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For peer review only

Perceived effects of the economic recession on population mental health, well-being and provision of care by primary

care users and professionals: A qualitative study protocol

Journal: BMJ Open

Manuscript ID bmjopen-2017-017032

Article Type: Protocol

Date Submitted by the Author: 02-Apr-2017

Complete List of Authors: Antunes, Ana; Nova Medical School, Nova University of Lisbon, Chronic Diseases Research Center (CEDOC) Frasquilho, Diana; Nova Medical School, Nova University of Lisbon, Chronic Diseases Research Center (CEDOC) Silva, Manuela; Nova Medical School, Nova University of Lisbon, Chronic Diseases Research Center (CEDOC) Pereira, Nádia; Institute of Social Sciences, University of Lisbon Cardoso, Graça; Nova Medical School, Nova University of Lisbon, Chronic Diseases Research Center (CEDOC) Caldas-de-Almeida, José Miguel; Nova Medical School, Nova University of Lisbon, Chronic Diseases Research Center (CEDOC) Ferrão, João; Institute of Social Sciences, University of Lisbon

<b>Primary Subject Heading</b>:

Mental health

Secondary Subject Heading: Qualitative research

Keywords: MENTAL HEALTH, QUALITATIVE RESEARCH, PRIMARY CARE

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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TITLE

Perceived effects of the economic recession on population mental health, well-

being and provision of care by primary care users and professionals: A

qualitative study protocol

Ana Antunes*, Diana Frasquilho, Graça Cardoso, Nádia Pereira, Manuela Silva, José Miguel Caldas-de-Almeida, João Ferrão Ana Antunes*, Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, NOVA University of Lisbon, Portugal. [email protected] Diana Frasquilho, Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, NOVA University of Lisbon, Portugal. [email protected] Manuela Silva, Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, NOVA University of Lisbon, Portugal. [email protected] Nádia Pereira, Institute of Social Sciences, University of Lisbon, Portugal. [email protected] Graça Cardoso, Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, NOVA University of Lisbon, Portugal. [email protected] José Miguel Caldas-de-Almeida, Chronic Diseases Research Center (CEDOC), NOVA Medical School | Faculdade de Ciências Médicas, NOVA University of Lisbon, Portugal.

[email protected] João Ferrão, Institute of Social Sciences, University of Lisbon, Portugal. [email protected] * Corresponding author Ana Antunes, NOVA Medical School | Faculdade de Ciências Médicas, Campo Mártires da Pátria, 130, 1169-056 Lisboa, Portugal E-mail: [email protected]

Word count: 3093

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ABSTRACT

Introduction: Economic recession periods can pose accentuated risks to population’s mental

health and well-being as well as additional threats to health systems. Users of health care and

health professionals are key stakeholders in care delivery; however, little attention has been

given to their experiences of the crisis. This paper presents a qualitative study protocol to

assess users’ and health professionals’ perceptions about the effects of the post-2008

economic recession on mental health and care delivery in the Lisbon Metropolitan Area,

Portugal.

Methods and analysis: A conceptual framework and methodology to assess perceived

effects of the economic recession by primary care users and professionals on population

mental health, well-being and provision of care is presented. Focus groups with users and

semi-structured interviews with health professionals will be carried out in three primary

health care units in Lisbon areas especially affected by the crisis. Thematic analysis of full

transcribed interviews will be conducted using an iterative and reflexive approach.

Ethics and dissemination: The study protocol was approved by the Ethics Committee of

NOVA Medical School, NOVA University of Lisbon. The findings will be useful for other

researchers and policymakers to develop and implement the assessment of prevailing

experiences of users and health professionals on the effects of the economic recession on

mental health and quality of care in primary health context, promoting their involvement and

contribution to services responsiveness.

Strengths and limitations

• Integration of the perspectives and experiences of two key informants: primary health care users and professionals

• Selection of primary health care centers in areas particularly affected by the economic crisis, based on key geographical indicators

• Studies about the impact of the economic crisis on mental health resorting to qualitative methods are scarce

• Dissemination of findings may contribute to redefine policy measures for better coordinated provision of care and efficiency improvement

Keywords: mental health, economic recession, qualitative research, user participation

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INTRODUCTION

In a period of economic recession, several health outcomes are likely to deteriorate,

particularly among those socially more vulnerable.[1] The potential negative effects of

economic recessions on mental health are likely to be more immediate and severe than those

on physical health and may include a higher proportion of mental health problems such as

common mental disorders, substance use disorders, and ultimately, suicidal behaviour.[1–4]

The latest economic recession that started in 2008 and affected many European

countries has hit hard Portugal and produced evident signs of economic contraction.[5] From

2011 to 2013 the country lost approximately 7% of GDP and the recession period was

characterized by rising deficits, which corresponded to 11.2% of GDP in 2010 and declined

to 4.4% in 2015, still above the 3% established limit of the European Union Stability and

Growth Pact.[6] Significant levels of government debt amounted 129% of GDP in 2013, a

value maintained in 2015.[7] The annual unemployment rate rose from 8.8% in 2008 up to

