For a few years now, a broad consensus has existed in the mental health field that services based on client needs are required to plan and direct staff interventions. However, service users and health care professionals have different perspectives on what constitutes a need (1). It was precisely to gauge the needs of people with severe mental health problems that the Camberwell Assessment of Need (CAN) questionnaire was developed (2). The CAN’s main feature is that it takes into account the viewpoint of both the user and the key health worker and thus provides a more comprehensive overview. The CAN’s reliability was tested over the past few years in the UK (3), in Scandinavia (4,5), in the Netherlands (6), and in Australia (7). However, few studies have used the CAN in a Canadian population. Moreover, except for studies by McCrone and others (8) and Najim and McCrone (9), few studies have analyzed the differences between users and staff by comparing different investigation sites. Further, earlier research has so far overlooked the relation between user–staff agreement in identifying problems and the capacity of local services to offer adequate help. This oversight is astonishing, given that the existence of a solid alliance between staff and patients is essential for the latter’s faithful adherence to treatment and medication (10).
This article aims to compare the responses of 165 pairs of users and staff regarding problems they have identified and the adequacy of help received through local services in 6 Quebec areas, using the French version of the CAN (11). This was the largest cohort to be studied with the CAN in a French-speaking area. This paper is drawn from a broader study of the capacity of integrated service systems to adequately meet the needs of individuals with severe mental health problems (12).
The study took place in a subregion of Montreal (Area 6), 2 local community service centre areas in the Quebec City region (Areas 3 and 5), and 3 areas in the peripheral regions (Area 1, Bas-Saint-Laurent; Area 2, ChaudiPre-Appalaches; and Area 4, Outaouais). Sites were selected to represent semiurban areas (Areas 1, 2, and 3), rural areas (Area 4), and urban areas (Areas 5 and 6). Populations ranged from 20 000 in Area 4 to 128 000 in Area 6.
The CAN covers 22 clinical and psychosocial domains grouped into 5 main categories: basic needs (accommodation, food, and daytime activities), health (physical health, psychotic symptoms, psychological distress, safety to self, safety to others, and alcohol or drug use), functioning (self-care, looking after the home, child care, education, and money), social (company, intimate relationships, and sexual expression), and services (information on the condition and its treatment, transports, telephone, and benefits). It has 4 distinct sections. In the first, the user indicates the problems perceived for each of the 22 domains on a
After approval by the hospital ethics committees, we selected users randomly from a list provided by hospital archives in the different areas. The targeted clientele, aged 18 to 65 years, had to have been hospitalized in the last year and diagnosed with severe mental health problems according to DSM-IV criteria. One staff worker identified by each user was also invited to answer the CAN. Recruitment was done from September 2003 to May 2004. The objective was to recruit 30 users and 30 staff per investigation site, except for the rural Area 4 (which had a recruitment target of 10 users and 10 staff) and the urban Area 6 (which had a target of 60 users and 60 staff). Last, the CAN was administered to a random sample of 186 users. The final total was 165 respondent pairs. The study focused on these 165 pairs, who were distributed as follows: Area 1, 30 pairs; Area 2, 30 pairs; Area 3, 26 pairs; Area 4, 10 pairs; Area 5, 24 pairs; and Area 6, 45 pairs. We conducted a statistical analysis of the data, using SPSS software (Version 11.5). We measured the level of agreement between the patients and their key health workers with the kappa coefficient.
Service Users’ Characteristics
The users were primarily men aged about 45 years (64.2%) and single (69%), childless (92.1%), unemployed (87.3%), with high school education (52.7%), and living in their own apartment (40.6%). In clinical terms, 92.8% were diagnosed with schizophrenia. Nearly 60% of the users in Areas 4 and 6 had been involved in displays of violence or prior legal problems. On average, they used 2.3 mental health resources (for example, outpatient clinics or follow-up in the community). Area 1 outranked the others with an average of 3.5 resources accessed per user, compared with 1.8 for Area 6.
Overall, 43.6% of the users identified a nurse as the most significant staff. Other professionals named by users were social workers (21.2%), psychiatrists (12.1%), educators (13.3%), community workers (6.1%), psychologists (2.4%), or occupational therapists (1.2%). Nurses formed a majority in Areas 1 and 6. Psychiatrists were primarily concentrated in Area 5, forming 50% of the staff. Social workers were the main professionals chosen in Area 2, and educators were the main ones chosen in Area 3. No category of professionals stood out in Area 4.
