1) Characteristics of the study participants
The 450 consultations included 442 patients (2% did not consent), and all 18 care providers completed the self-assessment form.
1.1 Characteristics of study participants
The characteristics (sex, age, level of education, whether the patient came alone or was accompanied at the consultation, whether the patient responded personally or via the accompanying person) did not differ significantly between MH+ and MH- groups. However, the proportion of children aged 6-17 was higher in MH+ than in MH- facilities (see Table 1).
Table 1: Patients’ characteristics
Characteristics
|
|
MH+
|
MH-
|
OR
|
Number
|
%
|
Number
|
%
|
Sex
|
Female
|
101
|
57,7
|
135
|
50,6
|
REF
|
|
Male
|
74
|
42,3
|
132
|
49,4
|
0.75
|
Age
|
0-5 years old
|
44
|
25,1
|
82
|
30,7
|
REF
|
|
6-17 years old
|
45
|
25,7
|
36
|
13,5
|
2.3*
|
|
18-44 years old
|
59
|
33,7
|
104
|
39,0
|
1
|
|
> 45 years old
|
27
|
15,4
|
45
|
16,9
|
1.1
|
Level of education
|
No schooling
|
78
|
44,6
|
134
|
50,2
|
REF
|
|
Primary school
|
63
|
36,0
|
71
|
26,6
|
1.5
|
|
Secondary school or higher
|
34
|
19,4
|
62
|
23,2
|
0.9
|
Manner of presentation
|
Patient came alone
|
60
|
34,3
|
99
|
37,1
|
REF
|
|
With a companion
|
91
|
52,0
|
147
|
55,1
|
1
|
|
With more than one companion
|
24
|
13,7
|
21
|
7,9
|
1.9
|
Respondent
|
Patient
|
84
|
48,0
|
149
|
55,8
|
REF
|
|
Companion
|
91
|
52,0
|
118
|
44,2
|
1.4
|
|
Total
|
175
|
|
267
|
|
|
REF= reference group; OR= Odds Ratio
* Statistical significance (threshold 0.05)
1.2 Care providers and consultation characteristics
A total of 18 care providers was consulted by 450 patients in 12 health facilities. Seven providers, including 5 doctors, 1 nurse and 1 social worker (a retrained biologist) carried out the consultations in the MH+ centres. In the MH- centres, the consultations were conducted by 11 providers: 9 doctors and 2 nurses. The median duration of a consultation was 7 minutes in both facilities, but with 6 minutes as percentile 25 and 11 minutes as percentile 75 in MH+ versus 5 minutes as percentile 25 and 9 minutes as percentile 75 in MH- facilities (p = 0.013, Mann-Whitney-Wilcoxon test).2
2) Analysis of the overall perception of patients of their involvement in the care process
The average participation score is 23.20 (with an average of 3.87 per question) and a standard deviation (SD) of 4.21 (range 11 to 30). Participation scores among providers range from 19.12 to 26.96 (p <0.001). Among health facilities scores range from 20.49 to 26.96 (p <0.001). The participation score varies according to the health centre and to the consulting provider. The mean participation score is 24.21 (SD 3.75) and 22.54 (SD 4.36) for respectively MH+ and MH- health centres (see table 2). For an increase of one unit in the participation score, the odds to have consulted a MH+ provider is five times higher than the odds to have consulted a MH- provider (crude odds ratio of 5.29 with a 95% CI of 1.35-20.78, p=0.02). In general, care providers working in MH- health centres obtain relatively low scores in comparison to those in MH+ centres. However, there are exceptions: a doctor running a solo practice in a rural area and working in a MH- centre obtained the highest score. The internal consistency of the 6 PPS questions is satisfactory with a total McDonald omega coefficient of 0.83 and a hierarchical omega coefficient of 0.58. In the multivariable analysis, patients who visited a MH+ centre have a significantly higher participation score than those who consulted in a MH- centre (adjusted OR of 4.06 with a 95% CI of 1.17-14.10; p = 0.03).
