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research-article2013

ISP60710.1177/0020764013511793International Journal of Social PsychiatryStefanatou et al.

E CAMDEN SCHIZOPH

Article

Measuring the needs of mental health patients in Greece: Reliability and validity of the Greek version of the Camberwell Assessment of Need

International Journal of Social Psychiatry 2014, Vol. 60(7) 662­–671 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013511793 isp.sagepub.com

Pentagiotissa Stefanatou,1 Eleni Giannouli,1 George Konstantakopoulos,1,2 Silia Vitoratou,3 and Venetsanos Mavreas4

Abstract Background: Evaluation of mental health services based on patients’ needs assessments has never taken place in Greece, although it is a crucial factor for the efficient use of their limited resources. Aim: To examine the inter-rater and test–retest reliability and the concurrent/convergent validity of the Greek research version of the Camberwell Assessment of Need–Research (CAN-R). Method: A total of 53 schizophrenic patient–staff pairs were interviewed twice to test the inter-rater and test–retest reliability of the Greek version of the CAN-R. The World Health Organization Quality of Life–Brief Form (WHOQOLBREF) and World Health Organization Disability Assessment Schedule–2.0 (WHODAS-2.0) were administered to the patients to examine concurrent validity. Results: The inter-rater and test–retest reliability of patient and staff interviews for the 22 individual items and the eight summary scores of the instrument’s four sections were good to excellent. Significant correlations emerged between CAN scores and the WHOQOL-BREF and WHODAS-2.0 domains for both patient and staff ratings, indicating good concurrent validity. Conclusion: Our results suggest that the Greek version of the CAN-R is a reliable instrument for assessing mental health patients’ needs. Moreover, it is the first CAN-R validity study with satisfactory results using WHOQOL-BREF and WHODAS-2.0 as criterion variables. Keywords Needs assessment, Camberwell Assessment of Need, mental health services, quality of life, Greece

Introduction Systematic need assessment has been highlighted as a crucial factor in the development, planning, organization and evaluation of mental health services, providing substantiated results on the adequacy and effectiveness of therapeutic interventions (Brewin, 1992; Brewin, Wing, Mangen, Brugha, & MacCarthy, 1987; Hansson, Björkman, & Svensson, 1995; Slade, Leese, Taylor, & Thornicroft, 1999). Given the underfunding of psychiatric services in Greece due to the current economic crisis, systematic need assessment is expected to contribute to the efficient use of their limited resources for the development of appropriate interventions to cover the needs of mental health patients (Slade & McCrone, 2001) and enhance their quality of life (QoL) (Lasalvia et al., 2005; Slade et al., 2004; Slade, Leese, Cahill, Thornicroft, &

Kuipers, 2005). However, service evaluation based on patients’ need assessments has never taken place in the 11st

Department of Psychiatry, Athens University Medical School, Eginition Hospital, Athens, Greece 2Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, King’s College London, London, UK 3Department of Statistics, Athens University of Economics and Business, Athens, Greece 4Department of Psychiatry, School of Medicine, University of Ioannina, Ioannina, Greece Corresponding author: Pentagiotissa Stefanatou, 1st Department of Psychiatry, Athens University Medical School, Eginition Hospital, Vas. Sofias Ave, 72-74, Athens 11528, Greece. Email: [email protected]

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Stefanatou et al. country. A recent external evaluation of the national mental health reform programme in Greece (Thornicroft, Craig, & Power, 2011) identified three predominant shortcomings: (a) lack of research on mental health services, (b) programmes developed without being geared towards user needs and (c) programme users do not participate in decision-making processes on policy design in the mental health sector. The Camberwell Assessment of Need (CAN) developed by Phelan et al. (1995) is the foremost instrument for assessing needs of individuals with severe mental disorders. It is based on the principle that need is a socially negotiated and subjective concept, as there may be different, but just as valid, views between mental health patients and mental health professionals about the presence or absence of a certain need (Slade, 1994). The CAN assesses patients’ clinical and social needs, but also fundamental human needs. Staff and patient views are recorded separately, through independent structured interviews. Different versions of the instrument have been developed: the CAN-R for research and the CAN-C for clinical purposes (Slade, Thornicroft, Loftus, Phelan, & Wykes, 1999). Two short versions also exist: CAN Short Appraisal Schedule clinician (CANSAS-C; Slade, Thornicroft, et al., 1999) and patient version (CANSAS-P; Trauer, Tobias, & Slade, 2008). The CAN has four sections for each of its 22 need areas (see Table 1). Section 1 investigates the presence or absence of a certain need and whether it is met or unmet. Sections 2–4 assess the level of help received from relatives/friends, help received and needed from formal services and satisfaction with the type and amount of help. The psychometric properties of the CAN have been tested in various cultures (Flisher, Sorsdahl, & Joska, 2012; Hansson et al., 1995; Ruggeri, Lasalvia, Nicolaou, & Tansella, 1999; Schlithler, Scazufca, Busatto, Coutinho, & Menezes, 2007; Yeh, Luh, Liu, Lee, & Slade, 2006), and a European version (CAN-EU; McCrone et al., 2000) has been developed in a cross-national study. There are no standardized needs assessment instruments in Greece. The CAN-R 3.0 was translated into Greek (Papageorgiou, Simos, & Dimitriou, 1996; Simos et al., 1996); however, its psychometric properties have not been examined yet. This study aimed to evaluate the reliability (inter-rater and test–retest) and the concurrent/ convergent validity of the Greek version of the CAN-R. Our study comprises assessments of all reliability aspects, specifically inter-rater and test–retest reliability of both patient and staff interviews and for all sections of the instrument. Such an extensive investigation of CAN’s reliability has been reported only by Phelan et al. (1995) for the original CAN-R. All other studies on the reliability of the CAN-R reported only some aspects of inter-rater or test–retest reliability (Arvidsson, 2003; Flisher et al., 2012; Hansson et al., 1995; Schlithler et al., 2007; Yeh et al., 2006).