Profile of Problems
On the whole, the average number of problems identified by users (6.03) and staff (6.15) was very similar. In Areas 2 and 3, however, service users and their staff expressed major differences of opinion. Area 3, paradoxically, was the one in which users identified the fewest problems overall (4.57), but staff reported the greatest number (7.30). Inversely, in Area 2, the number of problems indicated by users (6.83) was clearly higher than the number in other areas, whereas the number that their staff reported (5.60) was below the average.
The problems most commonly encountered by users were as follows: psychotic symptoms (78.2% of users), company (52.7%), food (48.4%), daytime activities (47.3%), and money (46%). These problems were also most often invoked by staff. The main discrepancies between staff and users related to self-care (27.9% of staff reported problems, compared with 8.5% of users), benefits (16.9% of users, compared with 2.4% of staff), and information (38.8% of users, compared with 24.2% of staff).
Staff reported a slightly greater number of serious problems on average than did users (2.0, compared with 1.75). According to both users and staff, serious problems were encountered in terms of social needs. Company (30.9%) and daytime activities (23.0%) were the main domains in which users experienced serious problems, followed by money (14.5%), transportation (14.5%), and psychotic symptoms (13.3%). The main points of divergence were related to information (8.5% of users, compared with 1.8% of staff) and self-care (0% of users, compared with 6% of staff).
The main differences between users and staff were once again evident in Areas 2 and 3. In addition, staff and users in Area 6 identified far more problems, compared with the other areas, whereas the opposite was observed in Area 5. In 18 domains, the percentage of serious problems identified by users or staff from Area 6 exceeded the overall average.
The ratio of serious problems to overall problems was higher among staff (32.4%) than among users (29.1%). There was a marked discrepancy between users (22.8%) and staff (36.9%) in Area 2. Serious problems represented more than one-third of the problems in Areas 4 and 6, according to users and their staff.
Agreement in User and Staff Responses
Table 1 presents agreement on the existence of a problem according to the kappa coefficient. Agreement was considered to be almost perfect above 0.80, substantial between 0.61 and 0.80, moderate between 0.41 and 0.60, fair between 0.21 and 0.40, and slight between 0 and 0.20. Overall, agreement between users and staff was 0.42, or moderate. Area 1 clearly demarcated itself with an average coefficient of 0.64. Here, agreement was substantial in 9 domains. This area also had the highest rate of agreement concerning psychotic symptoms. Areas 2, 3, and 5 had moderate agreement, and there was slight agreement in Areas 4 and 6. In Area 6, absence of agreement was observed in 12 domains, with disagreement in 6 others.
Adequacy of Help Received
For help received, staff reported a rate of over 80% in all the areas studied. Users’ responses varied considerably from one area to the next. Area 1 was considered most successful in meeting users’ needs: a rate of 93% was reported for help received and considered appropriate. Areas 3 and 5 followed, with a score of roughly 80%. Next in line was Area 2, with about 70%, and Areas 4 and 6, with 60%.
The main differences between users and staff were evident in social needs and needs for services. In 4 areas, less than 50% of social needs received adequate help according to users; the exceptions were Areas 1 and 5, which were outstanding, with a rate of appropriate assistance of more than 80%. As for needs for services, the percentage of adequate help was lower than 70%, except in Areas 1 and 5. In all 6 areas, the percentage of adequate help received to obtain information and daytime activities was less than 75%. Moreover, according to users, adequate help was provided for only 63.1% of users’ problems with safety to self, 61.5% of their problems with drugs, 50% of their problems with telephone use, 46.1% of their problems with alcohol, and 35.7% of their problems with benefits. Almost all these ill-solved problems, and most of the problems with money and safety to others that did not receive adequate help, were found in Area 6.
It is important, as well, that the greater the similarity in user–staff responses, the higher the percentage of appropriate services provided to address users’ problems. This finding was even more evident when only the problems identified by both users and staff were presented. User–staff responses in Areas 1, 3, and 5 were almost identical. Moreover, the percentage of problems that received adequate help according to users from Areas 2, 4, and 6 increased significantly, exceeding 75%.
On average, the serious and overall problems identified by users and staff compared fairly well with those in most studies using the CAN (Table 2). The lower results found in certain studies (13,14) can be explained by the presence in the cohort of clients without psychosis. The exceptionally high figures found in Macpherson’s study (15) can be explained by the fact that the interviewers, being clinicians involved in following the users surveyed, were well acquainted with their needs.