16.4%, one of the highest rates in Europe in 2013, declining to 12.6% in 2015, but still higher

than before the recession period.[8]

In 2011, Portugal had to reduce public spending while undergoing the financial

assistance programme from the European Union, the European Central Bank and the

International Monetary Fund (IMF), commonly known as Troika.[9] The memorandum

included an agreement to generate substantial cuts in the health system, which were achieved

through multiple ways, such as freezing or reducing salaries of health professionals and staff,

reducing existing staff and new hiring, increasing the number of patients per general

practitioner and reducing the amount paid for overtime work, as well as measures to reduce

demand of care by increasing co-payments. Nevertheless, broad co-payment exemptions in

health care delivery, based on several criteria such as economic deprivation, unemployment

and other vulnerable groups, may have reduced the impact of this measure.[5,10]

The economic recession, through its poor macroeconomic outlook and impact on the

economic, social and health system, is likely to have led to a deterioration of the mental

health of the population. This is particularly important considering that Portugal had already

one of the highest prevalence rates of mental disorders and mental health-related problems in

Europe before the recession (23%).[11] This scenario may have been further deteriorated by

changes in health care seeking behaviour and health care delivery due to problems such as

impoverishment, increased out-of-pocket payments in public services, and fear of

unemployment as a result of sick leave or time spent in health care.[10]

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Portugal, one of the European countries most affected by the economic crisis and

subsequent implementation of austerity measures, has been receiving proportionally less

attention regarding its population mental health and well-being consequences when compared

to other European countries, and studies on these matters are scarce.[5] Research on this

subject is increasingly relevant, mostly considering that appropriate policy responses may

ameliorate the potential rise of health and social inequalities in the Portuguese population.

The spill-over effects of the economic recession on mental health are difficult to

account for by quantitative measures. Thus, giving voice to users and health professionals is

imperative to better understand the economic crisis consequences and plan initiatives to

improve responsiveness of services, quality of care, and overall systems efficiency and

effectiveness.[12] Users and health professionals are major stakeholders in care delivery;

however, so far qualitative evidence of users and professionals’ experiences as result of

economic recession are very scarce and almost non-existent focusing mental health. This is,

to our knowledge, the first qualitative study in Portugal to explore, through the perceived

experiences of users and primary health care professionals, the effects of the current

economic recession on mental health of the population and on the health system.

METHODS AND ANALYSIS

Aims and objectives

The current study will be conducted under the scope of the Mental Health Crisis

Impact Study – MH Crisis Impact, which benefits from a grant from the Public Health

Initiatives Programme (PT06), financed by EEA Grants Financial Mechanism 2009-2014.

The objective of this study is twofold: 1) to follow-up participants of the World Mental

Health Survey Initiative Portugal carried out in 2008,[11,13] and compare epidemiological

data on mental health disorders, their determinants and use of services, before and after the

economic crisis; 2) to explore users’ and primary care health professionals’ perceptions on

the impact of the economic recession on mental health of the population and on mental health

care delivery.

Study design and setting

Given the exploratory nature of this research study, different qualitative methods were

considered to determine the best data collection procedure to address the study aims. The

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research team decided that the best methods were interaction with users in a group setting

(focus group interviews) and direct interaction with professionals on a one to one basis

through semi-structured interviews.

Primary health care centres were found to be the best setting for data collection. These

are proximity units, where local communities go to address their primary health care needs. A

geographical delimitation based on the socioeconomic typology of the Lisbon Metropolitan

Area – LMA was considered in order to select primary health care units that were in areas of

higher probability of economic recession impact (Table 1).[14] Three case studies were

selected: a suburban area located in an old industrial metropolitan axis (Póvoa Santa Iria

UCSP); a suburban area located in a recent metropolitan expansion axis, which is largely

occupied by semi and unskilled services and industry workers (São Marcos USF); and a

consolidated urban area where there is a mix of middle class neighbourhoods and social

housing (Olivais USCP).

Two existing types of primary health care units were considered for the purpose:

Personalized Health Care Centres (UCSPs) and Family Health Units (USFs). Some aspects of

the organization of the primary health care service are important to point out. In 2005 a

comprehensive reform was initiated to increase the accessibility, quality and efficiency of

primary care services, and to improve quality and satisfaction of both users and

professionals.[15] This reform lead to the creation of groups of health centres (ACES), to

aggregate and improve management of resources and structures, which are responsible to

ensure the provision of primary care to the population of specific geographic regions.[15]

Family Health Units (USFs) are constituted by small and interdisciplinary public primary

health care teams that provide individual and family health care with organizational,

functional and technical autonomy.[15,16] Personalized Health Care Centres (UCSPs) have a

similar size than USFs, with multiprofessional teams as well, providing personalized access

to care.[15] The two types of units differ by management model. In comparison with UCSPs,

USFs are autonomous in their action plans, make use of professionals’ participation in

management, and have a financial incentive scheme associated with the activity. Also in the

scope of access, the ratio of users to family doctor is higher in the model USF; however if all

enrolled users are considered, and not only those who have a family doctor, there are more

users enrolled per doctor in the UCSP.[17] At the moment, the study was approved in Póvoa

Santa Iria UCSP and São Marcos USF. Approval to conduct the study in Olivais USCP

awaits confirmation.

