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Proposal
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Anti-Stigmatization program for mental disorders in
south eastern Austria and Slovenia
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Lecture program: Current Issues in Health Policies
Winter Term 2014/15
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Authors:
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Anna-Sophia Bilgeri
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1410360014
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Katharina Diernberger
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1410360007
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Michelle Falkenbach
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1410360022
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Ross Hadfield
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1410360016
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Lisa Hasenöhrl
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1410360024
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An estimated four out of fifteen people in the
European region suffered from anxiety and/or some kind of depression in 2014. These
people do not only suffer from the illness, they also have to cope with the stigmatization
they face due to their illness (WHO, 2014).
Accordingly, the European Commission claimed the
reduction of stigmatization to be one of their goals in the Green Paper of the
World Health Organisation (WHO, 2005). It is therefore essential that the
member states of the European Union collaborate to focus their attention within
the field of mental health. The following proposal presents a strategy as to
how countries can limit the stigmatization of people suffering from mental
illness in Slovenia as well as in the cross border region to Austria.
A questionnaire identifies individuals at risk or
those already suffering from a mental disorder and is used as a tool for the
general practitioner (GP) to open a dialogue between GP’s and their patients.
This dialogue is the first step in early detection and prevention of severe
outbreaks of mental illnesses. If the GP then, after discussing the results of
the questionnaire with the patient, finds the patient to be at risk of suffering
from a mental illness, they will get referred to a psychologist in order to receive
professional treatment.
Early detection and prevention of mental illnesses
leads to: less chronically ill people, immense cost saving as a result of less
unemployment, a reduction of days off from work, and early retirement all due
to mental illness. The ultimate goal is for a mental illness to be perceived as
a treatable illness such as a physical illness. Thus the stigmatization of
people suffering from mental illnesses will be reduced and it will become more
common to talk about mental health problems.
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C
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Consultant
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EU
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European Union
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e.g.
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Example given
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GP
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General Practitioner
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LBI
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Ludwig Boltzmann Institute
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MM
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Marketing Manager
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PM
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Project Management
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PMA
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Project Management Assistance
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SP
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Sample Patient
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SO
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Seminar Organizer
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S
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Staff
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StS
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Stakeholder Sample
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St
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Stakeholders
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TF
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Task Force (core project team)
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WHO
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World Health Organization
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According
to statistics, 1 in 4 people will experience some kind of mental health problem
in the course of a year. The reason these affected people are, in most case,
not likely to seek help is due to stigmatization (WHO Regional Committee for Europe - 63rd
session, 2014). In order to reduce the stigma of
mental illness, the way we as a society talk about mental disorders and how we
act towards those affected are eminently affiliated and must be altered (WHO,
2005).
As a task
force of the Ludwig Boltzmann Institute (LBI) focusing on health promotion and
research in mental health, tackling stigmatization among the mentally ill is
the first step towards helping to cure their illness. In the regions of Eastern
Austria and in the country of Slovenia, this task force will attempt to reduce stigmatization
by increasing the knowledge and awareness of the general public through the
creation of open dialogues between general practitioner’s and their patients in regards to
mental health.
Stigmatization
is an attitude based on preformed ideas where people that are different from
the social norm are discriminated, devalued and shunned upon (Patrick & Watson, 2002). People suffering from a mental
illness are amongst those most tortured by societal stigmatization. Not only
are these people struggling with an illness, but they are also burdened by societal
views regarding their illness, making it more difficult for the affected people
to seek the help they need (Patrick & Watson, 2002).
There are
different types of stigmatization, which influence mentally ill people in a
negative way. The main distinctions are self- and public stigmatization,
whereas the later has an extensive impact on the system of support and the
community (Corrigan, Druss, &
Perlick, 2014). Public stigma consists of three
different parts: first and most importantly, societal fear in regards to people
who are mentally ill. Fear evolves out of misperceptions and lack of knowledge
leading to the discrimination and abuse of those that do not fit in. The second
and third parts dealing with public stigma have to do with misconceptions. It
is believed that people with (severe) mental diseases are not able to show
responsibility, think and live their lives, and therefore must be placed under
the control of another person. The third prejudice is that they have to be
cared for because they are like children. These factors, mainly formed through
the impact of the film industry, lead to public stigmatization making itself
most known in the forms of withholding help, forced treatment and avoidance.
