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Chapter 2: Purpose, Scope and Methodology

Background

The research addressed perceived gaps in information on the nature and scope of existing service provision in Scotland for people with co-morbid mental health and substance use problems.

The study was commissioned by the Effective Interventions Unit ( EIU) at the Scottish Executive as the first stage of its work in the field of co-morbidity. It complements the report of the SACAM/ SADAM Working Group, Mind the Gaps and a range of other UK-wide related initiatives and strategies. More detailed information on the nature and provision of care currently available will help to contribute to the development of the co-morbidity agenda in Scotland.

Purpose of the research

The study aimed to:

• identify the broad range of health and social care needs of people with co-morbid mental health and substance use issues in Scotland
• explore service users' experiences of accessing and receiving services from health, social care and independent organisations
• review the quality of current provision and organisation of health, social care and the independent sectors in meeting the needs of co-morbid individuals, identifying significant gaps in, and barriers to existing provision
• identify common factors that impede provision and organisation of health, social care and independent services for people with co-morbidity
• examine how different services relate to one another through informal and formal arrangements or protocols
• identify examples of good practice.

The research focused on the ways in which services were designed and delivered, and how services worked with each other to make sure that the individual needs of people with co-morbid problems were met. It did not examine the effectiveness of specific treatment interventions.

Practical objectives

The research programme was divided into two phases, a pilot phase and a main phase. The pilot phase tested the feasibility of the proposed main study and collected preliminary data. It provided advance warning of possible problem areas and indicated whether proposed methods or instruments were inappropriate or too complicated. It also helped highlight any logistical problems. The main part of the programme was revised to take account of these findings.

Parameters for the research study

Scope of Study

The study investigated the overall availability, nature and impact of service provision for co-morbid mental health and substance misuse across seven geographical locations, throughout Scotland. At each location in-depth interviews and focus group discussions were used to collect data from commissioners, service providers and service users.

Raising the profile of the project

Before the start of the main phase of the study, a number of presentations on the project took place at all research locations which were publicised by a combination of flyers, posters, advertisements and word of mouth. Potentially interested parties were invited to attend from a wide variety of backgrounds, including mental health, social work, substance misuse, general health and other social care agencies from the statutory and independent sectors.

The presentations served the dual purpose of recruiting focus group participants, both directly from the audience and indirectly, by members of the audience circulating information among their colleagues. Audience members were invited to place their name on a list of 'interested parties'.

Identifying the research localities

The study needed to capture a broad spectrum of practice and need across different geographical locations. This had to reflect the overall pattern of need throughout Scotland and cover both rural and urban locations.

Researchers used the Carstairs Deprivation Category ( DEPCAT) ¹ to identify different socio-demographic profiles within advantaged and disadvantaged geographical areas. They selected specific postcode areas based on a population size of around 100,000 to form the overall research locality boundary and maintain consistency throughout the seven study areas. These were divided by rurality and level of deprivation to create the following locality combinations:

• Metropolitan sites: SW Edinburgh (mixed levels of deprivation); NE Glasgow (high index deprivation)
• Largely urban: Dundee City in Tayside (largely high deprivation); Aberdeen in Grampian (largely low deprivation)
• Semi-rural: Levenmouth in Fife (high index deprivation); Falkirk in Forth Valley (mixed levels index deprivation)
• Largely rural: the Borders (low deprivation).

Collecting data

The main methods of data collection included in-depth, semi-structured face-to-face interviews with 26 commissioners and 38 service users. Focus group discussions were held with 90 service providers directly delivering interventions to service users. All interviews during the main stage of the study were either partially or fully transcribed to enable more efficient and consistent analysis.

The resulting narratives were subjected to Framework Analysis ², a form of thematic analysis developed specifically for public sector research.

Commissioners

Twenty six commissioners were interviewed for the project. These were core individuals from different public sectors who occupied senior managerial positions and had planning and commissioning responsibilities for their respective service sectors.

Selecting participants

The pilot stage of the project showed that identifying appropriate commissioners was not as straightforward as anticipated. Expert colleagues could not always agree on who could be defined as a commissioner, and identified individuals either denied that they occupied such a role or felt too uninformed to talk about aspects of co-morbidity.

Learning from the pilot phase, the research team worked with the EIU advisory group for the project to select and engage suitable commissioner participants. They identified specific positions identifiable by title in each region in order to offer consistency across research localities. The following participants were included in the study:

• Directors of Social Services: Local authority representatives. They oversee all social service departments and have a broad view of how these departments interlink with each other.
• Public health physicians: NHS representatives in field of general health. They are responsible for contributing to health improvement in their localities.
• Drug and Alcohol Action Team ( DAAT) co-ordinators: Accountable for the structural and procedural organisation around substance misuse. This includes the synchronising of their work with other relevant service providers.
• Lead Officers in Mental Health: Not necessarily from a mental health or medical background. This professional group brings a broad range of views on current issues in the mental health field.

Conducting interviews

The interview guide (see Appendix 2) was designed to enable the interviewer to cover a number of major topics in a systematic fashion while the unstructured nature captured rich accounts of service-related policy and practice. This allowed for an 'insider account' of the topic in question. It was important to capture the perspectives of the commissioners themselves, rather than allow researcher-bias to influence and shape the data gathered. The intention was to develop an account of the commissioners' broad views of issues relating to co-morbidity and to explore in depth specific issues relating to policy and practice. The methodology also had the benefit of being consistent with that used in gathering data for the service providers and service users.

Service Providers

Sixteen focus group discussions with service providers were carried out across the 7 locations. Each group was composed of between 8 and 10 people, on the assumption that around half the sample would attend. The actual size of the focus groups ranged between 3 and 14, with 90 service provider staff participating in total.