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Table 1. Primary care units considered for study

Primary health care units

Póvoa Santa Iria UCSP2 São Marcos USF3 Olivais UCSP2

Geographic Coverage

Civil Parish Póvoa de Santa Iria and Forte da Casa

Cacém and São Marcos Olivais

Municipality Vila Franca de Xira Sintra Lisbon

Region LMA LMA LMA

Primary health care centre characteristics

Typology UCSP USF (B) UCSP

ACES1 Estuário do Tejo Sintra Lisboa Central

Population (users) 26.483 13.306 17.657

Nº doctors 7 7 6

Nº nurses 11 6 10

Nº technical/operational assistants

9 5 5

1 ACES: Aggregation of Health Centres (Agrupamento de Centros de Saúde) 2 Data from 2016 3 Data from 2014 LMA - Lisbon Metropolitan Area

Participants

The study will be presented by the research team to the board of each primary health

care centre. A chosen delegate from the board of the primary care centre will be appointed as

the key contact with the research team. The semi-structured interviews with health

professionals and focus group interviews with users will be conducted together with socio-

demographic surveys. The following characteristics will be considered as inclusion criteria of

participants: being at least 18 years old, having the ability to understand and communicate in

Portuguese, and being a user or professional at that health care centre.

Health professionals

All health professionals (e.g. medical doctors, nurses, social workers, psychologists)

will be contacted by the delegate of the collaborating primary health care centre, to present

the study and invite them for the semi-structured interviews.

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Users

The delegate of the primary health care centres will present the study and request the

participation of a random and heterogeneous sample of users. In case of agreement, the users

will be contacted directly by the research team, communicating the date of the focus group

and confirming their attendance.

Data collection procedures

The interviews will cover broad themes around the perceived effects of the economic

recession on mental health and well-being of the population, and also on the healthcare

system. Interviews and focus group will take place at the health care centres.

The focus group interviews (Table 2) with users will enable researchers to collect

information about the patients’ perceptions of the impact of the current economic crisis on

their personal, occupational and family well-being, as well as information about the access

and utilization of health care services and proposed suggestions for measures to alleviate the

impact of the economic crisis in daily life, mental health and well-being at the health care

centre level and at a national level.

Table 2. Users’ focus groups topic guide

Broad topics Specific topics

Recession related risk factors for mental health problems

Employment, family, economic, social, lifestyle and health areas.

Changes in mental health and well-being

Perceived increase in psychological distress and its impacts on daily life.

Help-seeking behaviours At ease to seek for help for mental health problems; If positive, where and who.

Health provision Satisfaction with health care solutions; perceived changes in health provision during the economic crisis.

Proposed solutions Proposed measures to alleviate the impact of the economic crisis in daily life, mental health and well-being.

The health professionals’ semi-structured interviews will follow a protocol similar to

other relevant research in the area of health systems,[18,19] and will focus on professionals’

views about the potential consequences of the economic crisis on mental health and well-

being of the population, possible key determinants, their experience on its impact on the

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health care system and delivery of care, and proposed policy-measures to improve health care

delivery at local and national level during the economic crisis (Table 3).

Table 3. Semi-structured interviews topic guide with health professionals


Impact of the economic crisis in population mental health and well-being

Fluctuations in number of patients resorting to primary care; changes in health complaints; mental health problems; prescription of psychotropic medication; users’ social and economic complaints from the users.

Access to and quality of care Perceived changes in access and quality of care at local and national level; introduction of co-payments; short and long term impacts of austerity measures; changes in user's satisfaction.

Proposed Solutions Proposed policy-measures to improve population mental health, well-being, and access to and quality of care during the economic crisis.

Data analysis

All semi-structured interviews and focus groups will be transcribed verbatim,

analysed and codified, resorting to content analysis through an iterative and reflexive process.

Findings will emerge directly from raw data, based on an inductive approach. A hermeneutic

analysis of the transcripts, using constant comparison and category building procedures, will

allow the researchers to identify major themes supported with QSR NVivo 10 Software.[20]

An initial coding of the segments of the transcriptions, quotation by quotation, will be

conducted by two independent researchers following the protocol of Stemler and

collaborators.[21] The segments of coded text will be synthetized into categories and further

grouped into recurrent or most important themes.[22,23] The researchers will discuss on the

interpretation of the data and disagreements with a third researcher until consensus is

reached.

ETHICS AND DISSEMINATION

The protocol of the MH Crisis Impact Study, in which this study is integrated, was

approved by the Ethics Committee of the NOVA Medical School, NOVA University of

Lisbon. An information sheet with a description of the study design and objectives will be

presented to all participants. Each participant will be given a written informed consent for the

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interview recordings and collected materials. All data will be anonymous and confidential.

Data protection will be ensured by separating audio records, transcripts, consents, and

questionnaires. Code linking data to individuals will be safely stored and only accessible to

the research team. Furthermore, the transcription process and dissemination of the study will

anonymise the participants in order to protect their identity. All study materials will be

subject to strict protection and only available to the research team members.

