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BRIEF COMMUNICATION |
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Year : 2012 | Volume
: 1
| Issue : 4 | Page : 293-296 |
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Web model of pathways to psychiatric care for Indian setting
Sumit Kumar Gupta
Department of Psychiatry, Institute of Human Behaviour and Allied Sciences, Dilshad Garden, Delhi, India
Date of Web Publication | 27-Feb-2013 |
Correspondence Address: Sumit Kumar Gupta CP-98, Pitampura, Delhi - 110 034 India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/2278-344X.107896
Context: The current linear models of pathways to psychiatric care fail to explain the complexities of pathways to psychiatric care found in Indian setting. Aims: To examine the pathways to psychiatric care taken by patients before attending the psychiatry outpatient department (OPD). Settings and Design: A cross-sectional descriptive study of pathways taken by patients attending the Psychiatry OPD of a tertiary care referral hospital in Delhi. Materials and Methods: All new patients attending the Psychiatry OPD who provided informed consent were asked questions as per a specifically designed semistructured proforma for collecting relevant data on pathways to psychiatric care. Statistical Analysis: Descriptive statistical analysis was employed in this study. Results: A total of 225 patients were analyzed for pathways to psychiatric care. No set sequence of any carer in pathway could be found. Hence, a web model of pathways to psychiatric care was used to explain the pathways. Conclusions: Web model is most suitable model to explain the complexities of pathways to psychiatric care found in Indian setting. Keywords: Care, pathway, model, psychiatric, web
How to cite this article: Gupta SK. Web model of pathways to psychiatric care for Indian setting. Int J Health Allied Sci 2012;1:293-6 |
Introduction | | | "Pathways to care" has been defined as "the sequence of contacts with individuals and organizations prompted by the distressed person's efforts, and those of his or her significant others, to seek help, as well as, the help supplied in that response." [1] Pathway has a "direction" (sequential ordering of individuals and organizations contacted during the effort) and "duration" (time lapse between the initiation of help seeking and the formation of contacts). [1]
A key concept of how people come to use health services is that of, illness behavior, developed by Mechanic (1968), which refers to the ways in which individuals, and significant others, perceive, evaluate, and act upon the symptoms of illness. [2] According to him, it is influenced by nature of symptoms; influence of cultural factors, particularly beliefs about illness; impact of symptoms on family and social functioning; response of significant others; and range of treatment responses available.
The first attempt to study the pathway to mental health care was made by Goldberg and Huxley. [3] Goldberg and Huxley conceptualized the pathway to psychiatric care as a progression through a series of levels, each separated by variably permeable filters. [4] Thus the first level is the prevalence of psychiatric disorders in the community, and the first filter is the decision to seek help. The second level is the proportion of those with a disorder who seek help, and the second filter is the recognition of a psychiatric disorder by the primary care provider. "Primary care total" is the population that consults general practitioners (GP) and has a mental disorder. "Primary care conspicuous" is a proportion that is detected by the GP. Further levels consider referral to specialized care and admission to hospital. This model fits well with a hierarchical system of care like in UK where the only access to specialized care is by referral from a primary care physician. This does not necessarily pertain to the Canadian or American system where there may be direct access to specialized care (termed as "The American bypass"). [4]
The Indian system is more complex than the Western system where there are multiple (and often unregulated) options available for the clients in all popular, folk, and professional sectors. [5],[6],[7] The linear sequential pathway to care proposed by Goldberg and Huxley or "The American bypass" model do not explain the haphazard sequence (or lack of sequence) found in Indian pathways to psychiatric care. The web model proposed in this study is an attempt to explain this complex nature of pathway to psychiatric care in Indian and many other similar societies.
Materials and Methods | | |
The study was carried out as part of MD thesis in University of Delhi. [8] The aim of the study was to examine the pathways to psychiatric care taken by patients before attending the psychiatry outpatient department (OPD). Universe of the study was the new patients attending the psychiatry OPD at the Govind Ballabh Pant hospital, a tertiary care referral hospital affiliated to Maulana Azad Medical College.
Inclusion criteria
- All new patients attending the psychiatric OPD of study hospital on Wednesdays and Saturdays.
- Those patients willing to give informed consent for participating in the study.
Study design
- The study is cross-sectional and observational in nature.
Methodology
- All the new patients coming to the psychiatry OPD of study hospital on Wednesdays and Saturdays who gave informed consent were taken up for the study.
- The semistructured proforma [Annexure 1] designed for the study was applied on these patients.
- A provisional diagnosis was made by a Senior Resident/Consultant (Psychiatry) on the basis of findings on clinical examination and investigations (if required).
Statistics
- The obtained data have been compiled and analyzed using descriptive methods.
Sample size
- A sample size of 225 patients was generated over a period of 10 months (January to October 2007).
