Patient satisfaction: ethnic origin or explanatory model?

Adapting the concept of explanatory models of illness to the study of youth violence

This study explores the feasibility of adapting Kleinman's concept of explanatory models of illness to the study of youth violence and is conducted within the hermeneutic tradition. Data were collected by interviewing 11 violent adolescents, their parents, and their caregivers. Four types of explanatory models representing the adolescent girls', the adolescent boys', the caregivers', and the parents' understanding of youth violence are found; they correspond sufficiently to Kleinman's concept and establish the feasibility of adapting it to the study of youth violence. The developmental nature of the parents' and adolescents' models makes it feasible to study them by means of hermeneutic methodology. There are some clinically significant discrepancies between the caregivers' and the clients' explanatory models; identifying such discrepancies is an essential step in the process of breaking down barriers to therapeutic communications. Violent adolescents should be encouraged to define their own explanatory models of violence through dialogue with their caregivers.

Parent-therapist communication and satisfaction with the services of a child development center: a comparison between Israeli parents-Jews and Bedouins

This study evaluates the level of general satisfaction with the services of a child development center in 2 groups of Israeli parents, Jews and Bedouins. It also assesses which 3 dimensions of therapist-parent communication significantly explain general satisfaction with the center's services. A total of 193 parents of children ranging from 6 months to 6 years of age participated in the study (84% response rate). Parents' attitudes regarding their communication with the center's therapists were evaluated by 15 items that were clustered into 3 dimensions of communication: caring, collaboration, and interest. General satisfaction with the center's services was high in both groups. Relatively high average scores were also given to the studied dimensions of communication. Jews were more satisfied with the center's services than were Bedouins and ranked caring and collaboration significantly higher than did Bedouins. Caring and collaboration best explained the variability in general satisfaction in a multivariate analysis. Being a Jew or a Bedouin parent was not found to be a significant explanatory variable of general satisfaction with the center's services. Therapists' expressions of care and collaboration with parents seem to be key factors in explaining parents' general satisfaction with rehabilitation services in the 2 different cultural groups. These factors should therefore be nurtured in order to ensure parents' satisfaction and participation in the ongoing and demanding process of child rehabilitation. The question of whether this finding is applicable to other populations has to be further studied.

Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting

Mutual understanding between physician and patient is essential for good quality of care; however, both parties have different views on health complaints and treatment. This study aimed to develop and validate a measure of mutual understanding (MU) in a multicultural setting. The study included 986 patients from 38 general practices. GPs completed a questionnaire and patients were interviewed after the consultation. To assess mutual understanding the answers from GP and patient to questions about different consultation aspects were compared. An expert panel, using nominal group technique, developed criteria for mutual understanding on consultation aspects and secondly, established a ranking to combine all aspects into an overall consultation judgement. Regarding construct validity, patients' ethnicity, age and language proficiency were the most important predictors for MU. Regarding criterion validity, all GP-related criteria (the GPs perception of his ability to explain to the patient, the patient's ability to explain to the GP, and the patient's understanding of consultation aspects), were well-related to MU. The same can be said of patient's consultation satisfaction and feeling that the GP was considerate. We conclude that the Mutual Understanding Scale is regarded a reliable and valid measure to be used in large-scale quantitative studies.

Culturally competent systems of care for children's mental health: advances and challenges

There has been a remarkable growth in cultural diversity in the United States over the past 20 years. The population of minority groups has increased at a much faster rate than the European-background population in America, and faster even among children and youth. At the same time, minority youth face increasing disparities in their mental health and in access to mental health services. These are related to the multiple challenges they already face in socioeconomic status, but are aggravated by the lack of culturally competent services that can address their specific mental health needs within the context of their culture, family, and community. This paper reviews the current knowledge about the mental health of culturally diverse youth in the United States, and provides guidance on approaches to address the disparities they face.

Explanatory models of illness in schizophrenia: comparison of four ethnic groups

BACKGROUND

Explanatory models of illness may differ between ethnic groups and influence treatment satisfaction and compliance.

AIMS

To compare explanatory models among people with schizophrenia from four cultural backgrounds and explore their relationship with clinical and psychological characteristics.

METHOD

Explanatory models, insight, treatment compliance, health locus of control, quality of life, treatment satisfaction, therapeutic relationships and symptomatology were assessed in UK Whites and Bangladeshis, African-Caribbeans and West Africans.

RESULTS

When biological and supernatural causes of illness were compared, Whites cited biological causes more frequently than the three non-White groups, who cited supernatural causes more frequently. When biological and social causes were compared, Whites cited biological causes more frequently than African-Caribbeans and Bangladeshis, who cited social causes more frequently. A biological explanatory model was related to enhanced treatment satisfaction and therapeutic relationships but not treatment compliance.

CONCLUSIONS

Explanatory models of illness contribute to patient satisfaction with treatment and relationships with clinicians.

The therapeutic relationship in the treatment of severe mental illness: a review of methods and findings

AIMS

To review the methods and findings from studies of the therapeutic relationship (TR) in the treatment of severe mental illness.

METHOD

A literature search was conducted to identify all studies that used an operationalised measurement of the TR in the treatment of severe mental illness.

RESULTS

Fifteen scales--the majority of which were developed for psychotherapy--and the expressed emotion index have been used. Most scales have acceptable internal, inter-rater and test-retest reliability. As none of the scales has been used in more than five studies, no single scale is widely established in psychiatric research. A more positive relationship consistently predicts a better short- and long-term outcome. It appears that a large global factor accounts for the greatest proportion of the variance in the therapeutic relationship.