In addition
to public stigmatization, many people are suffering from self-stigma as well.
This can come in the form of low self-esteem as well as righteous anger (Patrick & Watson, 2002). A further element of self-stigma
can be that “the person seems to accept a
negative stereotype and either becomes ashamed or simply hides some element of
their make-up that they perceive is unacceptable to others” (Saldivia et al., 2014)
In 2014, out of 83 million people
between the ages of 18 and 65, an estimated four out of fifteen people living
in the European region (all member states of the European Union (EU) including
Iceland, Norway and Switzerland) have suffered from anxiety and/or some kind of
depression (WHO
Regional Committee for Europe - 63rd session, 2014). According to a study conducted by
Wittchen in 2011 (Wittchen
et al., 2011), the rate of people in the EU
suffering from at least one out of 27 mental disorders amounted to 38.5%. The
highest prevalence had been found in anxiety disorders affecting 70 million
people, followed by unipolar depression and insomnia affecting 30 million
people and somatoform disorders, affecting 20 million people (Wittchen
et al., 2011).
In 2012 about 800.000 citizens
within the European region committed suicide, 11.4 out of 100.000 people. Men
are 3.5 times more likely to commit suicide than women in high income countries
and about 4 times more likely in middle and low income countries. More than 90%
of these deaths can be linked to mental illness (WHO,
2014).
As a program aiming to raise
awareness and reduce stigmatization towards mental disorders, HealthCheck has
chosen to focus on two areas: Slovenia and southeastern Austria in order to
provide the citizens with information and develop a sustainable change in
behaviour and attitude. As Slovenia, a member state of the EU, still faces
several severe challenges concerning mental disorders, the country has been
chosen in its entirety to be a special target region for the implementation of
the program. Furthermore, cross border relationships with Austria provide an
already existing network, and thus, Slovenia and the three eastern most
provinces of Austria (Styria, Carinthia and Burgenland) have been chosen as
well.
Slovenia shows a male suicide rate
of 34 out of 100.000 and a female rate of 10 out of 100.000. About 28% of all Slovenians
suffer from a neuropsychiatric disorder each year. Similar numbers in regards
to neuropsychiatric disorders have been found in Austria amounting to 31.6%.
The suicide rates, however, are slightly lower: 24 per 100.000 for men and 7.4
per 100.000 for women (Department
of Mental Health and Substance Abuse, 2011a, 2011b).
In general, suicide is directly
linked with the quality of life and general mood of that person. In the year 2006,
it was recorded that 70% of the male population in Austria had been predominantly
happy, whereas for women, the amount was only 64.6%. In the province of Styria
men and women had been happier than the average person with 76% and 70.6%
respectively. In Carinthia the statistical results showed the Austrian average.
Noticeably different were the results of the people living in Burgenland, there
the values showed 67% for men and 61% for women depicting values below the
Austrian average. Data also collected in 2006 shows that 6.7% of Austrian men
and 10.9% of women suffered from depression and the trend notes that the
prevalence increases with age.
Between the ages of 15 and 44 only
3.8% of men and 6.5% of women are affected. Values for men between the age of
45 and 64 show a depression rate of 9.4%, which increases up to 19% in those
people over the age of 64. 14.4% of the women between the ages of 45 and 64 are
depressed, and approach the same value as men in old age. While men from
Burgenland and Styria seem to be in the Austrian average with 6.1% and 7%,
Carinthian men seem to suffer less from depression with only 4%. The values for
women are remarkably higher than the ones for men, ranging from 9.2% to 12.1% (Klimont,
Kytir, & Leitner, 2007).
In comparison, Slovenia showed the
lowest self-reported rate of depression in the European Union with a depression
and anxiety rating of only 3% in 2007. In contrast to this low percentage,
2.910 people per 100.000 had been treated in outpatient facilities, 2.550 per
100.000 in psychiatric beds and nearly 580 per 100.000 in mental hospitals.