This qualitative approach will contribute to the current knowledge of the effects of the

economic crisis in Portugal on mental-ill health and well-being of the population. It will also

provide a better understanding to the follow-up epidemiological data on mental health

disorders and use of services. The added value of this study lies on its concern with

underlying values, perceptions, attitudes and behaviours related to mental health and

utilization of health care delivery of users and health professionals in the specific context of

an economic recession, in (sub)urban geographical areas particularly affected by its

consequences. Rigorous standards of qualitative research, namely credibility, dependability,

confirmability and transferability, will ensure that the findings obtained are consistent with

the methods of the interpretivist paradigm and its information sources.[23]

The combined perspectives of users (subjects and objects to which care is

administered) and health professionals, ensures that all views may contribute to help

redefining policy measures for better coordinated provision of care and efficiency

improvement.[24] The results will be published in international and national peer-reviewed

journals and presented in international conferences. Furthermore, the results will be

disseminated nationally in seminars directed to the general public, students and policy makers

in the health and social sectors.

In conclusion, this qualitative study will allow us to shed light on social and economic

processes associated with perceptions of health, well-being and use of services during the

economic crisis. Thus, it will provide an innovative contribution for policy-measures, both

place-based and nationally, to properly address the consequences of the economic recession

in Portugal.

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DECLARATIONS

Conflict of interest:

None.

Funding:

The present manuscript was granted by the Public Health Initiatives Programme (PT06),

financed by EEA Grants Financial Mechanism 2009-2014. For further information, please

visit http//www.eeagrants.gov.pt/.

Author’s contributions:

AA and DF conceptualised the design and drafted the paper. JMCA is the principal

investigator in the MH Crisis Impact study and oversaw all activities. JF coordinated the

study design and implementation. GC, NP and MS collaborated in the drafting and reviewing

this manuscript. All authors revised, reviewed and approved the final paper.

Acknowledgments:

Antunes A receives a grant from the Portuguese Foundation for Science and Technology

(FCT), reference PD/BD/105822/2014.

The authors wish to thank Dr. Luís Pisco from ARS-LVT, Dr. Carla Abril from USCP Póva

de Santa Iria, Dr. Jorge Caixinhas from USF São Marcos and Dr. Bruno Heleno from NOVA

Medical School. Thanks are extended to all members of the MH Crisis Impact Study.

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care users and professionals: A qualitative study protocol in Portugal

Journal: BMJ Open

Manuscript ID bmjopen-2017-017032.R1


Date Submitted by the Author: 10-May-2017



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qualitative study protocol in Portugal



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ABSTRACT


health and well-being as well as additional threats to health systems. Users and health

professionals are key stakeholders in care delivery; however, little attention has been given to

their experiences of the crisis. This paper presents a qualitative study protocol to assess users’

and health professionals’ perceptions about the effects of the post-2008 economic recession

on mental health and care delivery in the Lisbon Metropolitan Area, Portugal.

Methods and analysis: A conceptual framework and methodology to assess perceived

effects of the economic recession by primary care users and professionals on population

mental health, well-being and provision of care is presented. Focus groups with users and

semi-structured interviews with health professionals will be carried out in three primary

health care units in Lisbon areas especially affected by the crisis. Thematic analysis of full

transcribed interviews will be conducted using an iterative and reflexive approach.









• Selection of primary health care centres from areas particularly affected by the economic crisis, based on key geographical indicators

• Studies about the impact of the economic crisis on mental health resorting to qualitative methods are scarce



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INTRODUCTION



























health of the population, through identified risk factors such as unemployment, precarious

working conditions, debt and higher levels of inequality.[11] In fact, current epidemiological

evidence indicates that, among several health outcomes, the impact of the economic recession

was more consistent regarding mental health and suicide.[12] Overall, studies in Southern

European countries, such as Greece, Spain and Italy, indicate an association between

deteriorating economic indicators and poor mental health, although the results should be

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cautiously interpreted.[12] Most studies show an increase in the prevalence of mental health

problems, for which economic hardship, employment insecurity and unemployment were

found to be important contributors.[13–17]


subsequent implementation of austerity measures, has received proportionally less attention

regarding its population mental health and well-being consequences when compared to other

European countries.[5] For instance, in a recent systematic review of the evidence on the

health outcomes during the economic crisis in Europe, no studies conducted in Portugal were

included.[12] This is particularly important considering that Portugal had already one of the

highest prevalence rates of mental disorders in Europe, with a 22.9% prevalence of any 12-

month mental disorders before the recession.[18] This scenario may have been further

deteriorated by changes in health care seeking behaviour and health care delivery due to

problems such as impoverishment, increased out-of-pocket payments in public services, and

fear of unemployment as a result of sick leave or time spent in health care.[10] Research on

this subject is increasingly relevant, due to the need to evaluate the specific needs of the

Portuguese context that will support appropriate policy responses aiming at ameliorating the

potential rise of health and social inequalities in the population.

