Increasing the sensitivity of the AQoL inventory for the evaluation of interventions affecting mental health

This paper presents the rationale and psychometric analysis for extending the inventory of the Assessment of Quality of Life (AQoL)-6D instrument. The resulting AQoL-8D has an 8 dimensional, 35 item inventory with greater sensitivity in the domain of mental health.The paper briefly reviews the existing QoL instruments used for economic evaluation of health programs. It outlines the steps adopted in developing the AQoL descriptive inventories and, specifically, the methods adopted for data collection and analysis for the AQoL-8D inventory.Three instruments are presented. The first, PsyQoL, is a 22 item instrument which represents the best statistical fit for the measurement of mental health related quality of life. The second, PsyQoL-Brief is a reduced form instrument which is combined with AQoL-6D as the basis for the third instrument, the AQoL-8D. Psychometric properties of the first instrument are excellent and the second are good. The full AQoL-8D has satisfactory properties. Results from a comparison with the original AQoL-6D are reported. The mental health content of AQoL-8D is unique amongst MAU instruments and, along with other AQoL instruments, unique in its derivation from psychometric analysis. Its application to mental health patients and the public demonstrates its ability to discriminate between the groups with greater sensitivity than the previous AQoL-6D instrument.

Quantitative evaluation in health promotion : What's the difference?

This is the third in a series of articles on quantitative evaluation in health promotion written by Damien Jolley for the Health Promotion Journal of Australia. The first of these articles, published in the December 2000 issue, discussed the ideas behind sample surveys and how they can be used to improve evaluation of health promotion initiatives.1 The second, in the April 2001 issue, discussed confidence intervals in more detail and presented some strategies for computing confidence intervals for population percentages, both manually and using appropriate computer software. 2

Assessment of proximal outcomes of self-management programs : translation and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQtm)

Purpose This paper describes the translation, cultural adaption, and psychometric evaluation of a German version of the Health Education Impact Questionnaire (heiQ™), a widely used generic instrument assessing a wide range of proximal outcomes of self-management programs.

Methods The translation was carried out according to international standards and included forward and backward translations. Comprehensibility and content validity were tested using cognitive interviews with 10 rehabilitation inpatients. Psychometric properties were examined in rehabilitation inpatients (n = 1,202) with a range of chronic conditions. Factorial validity was assessed using confirmatory factor analysis; concurrent validity was explored by correlations with comparator scales.

Results The items of the German heiQ™ were well understood by rehabilitation inpatients. The structure of the eight heiQ™ scales was replicated after minor adjustment. heiQ™ scales had higher correlations with comparator scales with similar constructs, particularly mental health concepts than with physical health. Moreover, all heiQ™ scales differentiated between individuals across different levels of depression.

Conclusion The German heiQ™ is comprehensible for German-speaking patients suffering from different types of chronic conditions; it assesses relevant outcomes of self-management programs in a reliable and valid manner. Further studies involving its practical application are warranted.

Improving access to evidence-based acute stroke services: development and evaluation of a health systems model to address equity of access issues

Level 1 evidence for management of patients with stroke in a dedicated Stroke Care Unit (SCU) demonstrates improved outcomes by about 20%. It has been estimated that 21% of Australian hospitals provide an SCU and that these SCUs are mainly located in either metropolitan sites and/or in hospitals with more than 300 beds. To address equity issues related to access to SCUs, the National Stroke Foundation and the Australian Government undertook the National Stroke Units Program. One program outcome was the development of a conceptual model of acute stroke service delivery. The development process and initial evaluation of the model are described. Use of the model to increase capacity within the health care system to treat stroke is discussed.

