Ellie Fossey

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.

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.

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.

Relationship of behavioural and symptomatic syndromes in schizophrenia to spatial working memory and attentional set-shifting ability

BACKGROUND Behavioural syndromes (thought disturbance, social withdrawal, depressed behaviour and antisocial behaviour) offer a different perspective from that of symptomatic syndromes on the disability that may be associated with schizophrenia. Few studies have assessed their relationship with neuropsychological deficits. We hypothesized that these syndromes may represent behavioural manifestations of frontal-subcortical impairments, previously described in schizophrenia. METHOD Long-stay inpatients (n=54) and community patients (n=43) with enduring schizophrenia were assessed, using measures of symptoms and behaviour and tests of executive functioning. The relationship between syndromes and neuropsychological function was assessed using multiple regression and logistic regression analyses. RESULTS Significant associations were found between performance on the spatial working memory task and the psychomotor poverty symptomatic syndrome, and between attentional set-shifting ability and both disorganization symptoms and the thought disturbance behavioural syndrome. These results were not explained by the effect of premorbid IQ, geographical location, length of illness or antipsychotic medication. Length of illness was an independent predictor of attentional set-shifting ability but not of working memory performance. CONCLUSION The specific relationship between negative symptoms and spatial working memory is consistent with involvement of the dorsolateral prefrontal cortex. The associations between difficulty with set-shifting ability and both disorganization symptoms and behaviours may reflect inability to generalize a rule that had been learned and impaired ability to respond flexibly. The specific relationship of illness duration to set-shifting ability may suggest progressive impairment on some executive tasks. The nature of these relationships and their neurobiological and rehabilitation implications are considered.

A conceptual review of functioning: implications for the development of consumer outcome measures

Objective: Australias National Mental Health Strategy aims to achieve improved consumer outcomes. The development and refinement of consumer outcome measures is targeted within the Second National Mental Health Plan. The National Standards for Mental Health Services identify measures of functioning, quality of life and satisfaction with services as relevant to assessing and monitoring consumer outcome. Consumers have described gauging their own recovery through the achievement of functional goals in everyday life. This paper reviews how functioning is viewed within the mental health field, and implications for developing better functional outcome measures. Method: Literature describing the development of measures of functioning, principles of outcome measurement, and functional outcomes for people with severe mental illness was identified, using PsycLIT. A review yielded themes reflecting a number of assumptions about the concept of functioning. Results: Functioning is inadequately defined, raising issues about what is focused on, and from whose viewpoint, each of which has implications for using measures of functioning to monitor consumer outcome. Conflation of dissimilar functional domains, and flawed assumptions about the importance of symptomatology in influencing functional outcome limit the sensitivity to meaningful change of functional measures. Consumer perspectives are relatively neglected in functional tool development. Conclusions: A conceptual framework that recognizes lived experience and the interaction between persons and their environment is much needed to guide the development of functional outcome measures. Qualitative and quantitative research methodologies should be used to advance understanding of functioning and to address limitations of current approaches to functional outcome measurement.

Workplace Accommodations for People with Mental Illness: A Scoping Review

Purpose Disability discrimination legislation means that employees with a disability or mental illness are legally entitled to reasonable workplace accommodations that enable them to work effectively and safely. This scoping review aims to investigate the types of workplace accommodations provided for people with mental illness, and their costs and benefits. Methods A literature search was conducted using five electronic databases. Peer reviewed research articles published between 1993 and June 2013 were included in this scoping review and their quality was assessed. Opinion papers, reports, and case descriptions were excluded. Results Nine studies explored workplace accommodations for people with mental illness. The most commonly reported work-related accommodations were flexible scheduling/reduced hours, modified training and supervision, and modified job duties/descriptions. The least common type of accommodation was physical modification to the workplace. For employees with persistent mental illness who were accessing a supported employment agency, the majority of accommodations related to support from the job coach or employment specialist, such as facilitating communication with the employer during hiring or on the job. The quality of the studies varied considerably and the benefits of the accommodations are not yet well documented. There is limited evidence that a larger number of workplace accommodations are associated with longer job tenure. Conclusions Workplace accommodations appear to be important to support employees with mental illness, but more accessible information about how disability discrimination legislation applies to this population is needed. Future research should address the implementation and effectiveness of mental health-related workplace accommodations.