In the context of the Portuguese National Health Service, primary health care

professionals have a crucial role as gatekeepers of the health system. Therefore, it is a key

action to continually promote primary health care as the first line of the health system to

provide care for mental health problems, by ensuring access and quality of care, as well as

guaranteeing adequate cooperation between primary care and specialized mental health

services.[11] Thus, giving voice to users and health professionals is imperative to better

understand the economic crisis consequences and plan initiatives to improve responsiveness

of services, quality of care, and overall systems efficiency and effectiveness.[19] Users and

health professionals are major stakeholders in care delivery; however, so far qualitative

evidence of users and professionals’ experiences as result of economic recession are very

scarce and almost non-existent focusing mental health, with exception of two qualitative

studies conducted in Spain with health professionals.[20,21] To our knowledge, this is the

first qualitative study to explore the effects of the current economic recession on mental

health of the population and on the health system, through the perceived experiences of both

users and primary health care professionals, which may contribute to the design of innovative

policies addressing the health and social impact of the economic recession.

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Aims and objectives








the impact of the economic recession on mental health of the population and on primary care

and mental health care delivery. This study protocol presents the qualitative study designed to

fulfil the second objective, which will complement the quantitative data obtained through the

epidemiological survey, to provide a comprehensive assessment of the impact of the

economic crisis.






through semi-structured interviews. Focus groups were considered the adequate data

collection methods among users due to the need to obtain a diverse array of perspectives and

given the interest in the comparisons made by the participants between their experiences. The

decision to conduct semi-structured interviews was made after consulting with health care

professionals, who referred they might not feel fully comfortable sharing their honest opinion

in the presence of other colleagues.



geographical delimitation based on an evaluation of the municipalities more affected by the

crisis[23] and the socioeconomic typology of the Lisbon Metropolitan Area (LMA)[24] were

considered in order to select primary health care units in areas of higher probability of

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economic recession impact. Three case studies were selected: a suburban area located in an

old industrial metropolitan axis (Póvoa Santa Iria UCSP); a suburban area located in a recent

metropolitan expansion axis, which is largely occupied by semi and unskilled services and

industry workers (São Marcos USF); and a consolidated urban area where there is a mix of

middle class neighbourhoods and social housing (Olivais USCP) (Table 1).


Personalized Health Care Centres (UCSPs) and Family Health Units (USFs). It is important

to point out some aspects of the organization of the primary health care service. In 2005 a



professionals.[25] This reform led to the creation of groups of health centres (ACES), to









management, and have a financial incentive scheme associated with the activity. In relation to

access, the ratio of users to family doctor is higher in the model USF; however if all enrolled

users are considered, and not only those who have a family doctor, there are more users

enrolled per doctor in the UCSP.[27] At the moment, the study was approved in Póvoa Santa

Iria UCSP and São Marcos USF and conditionally approved in Olivais USCP.

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Geographic Coverage




Region LMA LMA LMA





Nº doctors 7 7 6

Nº nurses 11 6 10


9 5 5


Participants



the key contact with the research team. The semi-structured interviews with health

professionals and focus group interviews with users will be conducted together with socio-

demographic surveys. The following characteristics will be considered as inclusion criteria of

participants: being at least 18 years old, having the ability to understand and communicate in

Portuguese, and being a user or professional at that health care centre.



will be contacted by the delegate of the collaborating primary health care centre, for the study

to be presented to them and, in case of agreement, to be invited for the semi-structured

interviews.

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Users

A convenience sample of users will be invited to participate in the study by the

delegate of the primary health care centre. In case of agreement, the users will be contacted

directly by the research team, communicating the date of the focus group and confirming

their attendance.




system.

Interviews and focus groups will take place at the health care centres. The topics covered by

the focus groups (Table 2) were based on literature regarding the main risk factors for mental

health problems during the economic crisis and barriers in services access.[2,11,12,28,29]

This approach will enable the researchers to collect information about the patients’

perceptions of the impact of the current economic crisis on their personal, occupational and

family well-being, as well as information about the access and utilization of health care

services and proposed suggestions for measures to alleviate the impact of the economic crisis

in daily life, mental health and well-being at the health care centre level and at a national

level.










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delivery at local and national level during the economic crisis (Table 3). The semi-structured

interview and the focus group questions have been already piloted on a selected group of

respondents to assess the adequacy of research questions.







The study design was conceived taken into consideration the recommended principles of data

saturation, which indicate that the number of focus groups necessary to reach thematic

saturation may vary from three to five, which, however, does not constitute a standard.[30]

Concerning health professionals, given the differences in professional backgrounds among

the participants, interviews are planned to be carried out until thematic saturation is reached.

Thematic saturation is considered when new concepts and themes no longer emerge from the

data.[31]

Data analysis


analysed and codified, resorting to content analysis through an iterative and reflexive process.