Evaluation of outcome in child and adolescent mental health services: children with persistent conduct problems

This article focuses on the evaluation of outcome in child and adolescent mental health services. We examined the outcomes of 46 children with persistent conduct problems by gathering at baseline and six months information from multiple informants on multiple domains including the functioning of the child, risk factors, and parents’ and children’s perceptions of the treatment process. A statistically significant reduction in oppositional/conduct symptoms was reported six months after the initial clinical contact. However, the majority of the group still scored within the clinical range. The various outcome measures are correlated to only a mild to moderate degree. Teachers did not notice the same degree of change at school, despite the changes noticed by parents. Symptom improvement and satisfaction with a service are two separate issues. Parents’ satisfaction was related to their perception of the therapist and the therapy offered. Their satisfaction was high if they perceived that the therapist was able to communicate well, show care and concern, and if the therapy was perceived as organized. Much can be learned from a comprehensive outcome measurement system within a mental health service.

Evaluation of a community-based mental health drug and alcohol nurse in the care of people living with HIV/AIDS

There is a growing need for advanced practice mental health and drug and alcohol nursing roles in the care of people living with HIV/AIDS; however, limited publications address these domains. This study evaluated a community-based mental health drug and alcohol nurse role caring for people living with HIV/AIDS (Mental Health D&A Nurse) in a large not-for-profit district nursing organization providing care to people living with HIV/AIDS in an Australian city. Outcomes from a client assessment and 6–8-week follow-up by the Mental Health D&A Nurse are presented as captured by the Depression Anxiety Stress Scales (DASS 21), Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Health of the Nation Outcome Scales (HONOS) and WHOQoL BREF. Mean scores and caseness were analysed, and significant differences were found on the 'impairment' and 'social problems' subscales of the HONOS. Results of semi-structured interviews with clients describe effective and supportive mental health care and health-promoting education following visits by the Mental Health D&A Nurse. These positive findings support continuing implementation of the role within this community setting and indicate that even greater benefits will ensue as the role develops further. Findings are of interest to clinicians and policy makers seeking to implement similar roles in community-based HIV/AIDS care.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

Improving collaboration between private psychiatrists, the public mental health sector and general practitioners : evaluation of the Partnership Project

Objectives: We describe the evaluation of the Partnership Project, which was designed to improve linkages between public and private sector mental health services. We consider the Project's key elements: a Linkage Unit, designed to improve collaborative arrangements for consumers and promote systems-level and cultural change; and the expansion of private psychiatrists' roles to include supervision and training, case conferencing and secondary consultation. The evaluation aimed to describe the impacts and outcomes of these elements.

Method: The evaluation used de-identified data from the Linkage Unit database, the Project's billing system, and the Health Insurance Commission (HIC). It drew on consultations with key stakeholders (semistructured interviews with 36 key informants, and information from a forum attended by over 40 carers and a meeting of five public sector and three private sector psychiatrists) and a series of case studies.

Results: The Linkage Unit facilitated 224 episodes of collaborative care, many of which had positive outcomes for providers, consumers and carers. It had a significant impact at a systems level, raising consciousness about collaboration and influencing procedural changes. Thirty-two private psychiatrists consented to undertaking expanded roles, and the Project was billed $78 032 accordingly. Supervision and training were most common, involving 16 psychiatrists and accounting for approximately 80% of the total hours and cost. Commonwealth expenditure on private psychiatrists' participation in the expanded roles was not associated with a reduction in benefits paid by the HIC. Key informants were generally positive about the expanded roles.

Conclusions: The Project represented a considered, innovative approach to dealing with poor collaboration between the public mental health sector, private psychiatrists and GPs. The Linkage Unit achieved significant systems-level and cultural change, which has the potential to be sustained. Expanded roles for private psychiatrists, particularly supervision and training, may improve collaboration, and warrant further exploration in terms of costs and benefits.

Diamond Dialogue method for the evaluation of personal well-being after a maternal health intervention in Lao PDR

This paper follows the genesis of an evolving tool to measure the impact of development interventions on personal well-being in non-literate and non-numerate communities. The Diamond Dialogue was adapted to evaluate the impact on women of the establishment of 17 one stop maternity waiting home/health promotion/income generating centres (Silk Homes) in Southern Lao PDR. The tool elicited data not accessible by research methods which assume literacy and numeracy and revealed that 86% of women who used the Silk Homes experienced substantial improvements in quality of life. The Diamond Dialogue can be modified to assess the outcomes of development interventions in a myriad of contexts.