Real lives, real jobs: Sustaining consumer perspective work in the mental health sector

Abstract Australian mental health policies and service standards expect that people with expertise by experience of mental health issues are actively involved at all levels of service planning, delivery, and evaluation. This consumer-led participatory research investigated the workforce issues facing consumer workers who undertake consumer perspective work in Victoria’s mental health services. A reference group with diverse experience of consumer perspective work and research in mental health services guided its design and implementation. Twenty-four consumer workers participated in focus groups or indepth interviews, and the data were analysed thematically and collaboratively in the reference group. Findings include: that consumer perspective work was viewed as enriching, challenging, and enables individuals to contribute their expertise by experience to a broader movement and cause, but educational and peer supervision options were limited and underdeveloped. Participants described working conditions that inadequately acknowledge the reality of a working life or the job demands. They also reported wide-ranging attitudinal, resource and infrastructure barriers that highlight inequalities experienced by the consumer workforce within mental health services. Leadership within the consumer workforce and the mental health sector were each seen as critical to addressing these issues. Consumer perspective work is employment, and therefore improvements in working conditions and career development opportunities are critical to achieving a sustainable consumer perspective workforce.

The assessment of perceived need

This innovative book considers ways to resolve the imbalance between the demand and supply of mental health services. Treatment services in most countries reach only a minority of people identified as suffering from a mental disorder. Few countries can provide adequate health services for all the mentally ill, yet none has developed a rational system to decide who should be treated. The questions are clear. Could we develop a staged treatment process to reach all in need? If not, how do we decide who to treat? What should the criteria be for deployment of scarce treatment resources? How do we determine such criteria? What are the ethical implications of applying such criteria? In this pioneering work, an international team of eminent psychiatrists, epidemiologists, health administrators, economists and health planners examine these questions. The result will inform and encourage all concerned with the equitable provision of mental health care. Pioneering study of how to solve the worldwide problem of matching limited available treatment resources to the need of all those suffering from mental disorders • International, multi-disciplinary team of 63 eminent contributors: psychiatrists, epidemiologists, health administrators, economists and health planners • An essential study that will inform and encourage all those who care for the mentally ill

Time use of people with schizophrenia living in North London: Predictors of participation in occupations and their implications for improving social inclusion

Background: How people spend their time is one indicator of community participation. Aims: This study aimed to identify illness-related and socio-demographic predictors of the participation of people with schizophrenia. Method: Time use for 24 hours was gathered from a representative community sample (n = 192) of people with schizophrenia in London. Logistic regressions were conducted to examine predictors of participation in vocation-related, social and leisure occupations. Results: Symptoms were not predictive of participation in any occupation examined. Age was an important predictor of involvement in most occupations: younger age predicting vocation-related (odds ratio (OR) = 1.03; 95% CI: 1.01 – 1.06) and social (OR = 0.98; 95% CI: 0.96 – 1.00) participation, while older age predicted active (OR = 1.02; 95% CI: 1.00 – 1.05) and passive (OR = 1.04; 95% CI: 1.01 – 1.07) leisure participation. Living alone strongly predicted passive leisure participation (OR = 3.71; 95% CI: 1.05 – 13.07). Conclusions: Age-related barriers to involvement in leisure, education and workforce participation merit further exploration. Strategies to diminish these barriers should be part of policies and actions directed towards more inclusive participation of people with schizophrenia within their communities. Also, strategies to improve social connectedness should attend to the needs of those who live alone. Declaration of interest: None.

Effective Interdisciplinary Teamwork: An Occupational Therapy Perspective

Objective: First, to describe the focus and scope of occupational therapy and some contributions of occupational therapy in mental health settings. Second, to identify opportunities for enhancing interdisciplinary teamwork so as to effectively address the full range of needs and issues experienced by people living with mental illness, from an occupational therapists perspective. Conclusions: The significance of occupation for health and wellbeing needs to be better understood within the mental health field, and wider community, if interdisciplinary teams are to more effectively address the occupational and other needs of those living with mental illness. To this end, improved opportunities for dialogue through shared education and professional development, informed dialogue about balancing generic, specialist and nonprofessional roles in service delivery, as well as inclusion of consumers and carers in these dialogues, are recommended.