Previous studies of the CAN-R concurrent validity used the Global Assessment of Functioning scale (GAF; American Psychiatric Association, 1994) as a criterion variable and reported satisfactory results only for staff ratings (Ericson, Hansson, & Teike, 1997; Phelan et al., 1995). In the original psychometric study of the CAN, Phelan et al. (1995) found weak correlations between individual CAN item scores and the total GAF score, and moderate associations between the sum of seven staff-rated CAN items (which are more related to disability) and GAF ratings. The authors mentioned, ‘the lack of objective external criteria makes it difficult to establish concurrent validity’. Indeed, using the GAF as a criterion variable might have further contributed to this difficulty. The GAF is a crude estimate of global psychosocial functioning that has met with criticism in the past years as it incorporates psychopathological aspects and confuses them with psychosocial factors (Juckel et al., 2008). Despite evidence that patients are more reliable respondents (in terms of psychometric properties) than staff (MacCarthy, Benson, & Brewin, 1986; Slade, Leese, et al., 1999), previous studies testing the concurrent validity of the CAN-R yielded significant findings only for staff ratings, probably because comparisons were made with the GAF, which is a clinician-rated instrument. On the other hand, the subjective constructs of QoL and disability seem more closely related to the subjective concept of need on which the CAN is based, rather than the clinician-rated functioning. Besides, the strong associations found in a number of clinical studies between patient-reported needs through the CAN and subjective QoL (Hansson et al., 2003; Lasalvia et al., 2005; Slade et al., 2004; Slade et al., 2005; Slade, Leese, et al., 1999), as well as the significant correlations between perceived QoL and CAN factors (Korkeila et al., 2005), offer support to the aforementioned assertion. Against this background, we selected subjective QoL and disability assessment instruments as criterion variables to test concurrent validity of the Greek version of the CAN-R 3.0. We used patient-rated, valid and widely used scales, namely, the World Health Organization Quality of Life–Brief Form (WHOQOL-BREF; Ginieri-Coccossis et al., 2012; Skevington, Lotfy, & O’Connell, 2004) and the World Health Organization Disability Assessment Schedule–2.0 (WHODAS-2.0; Üstün et al., 2010).

Methods Sample A total of 53 patient–staff pairs were consecutively recruited from the outpatient and inpatient services of the Eginition Hospital, 1st Department of Psychiatry, University of Athens, and the University Mental Health Research Institute (UMHRI) in Athens. Of the above, 31 patients were treated in Eginition Hospital units (8 in

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inpatient psychiatric wards, 13 in a day-hospital and 10 in a community mental health centre), while 22 patients attended the UMHRI rehabilitation unit. Patient inclusion criteria were (a) diagnosis of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria (American Psychiatric Association, 2000), (b) aged 18– 65 years, (c) illness duration of at least 1 year and (d) clinical stability during the last month. Exclusion criteria included mental retardation and history of serious neurological disorder. The sample consisted of 40 males (75%) and 13 females (25%). The mean age of the sample was 37.1 (±8.7) years ranging from 20 to 55 years, and the mean years of education was 12.2 (±2.8) years. Most of the participants (75%) were unemployed, 15% were students or retired and only 15% were employed. The majority of the participants lived with their parents and/or other family members (66%). Only five patients (9.4%) were or had been married. The mean duration of illness was 15.2 (±8.2) years, and the mean number of hospitalizations was 2.2 (±2.1). All the patients were taking antipsychotic medication at the time of assessment. All patients and their treating clinicians or keyworkers were fully informed for the purposes of the study and provided written consent. The study was approved by the Eginition Hospital ethics committee.