CONCLUSIONS

The therapeutic relationship is a reliable predictor of patient outcome in mainstream psychiatric care. Valid assessments may need to take account of different, specific aspects of the relationship in psychiatric settings such as greater heterogeneity of treatment components and goals, increased variability of setting and the statutory responsibility of the clinician. Methodological progress may require conceptual work to ensure valid assessments of this central element of treatment.

Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry

It has been consistently reported that the African-Caribbean population in the UK are more likely than their White counterparts to access psychiatric services via the police and under compulsion. The reasons for these differences are poorly understood. This paper comprises two main parts. The first provides a comprehensive review of research in this area, arguing the current lack of understanding stems from a number of methodological limitations that characterise the research to date. The issue of ethnic variations in pathways to psychiatric care has been studied almost exclusively within a medical epidemiological framework, and the potential insights offered by sociological and anthropological research in the fields of illness behaviour and health service use have been ignored. This has important implications as the failure of research to move beyond enumerating differences in sources of referral to psychiatric services and rates of compulsory admission means no recommendations for policy or service reform have been developed from the research. The second part of the paper sets out the foundations for future research, arguing that the pathway to care has to be studied as a social process subject to a wide range of influences, including the cultural context within which illness is experienced. It is further argued that Kleinman's (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry, University of California Press, Los Angeles, 1980) Health Care System model offers a particularly valuable preliminary framework for organising and interpreting future research. It is only through gaining a more qualitative understanding of the processes at work in shaping different responses to mental illness and interactions with mental health services that the patterns observed in quantitative studies can be fully understood. This further reflects the need for a bridge between the social sciences and psychiatry if services are to be developed to respond to the increasing diversity of modern societies.

Changes in satisfaction with mental health services among blacks, whites, and Hispanics in the Department of Veterans Affairs

This paper presents an analysis of changes in satisfaction of minorities with inpatient mental health services provided by the Veterans Health Administration (VHA) during a period of major system change (1995-2001). Post discharge data from 16,223 veterans who received inpatient VHA mental healthservices at 87 medical centers during this period was examined using hierarchical linear models. Blacks were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different. There was little change over the study period in the relative satisfaction of minorities and whites. Changes in patterns of VHA mental health care have not adversely affected the satisfaction of minority veterans.

African-Caribbean interactions with mental health services in the UK: experiences and expectations of exclusion as (re)productive of health inequalities

In the context of current concerns about health inequalities among minority ethnic groups in the UK, this paper addresses perceptions of mental health services among members of an African-Caribbean community in a South England town. Efforts to reduce health inequalities must take account of the views of local community members on the sources of those inequalities and on local health services. The statistical existence of inequalities in diagnosis and treatment of African-Caribbeans in the UK is well-established, supported by sociological explanations of these inequalities which centre on social exclusion in a variety of forms: institutional, cultural and socio-economic. However, detailed studies of the perspectives of local communities on mental health issues and services have received less attention. In this case study of community perceptions of mental health services, we find that social exclusion comprises an explanatory framework which is repeatedly invoked by community members in describing their interaction with mental health services. Interviewees assert that experience and expectation of racist mis-treatment by mental health services are key factors discouraging early accessing of mental health services, and thereby perpetuating mental health inequalities. We conclude that participation and partnership are vital means by which to generate both the objective and subjective inclusion that are requirements for an accessible and appropriate health service.

Understanding the excess of psychosis among the African-Caribbean population in England. Review of current hypotheses

BACKGROUND

Increased rates of schizophrenia continue to be reported among the African-Caribbean population in England.

AIMS

To evaluate the competing biological, psychological and social explanations that have been proposed.

METHOD

Literature review.

RESULTS

The African-Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African-Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings.

CONCLUSIONS

More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

What do patients want and do we want to know? A review of patients' requests of psychiatric services

OBJECTIVE

A systematic review was conducted of the literature concerning patients' requests of psychiatric care in order to identify the types of requests patients make, psychiatrists' perceptions of their patients' requests, and the relationship between requests and the outcome of care.

METHOD

A total of 28 published original articles which fulfilled specific inclusion criteria were reviewed.

RESULTS

The studies showed that there are certain core requests that patients make irrespective of the type of service attended. Patients mainly request psychological approaches, and the most common requests are for 'clarification', 'psychological expertise' and 'psychodynamic insight'. There is evidence that patients normally feel inhibited about making requests, and that psychiatrists often fail to identify what their patients want.

CONCLUSION

The majority of patients attending psychiatric services have requests which they will express when encouraged to do so, but little is known about the relationship between patients' requests and the outcome of care. Recommendations are made for future research.

Not listening to patients--the use and misuse of patient satisfaction studies

Demand for the development of health services that are responsive to the views of users has led to a growing interest in the measurement of patient satisfaction. Initial reluctance to seek the views of users of mental health services focused on a debate about whether or not mentally disordered patients were able to make 'valid' comments about their treatment. More recently the development of questionnaires that claim to 'reliably measure' the views of patients have coincided with a greater acceptance of the role that such studies can play. However, it is argued that the use of these quantitative and often simplistic methods underestimate the dissatisfaction of many patients. Further exploration of the differing expectations of users and providers of services and a degree of willingness in both parties to change is required if services are to be developed that better meet the needs of patients.