Expenditures for psychiatric medication, especially for the treatment of
bipolar disorders, psychotic disorders, general anxiety disorders and mood
disorders amounted to $ 2.913.613 USD in 2010 per 100.000 people. In
comparison, the Austrian health system is more expensive amounting to approximately
$ 3.500.000 USD per 100.000 (Department
of Mental Health and Substance Abuse, 2011a, 2011b).
In addition to the human dimension
of mental health, the economic costs of mental disorders are increasing. In 2010,
the economic burden of people suffering from mental illnesses in Europe was
€798 billion. The most costly mental illnesses had been mood disorders [€113.4
billion], psychotic disorders [€93.9 billion], anxiety disorders [€74.4
billion], addiction [€65.7 billion], sleep disorders [€35.4 billion],
personality disorders [€27.3 billion] and somatoform disorders [€21.2 billion] (Olesen
et al. 2012).
According to the Annual Report of
the Chief Medical Officer in the United Kingdom, in 2013 only 10% are treatment
costs and medication. 90% of the costs resulting from depression are because of
absenteeism and unemployment: “More than
11% of the NHS budget is spent on treating illness – but the indirect costs
from unemployment, absenteeism and presentism can be higher. These indirect
costs totalled £30.3 billion in England in 2009/10 across all mental illnesses,
compared with direct health and social care costs of £1.6 billion.” (Knapp
& Iemmi, 2014)
Comparing the treatment- and
medication costs of mental disorders, Schizophrenia was shown to be the most
expensive amounting to approximately 7500€ per person per year in 2004, followed
by bipolar disorder and alcohol addiction with 6000€ and depression and drug
addiction with 4000€. Taking into account the number of individuals who are
suffering from mental diseases, depression accounts for more than one third of the
expenditure (Vieth,
2009).
Goal: The
overall goal is to
reduce stigmatization through increasing
the awareness regarding
mental illnesses
whereby creating an early detection & prevention
program, allowing
for the empowerment of citizens affected and resulting in the sustainable integration of mental health within
the accepted health concept.
Objective of the task force: To reduce stigmatization by increasing knowledge and awareness through
the creation of an open dialogue between general practitioner’s and patients regarding
mental health in south-eastern Austria and Slovenia.
Objective specification:
1.
Beginning
in the first quarter of 2016 and finishing the pilot period in the fourth quarter
of 2019, HealthCheck will have reduced the problem of self-stigmatization of mentally
ill people in their intervention area by raising awareness due to the
distribution of knowledge.
2.
Within
four years, HealthCheck will combat exterior stigmatization by shaping the
mind-set of the entire population in the intervention area by transferring
easily comprehensible knowledge.
3.
Within
the first year of intervention, HealthCheck will educate in regards to the complexity
and the increasing number of mental health problems. They will also be coached
so that they feel secure (and have enough evidence based knowledge) enough to
properly and effectively interact/communicate with potentially mentally ill patients.
4.
Within
the duration of the pilot project and beyond, HealthCheck will increase the early
prevention of mental illnesses by implementing an annual mental health check in
addition to the already existing physical check within every general
practioniers’s office in their intervention area.
5.
HealthCheck
aspires to equalise physical and mental health in order to acquire proper
finances for the treatment of mental health issues from the insurance
companies. In addition, the pilot project will focus on making mental health a
more political issue in order to create a binding framework creating conditions
for mental health promotion and treatment.
6.
Within
the pilot project period, HealthCheck intends to reduce the number of severely
mentally ill people with the need for long-term care. This is beneficial to
society because: a) It allows for higher quality of life for the mentally ill
people and their direct environment and b) the amount of money that will be
saved in the long-run by reducing treatment costs as well as diminishing the
economic burden of mental health issues is significant.
7.
Within
the pilot project period and beyond, it is HealthChecks’ ambition to reduce the
economic burden of mentally ill people by decreasing the number of suffers
forced into early retirement, curbing the amount of spent on unemployment
benefits due to mental illnesses and lowering the number of people who are
forced to take sick leave due psychological issues such as stress and
depression.