Instruments CAN.  In this study, the Greek translation of the CAN-R 3.0 was used. The Greek version of CAN-R (Papageorgiou et al., 1996) has been refined through translation and back translation according to the instructions given by the originators of the scale (Simos et al., 1996). The assessment procedure of the CAN-R has four sections for each of its 22 need areas (see Table 1). Section 1 assesses whether, during the last month, a need existed for each area as follows: 0 = no problem, no need; 1 = no/moderate problem due to effective help given, met need; 2 = current serious problem, regardless of any help received, unmet need; 9 = not known. Section 2 investigates the level of help the patient receives from relatives/friends. Section 3 investigates the level of help that is received (3.1) and needed by formal services (3.2). The items of Sections 2 and 3 are rated from 0 (none) to 3 (high help). Section 4 asks whether the help the patient receives is appropriate (4.1) and adequate (4.2). The second question is addressed only to the patient, and both questions are rated as yes or no. Summary scores are calculated for the total number of needs, met needs, unmet needs, total level of help received by relatives/friends and services, help needed by services and the total level of satisfaction with the type and amount of help. Summary scores are calculated separately for staff and patients.

WHOQOL-BREF. The WHOQOL-BREF (Skevington et al., 2004) is the abbreviated form of the WHOQOL-100 developed by the World Health Organization. The Greek version (Ginieri-Coccossis et al., 2012) is expanded by 4 items added for cultural adaptation purposes. The initial 26 items comprise four topics (domains): (a) Physical health and level of independence, (b) Psychological health and spirituality, (c) Social relationships and (d) Environment. The four additional items examine the following domains: (a) Nutrition, (b) Social life, (c) Family life and (d) Job satisfaction. All items are rated using a 5-point Likert scale. Two items are examined separately: question 1 asks about the individual’s overall perception of his or her QoL, and question 2 asks about his or her overall perception of his or her health. WHODAS-2.0.  WHODAS-2.0 (Üstün et  al., 2010) includes 36 items (rated with a 5-point Likert scale) which assess functioning and disability in six domains: (a) Understanding and communicating, (b) Getting around, (c) Self-care, (d) Getting along with people, (e) Life activities and (f) Participation in society. A profile of functioning is derived across the six domains, as well as a general disability score.

Procedure To assess inter-rater reliability, interviews were held by two clinical psychologists experienced in psychotic disorders and fully trained in the administration of the CAN. In particular, rater 1 conducted the interview, while rater 2 observed in silence (first assessment). The raters were not allowed to communicate, during or after the interview, regarding their evaluations. After 2 weeks, rater 1 repeated all interviews (second assessment) in order to assess test– retest reliability. Patient and staff interviews were conducted separately, but their interval never exceeded 5 days. A third rater (psychiatrist) administered the WHOQOLBREF and WHODAS-2.0 to the patients within 1–7 days of the first assessment in order to assess concurrent validity.

Statistical analysis In Section 1 of the CAN, two types of binary variables were constructed that indicate (a) the presence or absence of a need and (b) whether the need (if present) was met or unmet, for each area separately. Cohen’s kappa was then implemented to estimate the degree of agreement between raters and between assessments, according to the Landis and Koch (1977) classification. Subsequently, summary scores over all areas were computed for the total number of needs, as well as for the total number of met and unmet needs. Five total scores were constructed for Sections 2, 3.1, 3.2, 4.1 and 4.2 by summing the homonymous items

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Table 1.  Inter-rater reliability of Section 1 of the 22 CAN areas, for patient and staff ratings (N = 53), according to Cohen’s kappa (κ). CAN items

Patients

Staff



Presence or absence of need



%

κ

p

N

%

κ

p

Accommodation Food Looking after home Self-care Daytime activities Physical health Psychotic symptoms Information on condition Psychological distress Safety to self Safety to others Alcohol Drugs Company Intimate relationships Sexual expression Child care Education Telephone Transport Money Benefits

98.1 98.1 98.1 98.1 100 98.0 100 100 100 100 100 100 100 96.2 100 100 100 100 100 98.1 100 100

0.95 0.96 0.88 0.88 1.00 0.96 1.00 1.00 1.00 1.00 1.00 1.00

Measuring the needs of mental health patients in Greece: reliability and validity of the Greek version of the Camberwell assessment of need.

Evaluation of mental health services based on patients' needs assessments has never taken place in Greece, although it is a crucial factor for the eff...
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