Findings will emerge directly from raw data, based on an inductive approach. A hermeneutic

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analysis of the transcripts, using constant comparison and category building procedures, will

allow the researchers to identify major themes supported with QSR NVivo 10 Software.[32]

An initial coding of the segments of the transcriptions, quotation by quotation, will be

conducted by two independent researchers following the protocol of Stemler and

collaborators.[33] The segments of coded text will be synthetized into categories and further

grouped into recurrent or most important themes.[34,35] In a first approach, focus groups and

semi-structured interviews will be analysed separately, through a detailed description and

interpretation of the main themes. In a subsequent approach, comparative and relational

analysis from the focus groups and semi-structured interviews will be carried out, in order to

identify how the perspectives of users and health professionals may converge or diverge in

specific subjects. The researchers will discuss on the interpretation of the data and

disagreements with a third researcher until consensus is reached. Findings will be reported

following the COREQ (Consolidated Criteria for Reporting Qualitative Research)

guidelines.[36]










anonymise the participants as a way of protecting their identity. All study materials will be







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the methods of the interpretivist paradigm and its information sources.[35] The limitations of

the present study are related to the research method itself, since the findings cannot be

extrapolated to other contexts. Another potential limitation anticipated by the researchers is

the possibility of over-representation of certain groups, such as retired or unemployed people,

which are more likely to participate in the focus groups.







in the health and social sectors and will contribute to the development of policy

recommendations, under the objectives of the MH Crisis Impact Study.





in Portugal.

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DECLARATIONS


None.

Funding:









Acknowledgments:




de Santa Iria, Dr. Jorge Caixinhas from USF São Marcos, Teresa Santos and Dr. Bruno

Heleno from NOVA Medical School. Thanks are extended to all members of the MH Crisis

Impact Study.

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References




economic recession : a systematic literature review. BMC Public Health Published

Online First: 2016. doi:10.1186/s12889-016-2720-y



6736(12)61228-8

4 World Health Organization Regional Office for Europe. Impact of economic crisis on

mental health. 2011.

http://www.euro.who.int/__data/assets/pdf_file/0008/134999/e94837.pdf (accessed

Feb 2017).



Health Policy (New York) 2016;120:833–9. doi:10.1016/j.healthpol.2016.04.009


Parliament 2015.




http://dx.doi.org/10.1787/na_glance-2015-en


nationality. 2017.http://ec.europa.eu/eurostat/web/lfs/data/database (accessed Feb

2017).


2014. doi:10.2765/85246



11 Martin-Carrasco M, Evans-Lacko S, Dom G, et al. EPA guidance on mental health and

economic crises in Europe. Eur Arch Psychiatry Clin Neurosci 2016;266:89–124.

doi:10.1007/s00406-016-0681-x

12 Parmar D, Stavropoulou C, Ioannidis JPA. Health outcomes during the 2008 financial

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crisis in Europe: systematic literature review. BMJ 2016;354:i4588.

13 Fiori F, Rinesi F, Spizzichino D, et al. Employment insecurity and mental health

during the economic recession: An analysis of the young adult labour force in Italy.

Soc Sci Med 2016;153:90–8. doi:10.1016/j.socscimed.2016.02.010

14 Economou M, Angelopoulos E, Peppou LE, et al. Enduring financial crisis in Greece:

prevalence and correlates of major depression and suicidality. Soc Psychiatry

Psychiatr Epidemiol 2016;51:1015–24. doi:10.1007/s00127-016-1238-z

15 Drydakis N. The effect of unemployment on self-reported health and mental health in

Greece from 2008 to 2013: A longitudinal study before and during the financial crisis.


16 Gili M, Roca M, Basu S, et al. The mental health risks of economic crisis in Spain:

evidence from primary care centres, 2006 and 2010. Eur J Public Health 2013;23:103–

8. doi:10.1093/eurpub/cks035

17 Urbanos-Garrido RM, Lopez-Valcarcel BG. The influence of the economic crisis on

the association between unemployment and health: an empirical analysis for Spain.

Eur J Heal Econ 2015;16:175–84. doi:10.1007/s10198-014-0563-y





involvement in mental health service planning and evaluation. 2005;14(01):1-3.










Health Syst 2013;7:19. doi:10.1186/1752-4458-7-19

23 Ferrão J. Território [Territory]. In: Portugal Social de A a Z: Temas em aberto.

Impresa Publishing 2013. 245–60.


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Oporto - 2011]. 2014.







Colet 2011;16:2841–52.








29 Andrade LH, Alonso J, Mneimneh Z, et al. Barriers to Mental Health Treatment:

Results from the WHO World Mental Health (WMH) Surveys. Psychol Med

2014;44:1303–17. doi:10.1017/S0033291713001943.

30 Morgan DL. Focus Groups as Qualitative Research. Sage Research Methods 2013;32–

46. doi:10.4135/9781412984287

31 Flick U. The SAGE handbook of qualitative data analysis. Sage 2011.

doi:10.4135/9781446282243.n33

32 Castleberry A. NVivo 10 [software program]. Version 10. QSR International; 2012.

Am J Pharm Educ 2014;78:1–2. doi:10.1016/j.asieco.2012.10.004

33 Stemler S, Colors P. An overview of content analysis - Practical Assessment, Research

& Evaluation. 2001;7:1–6.



2005;10:6–20. doi: 10.1258/1355819054308576.