Results | | |
Of the 225 patients enrolled, 120 (53.3%) were males and 105 (46.7%) were females. Of them, 152 (67.55 %) were from Delhi itself and the rest came from outside. Most of the patients assigned themselves to lower socioeconomic status (62.6%) with the rest to middle (36.9%) and upper (0.4%). Most of the patients were referred from other departments from within the study hospital (26.2%) or its associated hospitals (53.3%). Median duration of illness before reaching the study hospital was 2 years. Patients alone (16.9%) or with someone else's help (51.5%) initiated help seeking in most of the pathways. Physician (with degree/diploma in Medicine) were the most common first sources of help (30.2%), with general practitioners (MBBS) being the second most common (25.8%), and Psychiatrists at third place (15.6%). Each person had on average consulted more than three carers before coming to study hospital.
[Table 1] shows the transitions between subsequent carers in the pathway and delays between the first contact with the first carer and the first contact with the next carer (referred to as retention time). The longest retention time was seen for the study center psychiatrist. GPs and faith healers have short retention time.
In the light of findings of this study, a Web Model [Figure 1] of pathways is suggested in which there is no set sequence of any carer in the pathway and patients can contact any carer at any point of time. The curved arrows show that a single patient may consult different carers in the same category. The thickness of the arrows is proportional to the relative proportions found in the study. The straight arrows coming from outside indicate the first contact with carer. | Figure 1: Pathway diagram (the web model) Explanations: (1) Thickness of arrows is proportional to the number of patients in that part of 'pathway to care', (2) Arrows pointing from outside indicate the first contact with the carer, (3) Curved arrows imply the change in carer but within the same carer category, (4) Please note that there is no discernable sequence of carers in the pathway diagram (except the largest proportion of patients coming to 'study hospital psychiatrist' from 'medical specialists', which is an artefact created by nature of study hospital being a referral hospital (most patients went to the medical specialist in hospital associated with study hospital for referral purpose only))
Click here to view |
Discussion | | |
The formulation of pathways to psychiatric care on the basis of study findings was not possible on existing models. [Table 1] shows that patients have tendency to go to the other carer group or other carer from within the same carer group without a clear sequence. The proposed web model of pathways to psychiatric care is better able to depict the picture than the usual linear models because of the following:
- It does not assume any carer as the first carer in the pathway.
- It does not assume that patients are always propelled to more professional or specialized care.
- The relative importance of the carer group can also be visually found out in the diagram by the thickness of arrows around them.
The limitations of the study are as follows:
- The pathway of help seeking might not have ended at the study point. The cross-sectional nature of the study could have potentially restricted the unfolding of actual longer pathway.
- For some of the variables like socioeconomic status and mode of onset, patient or caregivers' definition was accepted, and no scale has been used. For the purpose of getting patients' perception, objectivity may have been compromised.
- Study center is situated in the capital along with 8-10 more government centers (providing free of cost services), which range from OPD services to Psychiatric Hospital through General Hospitals. Besides this, there are many private Psychiatrists and private Hospitals. Every center has different assets and liabilities. Pathway is not only guided by push, but also from pull. Therefore, study center might be having different type of pull and may be attracting patients of specific socioeconomic status, attitudes, and awareness.
Despite these limitations of this study, the model retains its utility in similar complex settings. As the pathways are unique for each set-up, each set-up should study its pathway and make necessary changes to better target the resources to those who need them. The methodology used should be designed keeping in mind the objectives, and should be tailor-made to the specific needs.
Acknowledgments | | |
The author thankfully acknowledges the supervision and support provided by his supervisors Dr. (Prof) Agrawal A and Dr. (Prof) Jiloha RC.
References | | |
1. | Rogler LH, Cortes DE. Help-seeking pathways: A unifying concept in mental health care. Am J Psychiatry 1993;150:554-61. [PUBMED] |
2. | Gill HP, Singh G, Sharma KC. Study of dropouts from a psychiatric clinic of a general hospital. Indian J Psychiatry 1990;32:152-8. [PUBMED] |
3. | Goldberg D, Huxley P. Mental Illness in the Community: The Pathway to Psychiatric Care. London: Tavistock; 1980. |
4. | Bland RC, Newman SC, Orn H. Help-seeking for psychiatric disorders. Can J Psychiatry 1997;42:935-42. [PUBMED] |
5. | World Health Organization. Mental Health Atlas. Geneva: World Health Organization; 2005. p. 232-5. |
6. | Thara R, Padmavati R, Srinivasan TN. Focus on psychiatry in India. Br J Psychiatry 2004;184:366-73. [PUBMED] |
7. | Khandelwal SK, Jhingan HP, Ramesh S, Gupta RK, Srivastava VK. India mental health country profile. Int Rev Psychiatry 2004;16:126-41. [PUBMED] |
8. | Gupta SK, Agrawal A, Jiloha RC. To Study The Pathways To Psychiatric Care In Patients Attending Psychiatry Out Patient Department Of A Referral Hospital. Thesis for the Degree of Doctor of Medicine (Psychiatry), University of Delhi. Create Space, 2012 ISBN 146816595X, 9781468165951.2012. |
[Figure 1]
[Table 1]
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