative studies were embedded in a retrospective cross-sectional clinical file audit. A randomly selected 226 episodes of admissions including 178 patients during a twelve-month period were reviewed. A total of 286 variables were collected and analysed. A case control study was employed in the study of length of stay. A retrospective cohort study was used to investigate the predictors for the risk of readmission. Results: Logistic regression analyses showed that 10 variables were associated with length of stay. Seclusion during the index admission, accommodation problems and living in an area lacking community services predicted longer stay. During the follow-up period 82 patients (46%) were readmitted. Cox regression analyses showed 9 variables were related to the risk of readmission. Six of these variables increased the risk of readmission, including history of previous frequent admission, risk to others at the time of the index admission and alcohol intoxication. More active and assertive treatment in the community post-discharge decreased the risk of readmission. Conclusions: Length of stay is multifactorially determined. Behavioural manifestations of illness and lack of social support structures predicted prolonged length of stay. Good clinical practice did not necessarily translate to a shorter length of stay. Therefore, length of stay is predictable, but not readily modifiable within the clinical domain. Good clinical practice within the community following discharge likely reduces the risk of readmission. Quality of inpatient care does not influence the risk of readmission, which therefore raises a question about the validity of using the rate of readmission as an outcome measure of psychiatric inpatient care.

Perceived need for mental health care, findings from the Australian National Survey of Mental Health and Well-being

BACKGROUND The Australian National Survey of Mental Health and Well-being was designed to detect and describe psychiatric morbidity, associated disability, service use and perceived need for care. The survey employed a single-phase interview methodology, delivering a field questionnaire to a clustered probability sample of 10,641 Australians. Perceived need was sampled with an instrument designed for this survey, the Perceived Need for Care Questionnaire (PNCQ). This questionnaire gathers information about five categories of perceived need, assigning each to one of four levels of perceived need. Reliability and validity studies showed satisfactory performance of the instrument. METHODS Perceived need for mental health care in the Australian population has been analysed using PNCQ data, relating this to diagnostic and service utilization data from the above survey. RESULTS The survey findings indicate that an estimated 13.8% of the Australian population have perceived need for mental health care. Those who met interview criteria for a psychiatric diagnosis and also expressed perceived need make up 9.9% of the population. An estimated 11.0% of the population are cases of untreated prevalence, a minority (3.6% of the population) of whom expressed perceived need for mental health care. Among persons using services, those without a psychiatric diagnosis based on interview criteria (4.4% of the population), showed high levels of perceived met need. CONCLUSIONS The overall rate of perceived need found by this methodology lies between those found in the USA and Canada. The findings suggest that service use in the absence of diagnosis elicited by survey questionnaires may often represent successful intervention. In the survey, untreated prevalence was commonly not accompanied by perceived need for mental health care.

The relationship between social networks and occupational and self-care functioning in people with psychosis.

Abstract.Background: Relatively few studies have examined relationships between the social networks of people with psychotic disorder and other aspects of their functioning. The aim of this paper is to describe the social networks of people with psychosis and to investigate relationships between social networks and personal and occupational functioning, taking account of illness course. Methods: A two-phase epidemiological survey of persons with psychosis was conducted in four predominantly urban areas of Australia. A census and screen for psychosis was followed by a semi-structured interview of a stratified random sample of participants to assess their functioning. Data relating to functioning and social networks from 908 individuals (most with a diagnosis of schizophrenia) were analysed using structural equation modelling (SEM). Results: The majority of people with psychosis (67 %) had a network comprising of family and friends, 15 % were defined as having a family-dominated network, 11 % a friends-dominated network and 7 % of participants were defined as socially isolated (no family or friends). Participants who had friends and family in their network (12 %) or who had a family-dominated network (7 %) were more likely to be in full-time employment compared with those with a friends-dominated network (4 %) or those who were socially isolated (5 %). Dysfunction in self-care was more frequently reported among socially isolated people (50 %) and those with family-dominated networks (47 %) than among those with friends-dominated networks (35 %) and those who had friends and family in their social network (23 %). SEM revealed a strong association between social integration and functioning (r = 0.71), even after controlling for illness course. Social integration was defined as having contact with family and/or friends and functioning was defined as having employment and no difficulties in self-care. Male gender was associated with poorer self-care, and female gender was slightly, but significantly, associated with a greater likelihood of having friends. Conclusion: There is a strong relationship between social networks and functioning after taking account of course of illness. That is, the presence of family and friends is generally associated with better self-care and employment. Interventions that are targeted at improving social relationships are likely to have a positive impact on self-care and occupational functioning (and vice versa).