36 Tong A, Sainsbury P, Craig J. Consolidated criterio for reporting qualitative research

(COREQ): a 32- item checklist for interviews and focus group. Int J Qual Heal Care

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2007;19:349–57. doi:10.1093/intqhc/mzm042



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care users and professionals: A qualitative study protocol in Portugal

Journal: BMJ Open

Manuscript ID bmjopen-2017-017032.R2


Date Submitted by the Author: 13-Jun-2017



Mental health




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TITLE



qualitative study protocol in Portugal



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ABSTRACT


health and well-being as well as additional threats to health systems. Users and health

professionals are key stakeholders in care delivery; however, little attention has been given to

their experiences of the crisis. This paper presents a qualitative study protocol to assess users’

and health professionals’ perceptions about the effects of the post-2008 economic recession

on mental health and care delivery in the Lisbon Metropolitan Area, Portugal.

Methods and analysis: The methodology to assess perceived effects of the economic

recession by primary care users and professionals on population mental health, well-being

and provision of care is presented. Focus groups with users and semi-structured interviews

with health professionals will be carried out in three primary health care units in Lisbon areas

especially affected by the crisis. Thematic analysis of full transcribed interviews will be

conducted using an iterative and reflexive approach.









• Selection of primary health care centres from areas particularly affected by the economic crisis, based on key geographical indicators

• Studies about the impact of the economic crisis on mental health using qualitative methods are scarce



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INTRODUCTION



























health of the Portuguese population. Studies in other Southern European countries indicate

that changes in socioeconomic conditions, such as economic hardship, job insecurity and

unemployment have a detrimental effect on mental health.[5,12–16] At the health-system

level, the additional pressures due to cuts in public funding are likely to endanger the health

system performance, affecting both demand (e.g. out-of-pocket payments) and provision of

care (e.g. cuts in human resources).[11,17] Therefore,despite increasing needs, the economic

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crisis may exacerbate existing problems and add new ones to the health systems, creating

additional challenges to the provision of care.[18]

It is important to aknowledge that the consequences of the economic crisis are likely

to vary across countries, with health system responses reflecting differences in context,

economic situation, type of welfare state and policy choices. Therefore, to design appropriate

policy recommendations, the specificty of each country and of its responses to the economic

crisis must be previously assessed.[17]


subsequent implementation of austerity measures, has received proportionally less attention

regarding its population mental health and well-being consequences when compared to other

European countries.[6] For instance, in a recent systematic review of the evidence on the

health outcomes during the economic crisis in Europe, no studies conducted in Portugal were

included.[5] This is particularly important considering that Portugal had already one of the

highest prevalence rates of mental disorders in Europe, with a 22.9% prevalence of any 12-

month mental disorders before the recession.[19] This scenario may have been further

deteriorated by changes in health care seeking behaviour and health care delivery due to

problems such as impoverishment, increased out-of-pocket payments in public services, and

fear of unemployment as a result of sick leave or time spent in health care.[11] Research on

this subject is increasingly relevant, due to the need to evaluate the specific needs of the

Portuguese context that will support appropriate policy responses aiming at ameliorating the

potential rise of health and social inequalities in the population.

In the context of the Portuguese National Health Service, primary health care

professionals have a crucial role as gatekeepers of the health system. Therefore, it is a key

action to continually promote primary health care as the first line of the health system to

provide care for mental health problems, by ensuring access and quality of care, as well as

guaranteeing adequate cooperation between primary care and specialized mental health

services.[20] Thus, giving voice to users and health professionals is imperative to better

understand the economic crisis consequences and plan initiatives to improve responsiveness

of services, quality of care, and overall systems efficiency and effectiveness.[21] Users and

health professionals are major stakeholders in care delivery; however, so far qualitative

evidence of users and professionals’ experiences as result of economic recession are very

scarce and almost non-existent focusing mental health, with exception of two qualitative

studies conducted in Spain with health professionals.[22,23] To our knowledge, this is the

first qualitative study to explore the effects of the current economic recession on mental

Page 4 of 16


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health of the population and on the health system, through the perceived experiences of both

users and primary health care professionals, which may contribute to the design of innovative

policies addressing the health and social impact of the economic recession.


Aims and objectives








the impact of the economic recession on mental health of the population and on primary care

and mental health care delivery. This study protocol presents the qualitative study designed to

fulfil the second objective, which will complement the quantitative data obtained through the

epidemiological survey, to provide a comprehensive assessment of the impact of the

economic crisis.






through semi-structured interviews. Focus groups were considered the adequate data

collection methods among users due to the need to obtain a diverse array of perspectives and

given the interest in the comparisons made by the participants between their experiences. The

decision to conduct semi-structured interviews was made after consulting with health care

professionals, who referred they might not feel fully comfortable sharing their honest opinion

in the presence of other colleagues.

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geographical delimitation based on an evaluation of the municipalities more affected by the

crisis[25] and the socioeconomic typology of the Lisbon Metropolitan Area (LMA)[26] were

considered in order to select primary health care units in areas of higher probability of

economic recession impact. Three case studies were selected: a suburban area located in an

old industrial metropolitan axis (Póvoa Santa Iria UCSP); a suburban area located in a recent

metropolitan expansion axis, which is largely occupied by semi and unskilled services and

industry workers (São Marcos USF); and a consolidated urban area where there is a mix of

middle class neighbourhoods and social housing (Olivais USCP) (Table 1).