HealthCheck targets all public general
practitioners in Slovenia as well as those residing in the Austrian provinces
of Styria, Carinthia and Burgenland and their patients. Austrian Statistics
stated that 80% of the population older than 15 have visited their GP in 2009 (Statistik
Austria, 2010). Within this group, HealthCheck is
attempting to detect mental issues at an early stage through their questionnaire
as well as focus on those people with severe mental disorders by referring them
to the psychologist for more intensive treatment. A further objective is to
raise awareness regarding mental health as well as the variety of mental illnesses
by making HealthCheck a mandatory addition to the physical assessment, thus
reducing exterior stigmatization.
According to data of the statistical
office of Slovenia: in 2014 there were about 2.070.000 people living in
Slovenia. In Austria, the provinces of Styria, Carinthia and Burgenland have
populations of, respectively, 1.207.202, 556.398 and 285.006
people – this southeastern
region of Austria amounts to a total population of 2.048.606 people according
to the figures of Statistic Austria from 2014. (Statistik
Austria, 2014)
The
target region was chosen to enforce the cross-border cooperation and
collaboration between one developed and one less developed country in terms of
mental health prevention as well as to ultimately reduce stigmatization
concerning mental disorders.
This
cross-border collaboration was first conducted by the organisation European
Territorial Cooperation (ETZ Europäische Territoriale Zusammenarbeit), in a
program that was implemented from 2007 until 2013 and focused on a sustainable collaboration
for a stronger integration of the cross border region and their socio-economic
development following the principle of equal opportunities (ETZ, 2015).
In
2014, a new program was started focusing on integrated economic growth that
shall be conducted until 2020. In order to provide mental health and well-being
for the population within this program, HealthCheck should be introduced in
this area. In order to ensure that the majority of people would be reached
through HealthCheck while using the provided financial resources, the broader
region of Eastern Austria including Slovenia as a whole was considered.
In Austria, four out of five people
visit their general practitioner once every year. The relationship of women to
men is 82% to 76% (Statistik Austria 2010). According to a publication from the
ÖÄK, (Österreichische Ärztekammer; Austrian chamber of physicians) in 2012 the GP’s
should have focused on early prevention of mental illnesses and, furthermore, subsequently
referred those affected to specialised physicians if necessary. Ideally, the GP
would strengthen their “gatekeeper”- function, serving as a first contact point
for patients with mental illness, as well as representing a person of trust
that patients and their families are able to confide in. In conclusion, the
physicians should stay a person of trust (ÖÄK,
2012).
In the target region there is an
approximate total of 1.631 public GP’s. In 2015, the following statistics were
reported: 600 GP’s worked in Styria, 288 in Carinthia and 143 in Burgenland. In
Slovenia, approximately 600 GP’s had practices in the year 2012 (Ärztekammer
für Burgenland/Steiermark/Kärnten am 26.01.2015; Vuckovic
et al., 2014).
HealthCheck
is focusing on the reduction of stigmatization and the early detection of
mental illnesses. These problems will be addressed in a proposed change
regarding the perception of mental illnesses by an attempt to equalize the
importance of physical and mental illnesses. This process will be stimulated
through a questionnaire filled out by the patients in their respective GP
offices. The questions concerning mental health will be located on the flip
side of the already existing questionnaire regarding physical health. This step
will lead to the perception of mental health being an integrated part of a person’s
overall health status. Patients will fill out the questionnaire while they are
waiting to be called into their appointment. The questionnaire will be entered
in by the reception staff and calculated by the extension software program of
PGP EDV software. The GP will then receive the results and will be able to discuss
with the patient in the case that the questionnaire showed any “warning signs”
pointing to a deviation of a healthy mental status. At this point, the GP can
open a dialogue with the patient concerning their mental health status and refer
him to a psychologist if necessary. GP’s will no longer have the authority to prescribe pharmaceutical drugs
relation to mental health. Patients are then able to discuss possible issues
with a trained professional in a free consultation session with a psychologist
and then decide if follow-up treatment is necessary. Ideally, this follow up
treatment, if necessary, will be covered, in full, by the insurance companies. This described sequence of actions
will help detect mental illnesses at a very early stage and prevent more severe
outbreaks in later stages. Seeking help in the early stages of an illness will
prevent the patients from spiralling into a deeper state of that illness making
it much harder to escape and even more difficult to treat.