‘Earning and learning’ in those with psychotic disorders: The second Australian national survey of psychosis:

Objective: Participation in mainstream education and employment facilitates both the recovery and the social inclusion of people with psychotic disorders. As part of the second Australian survey of psychosis, we assessed labour force activity and participation in formal education among working age adults with psychotic disorders. Method: Data were drawn from a large national community prevalence survey of adults with psychotic disorders. Known as the Survey of High Impact Psychosis (SHIP), it was conducted in seven Australian catchment areas during March to December 2010. Current and past year labour force activity, current employment, past year participation in formal education and vocational training, and key clinical and demographic characteristics were examined in a sample of 1825 participants. Results: Only 22.4% of people with psychotic disorders were found to be employed (either full-time or part-time) in the month prior to the survey. In the previous 12 months, 32.7% were employed at some time. Of those in competitive employment, the majority worked part-time (63.9%), while a quarter worked 38 or more hours per week (23.4%). In terms of educational attainment, 18.4% reported difficulties with reading or writing, while 31.9% completed high school, which represents 12 years of formal education. Conclusions: The proportion currently employed has remained stable at 22% since the last national survey in 1997. Policy makers and service providers could do more to ensure people with psychotic disorders obtain access to more effective forms of assistance with respect to both their continuing education and employment. More effective vocational and educational interventions for people with psychotic disorders appear to be urgently needed.

Perceived need for mental health care: influences of diagnosis, demography and disability.

BACKGROUND Recent major epidemiological studies have adopted increasingly multidimensional approaches to assessment. Several of these have included some assessment of perceived need for mental health care. The Australian National Survey of Mental Health and Wellbeing, conducted in 1997, included a particularly detailed examination of this construct, with an instrument with demonstrated reliability and validity. METHODS A clustered probability sample of 10641 Australians responded to the field questionnaire for this survey, including questions on perceived need either where there had been service utilization, or where a disorder was detected by administration of sections of the Composite International Diagnostic Interview. The confidentialized unit record file generated from the survey was analysed for determinants of perceived need. RESULTS Perceived need is increased in females, in people in the middle years of adulthood, and in those who have affective disorders or co-morbidity. Effects of diagnosis and disability can account for most of the differences in gender specific rates. With correction for these effects through regression, there is less perceived need for social interventions and possibly more for counselling in females; disability is confirmed as strongly positively associated with perceived need, as are the presence of affective disorders or co-morbidity. CONCLUSIONS The findings of this study underscore the imperative for mental health services to be attentive and responsive to consumer perceived need. The substantial majority of people who are significantly disabled by mental health problems are among those who see themselves as having such needs.

'Earning and Learning' in those with psychotic disorders : the second Australian survey of psychosis.

Objective: Participation in mainstream education and employment facilitates both the recovery and the social inclusion of people with psychotic disorders. As part of the second Australian survey of psychosis, we assessed labour force activity and participation in formal education among working age adults with psychotic disorders. Method: Data were drawn from a large national community prevalence survey of adults with psychotic disorders. Known as the Survey of High Impact Psychosis (SHIP), it was conducted in seven Australian catchment areas during March to December 2010. Current and past year labour force activity, current employment, past year participation in formal education and vocational training, and key clinical and demographic characteristics were examined in a sample of 1825 participants. Results: Only 22.4% of people with psychotic disorders were found to be employed (either full-time or part-time) in the month prior to the survey. In the previous 12 months, 32.7% were employed at some time. Of those in competitive employment, the majority worked part-time (63.9%), while a quarter worked 38 or more hours per week (23.4%). In terms of educational attainment, 18.4% reported difficulties with reading or writing, while 31.9% completed high school, which represents 12 years of formal education. Conclusions: The proportion currently employed has remained stable at 22% since the last national survey in 1997. Policy makers and service providers could do more to ensure people with psychotic disorders obtain access to more effective forms of assistance with respect to both their continuing education and employment. More effective vocational and educational interventions for people with psychotic disorders appear to be urgently needed.