Personalized Health Care Centres (UCSPs) and Family Health Units (USFs). It is important

to point out some aspects of the organization of the primary health care service. In 2005 a



professionals.[27] This reform led to the creation of groups of health centres (ACES), to









management, and have a financial incentive scheme associated with the activity. In relation to

access, the ratio of users to family doctor is higher in the model USF; however if all enrolled

users are considered, and not only those who have a family doctor, there are more users

enrolled per doctor in the UCSP.[29] At the moment, the study was approved in Póvoa Santa

Iria UCSP and São Marcos USF and conditionally approved in Olivais USCP.

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Geographic Coverage




Region LMA LMA LMA





Nº doctors 7 7 6

Nº nurses 11 6 10


9 5 5


Participants



the key contact with the research team.

The semi-structured interviews with health professionals and focus group interviews

with users will be conducted together with socio-demographic surveys. The following

characteristics will be considered as inclusion criteria of participants: being at least 18 years

old, having the ability to understand and communicate in Portuguese, and being a user or

professional at that health care centre.

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will be contacted personally by the delegate of the collaborating primary health care centre,

for the study to be presented to them and, in case of agreement, to participate in the semi-

structured interviews. The delegate will also be responsible to direct the health professionals

to the research team during data collection.

Users

A convenience sample of users will be recruited by the delegate of the primary health

care centre or their GP, who will reiterate that participation is voluntary. In case of

agreement, the telephone contacts will be provided to the research team to confirm the

attendance of the participants in the day of the focus group. Participants may also be recruited

in the waiting room during the day of the focus group by the delegate or by members of the

research team.




system.

Interviews and focus groups will take place at the health care centres. The topics covered by

the focus groups (Table 2) were based on literature regarding the main risk factors for mental

health problems during the economic crisis and barriers in services access.[2,5,20,30] This

approach will enable the researchers to collect information about the patients’ perceptions of

the impact of the current economic crisis on their personal, occupational and family well-

being, as well as information about the access and utilization of health care services and

proposed suggestions for measures to alleviate the impact of the economic crisis in daily life,

mental health and well-being at the health care centre level and at a national level.







Page 8 of 16


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delivery at local and national level during the economic crisis (Table 3). The semi-structured

interview and the focus group questions have been already piloted on a selected group of

respondents to assess the adequacy of research questions.







The study design was conceived taken into consideration the recommended principles of data

saturation, which indicate that the number of focus groups necessary to reach thematic

saturation may vary from three to five, which, however, does not constitute a standard.[31]

Concerning health professionals, given the differences in professional backgrounds among

the participants, interviews are planned to be carried out until thematic saturation is reached.

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Thematic saturation is considered when new concepts and themes no longer emerge from the

data.[32]

Data analysis


analysed and codified. Content and thematic analysis will be conducted through an iterative

and reflexive process. Findings will emerge directly from raw data, based on an inductive

approach. A hermeneutic analysis of the transcripts, using constant comparison and category

building procedures, will allow the researchers to identify major themes supported with QSR

NVivo 10 Software.[33] An initial coding of the segments of the transcriptions, quotation by

quotation, will be conducted by two independent researchers following the protocol of

Stemler and collaborators.[34] The segments of coded text will be synthesized into categories

and further grouped into recurrent or most important themes.[35,36] In a first stage, focus

groups and semi-structured interviews will be analysed separately, through a detailed

description and interpretation of the main themes. In a subsequent stage, comparative and

relational analysis from the focus groups and semi-structured interviews will be carried out,

in order to identify how the perspectives of users and health professionals may converge or

diverge in specific subjects. The researchers will discuss on the interpretation of the data and

disagreements with a third researcher until consensus is reached. Findings will be reported

following the COREQ (Consolidated Criteria for Reporting Qualitative Research)

guidelines.[37]









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anonymise the participants as a way of protecting their identity. All study materials will be











the methods of the interpretivist paradigm and its information sources.[36] The limitations of

the present study are related to the research method itself, since the findings cannot be

extrapolated to other contexts. Another potential limitation anticipated by the researchers is

the possibility of over-representation of certain groups, such as retired or unemployed people,

which are more likely to participate in the focus groups. Furthermore, by focusing on primary

health care users and professionals, the scope of this study does not allow to fully assess the

impact of the economic crisis in the health system, in matters such as the perspectives of

mental health professionals towards the provision of specialized mental health services

during the economic crisis.







in the health and social sectors and will contribute to the development of policy

recommendations, under the objectives of the MH Crisis Impact Study.





in Portugal.

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DECLARATIONS


None.

Funding:









Acknowledgments:




de Santa Iria, Dr. Jorge Caixinhas from USF São Marcos, Drª Paula Broeiro from USCP

Olivais and Dr. Bruno Heleno from NOVA Medical School. Thanks are extended to all

members of the MH Crisis Impact Study.

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