The
implementation of the questionnaire as a core element goes hand-in-hand with an
accompanying campaign: flyers and brochures for both GP’s and patients,
informing all parties of the implementation process as well as posters will be put
up in the various GP practices and available to take. GP’s will be asked to
attend a mandatory training session offered one week a month for the first six
months of the pilot program. Training session will last for five hours so that
the GP’s are introduced to the concept, are able to fully understand the
meaning and effect of the HealthCheck program and most importantly, that they
know how crucial their role is in this process. Each GP will visit a 5h
training session to be introduced to the HealthCheck program in general, the
questionnaire and deepen their knowledge regarding mental health. Associations
will sponsor these seminars in cooperation with the European Network for Mental
Health Promotion ENMHP.
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Press
conferences with media representatives will take place at the beginning of the
kick-off phase (including all stakeholders) as well as at the beginning of the implementation
phase so as to create a strong communication network and keep all partners
informed about the actual pilot projects status.
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Informational
material (e.g. brochure) regarding the questionnaire, the questionnaire itself and
information about the seminars for GP’s will be sent in printed form by post
and via email to the GP´s offices.
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A
survey measuring the level of stigmatization will be sent twice (pre-survey in the
kick-off phase and post-survey at the end of implementation process) in order
to evaluate the effect of the program.
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The
seminars for all public GP’s in the target region (1.631 GP’s) will take place
within the kick of phase and cover a period of six month (provided by medical
camber of GP’s of Austria/Slovenia).
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Flyers
and brochures (info material) will be given to patients to explain the referral
process and will give some more details about mental disorders and the possibilities
as to how to treat them.
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There
will be various press releases as well as dissemination via social media (Facebook,
Twitter, etc.) networks stating the success of the project after conducting the
evaluation phase and also during its implementation to continue to raise the awareness
of citizens.
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A
web page will be created stating the objectives of HealthCheak and how the
project works. The site will be regularly updated and monitored and will provide
answers for the most frequently asked questions. The web page will also provide
further information about mental illnesses and stigmatization.
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The
posters promoting HealthCheck will be put up in the waiting rooms of the GP’s practices
to enhance patients’ consciousness about the program.
A very important critical success
factor is the motivation of GP’s to cooperate due to the additional time needed
per patient to talk with them about their mental health status if recommended
by the results of the questionnaire.
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Under
the Hippocratic oath taken by all medical professionals, it is their duty first
and foremost to help patients.
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The
implementation of the questionnaire will save the GP´s time due to the fact
that many people consult a GP in order to have someone to talk to. Many elderly
people feel very lonely and need someone who listens and talks with them. Those
people would be referred to life coaches to provide them with an interlocutor
and not occupy the resources of the GP.
The lack of willingness to cooperate
due to a lack of experience and social empathy for mental health patients (stigmatization
of mentally ill patients among doctors) might cause severe challenges.
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In
fact, the stigma a GP might have towards the mentally ill will be reduced
because of the changed attitude towards mental illnesses. Not only will mental
and physical health be put on the same level as far as treatment possibilities
are concerned, an open dialogue will help to make mental illnesses less taboo.
As soon as mental illnesses are seen as something “normal,” something that
could potentially affect anyone, the stigmatization will decline.
Furthermore, patients have to
understand the questionnaires and GP’s office staff must be able to assist them
in case of any misunderstandings or questions from the patient’s side.
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The
informational material sent in advance to the GPS’ offices would reduce this potential
risk factor. It will give the office staff the knowledge and ability to explain
the questionnaires and help with any concerns that might arise.
The motivation of the patients to accurately
fill out the new questionnaire and subsequently, if necessary see a
psychologist after the referral.
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As
patients have wait in the waiting room, they will have enough time to fill out
the additional part of the questionnaire in regards to their own mental health.
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For
people who are really in need of help, this opportunity might be a good
incentive to take a first step to communicate their problems and concerns.
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Some
patients may realise, due to the questionnaire results, that they need help and
can receive this help by seeing a psychologist.