Table 2. Perception of patients of their involvement in the consultation process: Multivariable analysis based on a linear 'Generalised Estimate Equation' model
Characteristics
|
Mean score (SD) of participation
|
Crude OR (95% CI)
|
Adjusted OR (95% CI)
|
Mental health
- MH+
- MH-
|
24.21 (3.75)
22.54 (4.36)
|
5.29 (1.35-20.78) *
1
|
4.06 (1.17-14.10) *
1
|
Patient’s age (continuous variable)
|
NA
|
1.00 (0.97-1.03)
|
|
Patient’s gender
- Male
- Female
|
23.11 (4.15)
23.29 (4.27)
|
0.96 (0.52-1.74)
1
|
|
Patient’s level of education
- University
- Secondary
- Primary
- No schooling
|
22.90 (5.20)
23.23 (4.39)
22.79 (4.04)
23.49 (4.11)
|
0.95 (0.08-10.68)
1.26 (0.49-3.23)
0.47 (0.20-1.09)
1
|
|
Interview language:
- Soussou
- Poular
- Malinke
- French
|
21.60 (4.29)
23.82 (3.77)
21.16 (4.53)
23.24 (4.56)
|
0.47 (0.10-2.29)
0.28 (0.08-0.96)
0.49 (0.07-3.61)
1
|
|
Age of the care provider (continuous variable)
|
NA
|
1.03 (0.93-1.14)
|
|
Number of years of experience of the care provider (continuous variable)
|
NA
|
1.01 (0.93-1.10)
|
|
Professional level of care provider:
- Doctor
- Non-medical
|
23.25 (4.33)
22.96 (3.56)
|
1.33 (0.23-7.60)
1
|
|
|
|
|
|
Duration of the consultation (continuous variable)
|
N/A
|
1.22 (1.08-1.37) *
|
1.21 (1.08-1.37) *
|
*value p<0.05
N/A: Not Applicable
3) Analysis of the different dimensions of patients' perception of their involvement in the care process
Out of the 8 exit interview questions, patients disagree most on questions 1 and 4 (Figure 1). The answers reflect the extent to which the patients feel supported by the care provider in participating in the consultation. The answers to question 8 suggest that patients want to be more actively involved in decision-making about their treatment. Paradoxically, the answers to questions 6 and 7 are generally positive, suggesting that participants are satisfied with their level of involvement. The answers to questions 2 and 3 indicate that patients generally believe that care providers adequately understand and address their concerns, and question 9 indicates that they are generally satisfied with the consultation process. The results presented in Figure 1 indicate a difference in favour of facilities that offer an integrated mental health package, with the exception of questions 8 and 9.
4) Comparison of care providers
Figure 2 shows the proportion of positive responses given by the patients in relation to the type of care provider (MH+ centres on the left side of the dotted line and MH- centres on the right). We note substantial variance in the proportion of positive responses across care providers for all questions except for question 9. The intraclass correlation coefficient (ICCs in Table 3), obtained from a multilevel multivariable analysis, indicates the variance in the scores because of different care providers. For questions 1 to 4, this coefficient lies between 4 and 8 percent. This indicates that the care provider plays a relatively important role in the score of these questions. For question 7, this is relatively less, but still considerable. There is no indication that the type of provider - physician or non-physician - has an influence on the outcome of the separate questions (Figure 2). However, as non-physicians are in the minority (4/18), the scope of our study does not allow us to take a clear stance on this issue.
Table 3: Results of the multi-level logistic regression
|
Q1: Comprehension support
|
Q2: Understanding of the concerns
|
Q3: Worries are alleviated
|
Q4: Participation in decision-making
|
Q7: Satisfaction
about the process
|
Q9: General satisfaction
|
Fixed effects
|
est
|
IC 95
|
est
|
IC 95
|
est
|
IC 95
|
est
|
IC 95
|
Est
|
IC 95
|
est
|
IC 95
|
Intercept
|
0.68
|
0.39-1.20
|
8.80
|
3.03-25.58
|
6.90
|
3.02-15.75
|
0.27
|
0.14-0.53
|
13.66
|
3.30-56.46
|
70.57
|
7.43-670.20
|
MH+
|
1.82
|
0.95-3.49
|
2.68
|
0.77-9.31
|
1.79
|
0.70-4.59
|
1.93
|
0.91-4.09
|
8.69
|
1.18-64.02
|
1.78
|
0.24-12.90
|
Age
|
1.00
|
0.99-1.01
|
1.00
|
0.98-1.02
|
1.00
|
0.98-1.02
|
0.99
|
0.98-1.00
|
1.02
|
1.00-1.04
|
1.01
|
0.97-1.05
|
Sex
|
0.91
|
0.61-1.37
|
1.83
|
0.79-4.28
|
1.01
|
0.54-1.90
|
0.96
|
0.59-1.55
|
1.11
|
0.49-2.54
|
2.38
|
0.44-12.92
|
Education
|
0.70
|
0.46-1.05
|
0.72
|
0.31-1.66
|
1.23
|
0.64-2.34
|
0.90
|
0.55-1.47
|
0.42
|
0.16-1.08
|
0.41
|
0.07-2.28
|
Random effects
|
var
|
CCI
|
var
|
CCI
|
var
|
CCI
|
var
|
CCI
|
Var
|
CCI
|
var
|
CCI
|
Care providers
|
0.2868
|
0.084
|
0.6176
|
0.068
|
0.4375
|
0.055
|
0.3431
|
0.054
|
1.948
|
0.19
|
0.9483
|
0.014
|
Legend. est: parameter estimate, var: variance between facilities, IC 95: 95% confidence interval, ICC: intra-class correlation coefficient, MH+: integrated mental health
5) Comparison of perceptions of care providers and patients
The scores that providers (MH+ and MH-) give themselves are all positive (Figure 3). However, there are significant differences between this self-assessment and the perception of patients regarding the help they receive in understanding the information related to their illness (question 1) and regarding their involvement in the treatment decision-making (question 4). The agreement between patients is high for the other questions.