Identifying specific services

The research team assembled a list of all services available in the research localities, including services based in the social, mental health, and general health sectors as well as relevant agencies based in the independent sector. The objective was to obtain a cohort of participants from diverse backgrounds having either primary contact with co-morbid individuals, for example, addiction services or mental health services, or secondary contact, such as homeless associations and housing agencies.

Identifying individual providers

A multi-pronged approach was employed to recruit focus group participants. Initial presentations on the project served to heighten awareness and encourage participation. Members of the audience were invited to place their name on a list of willing parties and to inform their colleagues of the opportunity to participate. To complete the selection of participant providers, a diverse selection of agencies and organisations, identified via the list of services, were contacted at a later stage to recruit volunteers who had not attended the presentations.

Making initial contact

Following initial contact with a service, researchers liaised with a named member of staff to promote continued exchanges and to help with the final formation of the focus groups. These key contacts acted as 'champions' for the project to promote awareness and encourage participation.

Focus group composition

Focus group members were drawn from the following service groups:

• Mental Health services
• Primary Care services
• Addiction services
• Independent sector
• Social Services.

The focus groups were arranged by tier, to ensure a representative spread of participants by service type and by professional background. This structure also helped to discern service users' pathways through care and levels of interagency working, both formal and informal. The Tiers, as defined by Models of Care, consisted of a Tier 1 group (primary care, general mental health, social services, probation, etc), a Tier 2 group (open access or "street" agencies, info/advice shops, etc) and a group combining Tier 3 and 4 representatives (structured community services or structured day care, inpatient or residential specialist detoxification or rehabilitation services).

Tiers 1 and 2 were combined in the main part of the project, but the research team retained the ability to discern more generic service responses from more specialist service responses.

Conducting the groups

The discussions were conducted in relation to real co-morbid case histories in the form of vignettes. They were driven by a predetermined topic guide (see Appendix 3) based around practice and policy, assessment, treatment interventions and wider organisational issues. The vignettes covered different mental health and substance misuse combinations frequently encountered, including depression/anxiety and alcohol misuse and possible schizophrenia and cannabis use.

Respondents were encouraged to have a genuine discussion, talking between themselves rather than addressing all their remarks to the moderator. The moderator intervened, where appropriate, to probe and move the discussion on when necessary and to minimise interruptions and instances of more than one person talking at any given time. To ensure consistency of approach and to limit individual biases, the researchers met regularly both before and during fieldwork to reflect on the format of the topic guide, the emerging findings and to suggest changes in emphasis for future discussions.

Service users

Thirty eight service users were interviewed Difficulties encountered during the pilot stage of the project included identifying potential interviewees who would be able to contribute successfully in an in-depth interview situation via liaisons in the identified agencies and services. The unreliability of service users at times i.e. failure to attend interview appointments or attending intoxicated resulted in the need for re-scheduling. As a result of these obstacles volunteer Specialist Registrars in Addiction Psychiatry were recruited as interviewers across all localities as part of their research remit and one experienced Addictions Community Psychiatric Nurse in the Borders also offered their services. Each interviewer was briefed regarding the research protocol and the format for the interviews was explained.

Selecting participants

Purposive sampling was used to select a particular cohort of participants to reflect a range of experience and demographic variations, rather than random selection of a large sample which is statistically representative of the general population. The decision was to select the sample in order to reflect three main features (see Appendix 4):

• Different co-morbid combinations.
• Different age-bands (excluding those under 18 or over 65).
• Different demographic backgrounds in terms of the emphasised entity of the co-morbid situation (addiction services, mental health services, voluntary services).

In order to ensure representation of different co-morbid combinations, the sample included people with no formal diagnosis as well as those who had received a formal psychiatric diagnosis. The research team felt that it was important that some people with seemingly less marked mental health problems should be included because these cases often lead both to exclusion from studies of this kind and to being overlooked in policy development.

Problem severity proved difficult to judge. Due to the subjective nature of such judgments, severity of problem was determined in terms of the difficulties which significantly affected the person's ability to take part in the interview process.

The final sample of 38 respondents included more males (30) than females (8), similar numbers across different age-bands, a spread of co-morbid combinations, some people with complex personal and social situations and some respondents with less severe issues. While the co-morbid combinations are not exhaustive, the final sample does cover a wide range of experiences and reflects the most typical cases seen by professionals within the relevant services.

Conducting the interviews

Potential respondents were given information about the project and details of what would be involved. If they agreed to take part, a time and place for the interview was arranged. In most cases, the interviews took place in a community setting conducted by volunteer Specialist Registrars interested in the field.

The interview guide (see Appendix 4) was designed to enable the interviewer to cover a number of major topics in a systematic fashion. Interviews were based around service users' experiences and perceptions of service provision in relation to their mental health and/or substance misuse problems. The interviews provided insight to the different ways of accessing services, the types of treatment received, helpful and limiting experiences and what might be better provided in the future.

It was particularly testing to undertake interviews with people who exhibited cognitive impairments. Often these interviews remained focused on very concrete issues, on the here and now and on immediate concerns. They elicited very brief, limited responses. They did not yield the rich insights and reflections of the other interviews. It was nevertheless felt that these interviews, despite being somewhat 'thin', constituted valuable additions to the data. Their inclusion ensured that a range of experience was being sampled and helped to indicate the main concerns and preoccupations of the participants.

Ethical approval

Multi-site Research Ethical Approval was obtained before commencing the project. This included confirmation of participant confidentiality and anonymity where appropriate. For further details, please see MREC03/0/123 on the relevant website. The research project was also registered with the local research and development office in Tayside (the base for the project) and information to this effect circulated to all participating NHS boards.

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