Enough financial resources are
necessary to bring all parts of the campaign into action. Therefore, a precise
and accurate financial resource plan has to be developed.
- As seen on
page 29 of this proposal, the economic burden that affects each country without
the use of HealthCheck is phenomenal.
Therefore, the project team sees no reason that substantial financial
support will not be given for its implementation.
Another crucial factor for the
projects rollout is the potential future funding sources and cooperation with
new stakeholders.
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Stakeholders
were chosen, precisely in the given order so as to assure further funding for
the project.
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The
idea of the four-year plan in cooperation with the evaluation tools is to show
the stakeholders, the ministry’s of health and the insurance companies how much
they stand to save by further investment in HealthCheck.
Developing an individualized questionnaire
that is accurately able to detect mental illnesses is another essential success
element.
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The
questionnaire must be easy to understand for the overall population, avoiding
misunderstandings or ambiguous wording. Additionally, the valid significance of
the questionnaire must be tested before it is implemented.
A sufficient number of psychologists
or well-educated psychological staff must be available to treat people with
mental illnesses if a sudden increase in the number of patients seeking
psychological help occurs.
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As
the number of detected patients with mental illnesses will continually grow, there
is a need to broaden the psychological network so that it can cope with these
circumstances. Therefore, it is important to promote additional training for
medical staff regarding mental illnesses and support further occupational
groups in the mental health sector. A possible concept could be the
introduction of a qualified position somewhere below a psychotherapist standing
and above that of life coaches, who would then be able to offer their services
in addition to psychologists and psychotherapists.
A future challenge will be the referral
of many patients who are not able to afford psychological treatment without
sufficient financial support.
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If
the HealthCheck network expands, different consultancy opportunities would be
created and/or less expensive treatment outlets would be offered through the
introduction of further, qualified mental health positions.
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In
addition, adolescence and students should be better informed about the
possibilities of funded treatments offered by their respective countries as
well as the possibility to get free consultancy sessions.
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Furthermore,
the access to financial support for psychological treatment for young people
should be widened, driven by the fact that it is much cheaper for the
government to overtake these costs than to compensate the huge expenditures of
non-productive working time that a mentally ill person produces (see Economic Burden on page 29).
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In
the long term, the health insurance companies should overtake the expenditures
of psychological treatment because it is cheaper than the follow up costs that
might occur if the mental illness is not treated (see Economic Burden on page 29).
For an
effective realisation of the program, prior definition and further monitoring
of outcomes, outputs and deliverables are essential. In the following points
listed below, these aspects of HealthCheck will be elaborated.
The
deliverables will be developed during the first phase: “Planning & Concept”
of the pilot Projects Structure Plan PSP, which takes half a year:
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The
questionnaire is to be filled out by the patients in their respective general
practitioners’ practices.
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Informational
material for GPs’ practices and for the staff, psychologists, psychotherapists,
and psychiatrics will be made readily available.
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Informational
material/brochures for patients referred to a psychologist after having filled
out the questionnaire will be distributed.
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Posters
advertising the HealthCheck campaign so that the GP’s can promote the program
in their office and waiting rooms will be sent.
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Two
kinds of surveys for the evaluation of the project: the first will be sent to
the GPs’ offices in the Kick-off phase of the project and the second will be
sent out after the implementation phase has been completed.
The
experience and knowledge gained through the program will be shared with the
community through different channels:
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The
results of the evaluated questionnaire and its impact on stigmatization will be
communicated to the Ministries of Health in Slovenia and Austria in order to
provide the necessary information and statistics for the funding of further
projects and reforms.
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The
programs’ final report will be given to all stakeholders in order to inform
them about the success rate and so that it can be used for further research
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To
communicate the success of the pilot project to the media in order to inform
the public.
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Promoting
an open dialogue about mental illnesses in society between GP’s and patients
and within the general population.
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Curbing
stigmatization through equalising the perception that people have regarding physical
and mental illnesses.
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Decreasing
stigmatization of GP’s towards their patients regarding mental illnesses
through training seminars as well as through the creation of an open dialogue
about mental health and how to make it “normal” to talk about.