As in most of the recent studies, a slightly higher number of serious problems overall were identified by staff. There were major differences in the 6 areas studied. This can be explained by the different categories of staff answering the CAN in the various areas (16). In all categories of needs, nurses tended to identify more moderate problems than did users. The areas with the fewest overall problems identified by staff were also those involving the fewest nurses. In contrast, psychiatrists tended to report only serious health problems, whereas social workers and other professionals primarily identified serious problems in the domains of basic needs, functioning, and services.
Psychotic symptoms, psychological distress, company, daytime activities, money, food, and looking after the home were the domains in which users and staff tended more to identify overall problems. These domains are generally associated with schizophrenia (17), which was the diagnosis for 93% of the clientele surveyed. Serious problems were those that local mental health services had the most difficulty resolving. According to the data, company and daytime activities were by far the domains with the greatest number of serious problems for both users and staff, which corresponds to findings in most studies conducted thus far with the CAN administered to a clientele with severe mental health problems. These 2 problems underscore how important it is for local mental health areas to consolidate resources that facilitate reintegration into the community. Moreover, transportation posed serious problems in all regions except the metropolitan region. This phenomenon can be explained by the major distances that users have to cover for access to certain services.
Agreement of user’s responses with those of their staff was moderate, with a coefficient of 0.42, which corresponds almost exactly to that of Slade and others’ study (0.44) (18). Despite a moderate coefficient, the clientele’s needs were met at a rate of more than 75%, according to users, and at a rate of more than 80%, according to staff. Areas 1, 3, and 5, with the highest user–staff agreement, also exhibited the highest percentage of appropriately addressed needs, according to both users and staff.
Inversely, the poor levels of agreement encountered in Areas 4 and 6 were expressed by a high percentage of inadequately addressed needs. The high percentage of individuals with prior legal problems or problems of violence in these 2 areas can undoubtedly explain the poor level of agreement found between users and staff. This clientele was definitely more mistrustful of staff and more resistant to services that they did not want or that were imposed on them. These 2 areas also had the highest number of users with 10 problems or more. In the face of such complex issues, services had to concentrate on some of the more important problems to the detriment of others that were considered to be secondary. According to Middelboe and others, information, benefits, intimate relations, and sexual expression are considered by staff to be problems of lesser importance because they are not directly related to schizophrenia (18), which explains the inadequate help or insufficient services to meet those needs. Nevertheless, one-half of the serious problems identified by users from Area 4 and more than one-quarter of those from Area 6 were in those 4 domains. Areas 1, 3, and 5 were, on the whole, less affected by these secondary problems. Serious problems were primarily concentrated in domains in which there was a specific service to address them (19). The exceptionally high level of agreement on the issues of accommodation and food in Area 3 can be explained by the high percentage of users living in supportive housing. Moreover, Area 6 was grappling with a greater number of more serious problems involving more domains. This corresponds to the findings of McCrone and others (9) and Najim and McCrone (10) to the effect that more needs are found in large urban centres. Although more infrequent, problems of alcohol, drugs, safety to self, and safety to others required frequent and varied use of the overall set of mental health services and intersectoral resources (for example, detoxification resources), as well as more concerted actions among these resources, to be adequately resolved (20). However, users from Area 6 used few of these services, compared with the clientele from other areas.
This study confirmed the existence of major differences in the perceptions of users and staff in assessing needs. Nonetheless, these divergences did not culminate in poor results in terms of adequate help from mental health services insofar as the level of agreement between users and staff was good for the main problems encountered by the clientele. Local particularities, individual characteristics of users and staff, types of needs, and the degree to which the clientele used the services can explain the low levels of agreement and poor rates of adequate help reported. Metropolitan areas seemed to be particularly vulnerable to these different aspects.
Funding and Support
This study was supported by grants from the Canadian Health Services Research Foundation, the Conseil québécois de la recherche sociale, the Quebec department of health and social services (Ministère de la santé et des services sociaux du Québec), the Institut national de santé publique du Québec, and the regional agencies of Quebec City, Bas-St-Laurent, Chaudière-Appalaches, Montréal-Centre and Outaouais.
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Manuscript received September 2003, revised, and accepted July 2004.
1. Assistant Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Researcher, Douglas Hospital Research Centre, Montreal, Quebec.
2. Research Associate, Douglas Hospital Research Centre, Montreal, Quebec.
3. Professor, Department of Psychiatry, Université de Montréal, Montreal, Quebec; Researcher Centre de recherche Fernand-Séguin (Hôpital Louis-H Lafontaine), Montreal, Quebec.
Address for correspondence: Dr M-J Fleury, Douglas Hospital Research Centre, 6875 LaSalle Blvd, Verdun, QC H4H 1R3
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