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Reducing
self-induced stigmatization of people affected by a mental health illness by giving
mental illness the same status as physical illnesses; so that people with
mental health problems will no longer feel different and discriminated against amongst
their fellow citizens.
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Minimizing
the number of days off from work due to mental illnesses à high cost saving for the employers and health
insurance providers. (See Economic Burden
in the appendix).
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Improving
the health status in the target region would then lead to a more efficient work
force and a more harmonised family life.
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Reducing
the number of suicide victims due to early detection of mental disorders and the
focus on prevention.
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Sinking
the number of chronic cases of mental illnesses as a result of prevention and
treatment in an early stage of the illness.
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Granting
affordable psychological treatment in the long run for all affected persons due
to the possibility to prove to the insurance companies the cost saving effect
of early prevention through psychological treatment. By preventing a mental
illness from reaching a chronic stage, HealthCheck is limiting the number of
early retirement cases and the number of employees that take sick leave due to
the effects of their chronic mental illnesses, thus saving money (see Economic Burden on page 29).
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Lowering
the expenditure on pharmaceuticals for chronic mental illnesses (due to early
intervention).
The
name HealthCheck was chosen for the program to communicate that mental health
is also a part of the overall health status. This HealthCheck logo is inspired
by an already existing one and was adapted to the needs and structure of this
program (http://www.logomoose.com/logo-design/healthcheck/). In the event that
the realisation of the program takes place, the logo would be redesigned. Both,
physical and mental health must be fulfilled in order to assure a state of
“health,” as stated in the WHO Ottawa Charter of 1986. The heart within the
logo symbolises feelings, but also stands for physical health. The brain
describes rationality and mental health. In the HealthCheck program both aspects
will be addressed and guarantee the health of a person. The chosen colours
emphasize our message: the light blue stands for calmness and relaxation and
promotes physical as well as mental alleviation. The light blue colour also
enhances self-expression and the ability to communicate needs and wants that
people might have concerning their health. Grey, on the other hand, reflects a
lack of emotions that people suffering from depression or other mental
illnesses experience. Mental illness can also be seen as a grey shadow over the
affected person’s life. At the same time, grey presents solidity and stability
and can be perceived as a relief from chaos.
As
effective project tools to plan and structure the activities and competences, a
project structure plan and a gantt chart were developed. The project structure
plan gives an overview of all work packages as well as the different stages that
they find themselves in. The gantt chart additionally considers the project
time frame (visualised in individual quarters, milestones are coloured blue) and
the responsibilities for each work package (abbreviations can be found in the List
of Abbreviations on page iv).
|
TASKS
|
RESPONSIBE
|
2016
Q1
|
2016
Q2
|
2016
Q3
|
2016
Q4
|
2017
Q1
|
2017
Q2
|
2017
Q3
|
2017
Q4
|
2018
Q1
|
2018
Q2
|
2018
Q3
|
2018
Q4
|
2019
Q1
|
2019
Q2
|
2019
Q3
|
2019
Q4
|
|
1
|
Planning / Concept
|
|
|
|
|
|
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|
|
|
1.1
|
Define work packages
|
TF
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1.2
|
Gather Research "Desk
Analysis"
|
LBI & TF
|
|
|
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|
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|
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|
|
1.3
|
Project Management
|
PM & PMA & TF
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1.4
|
Establish Best & Worst case scenarios
|
PM & PMA & C & TF
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|
1.5
|
Specify concept and content for GP
Education (seminars)
|
TF
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1.6
|
Define survey and evaluation indicators
|
TF
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1.7
|
Select a questionnaire
|
TF
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|
M
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1.8
|
Acquire Partnerships
|
TF & MM
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1.9
|
Rent Seminar facilities
|
PM & PMA
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|
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Establish
a complete & implementable project
|
|
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|
2
|
Kick off
|
|
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|
2.1
|
Press conferences with stakeholders
& Eastern Austria)
|
TF
|
|
|
|
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|
|
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|
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|
|
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|
|
|
2.2
|
Distribution of Question. to GPs
|
PM & PMA
|
|
|
|
|
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|
|
|
|
|
2.3
|
Distribution of
"Info-material"
|
PM & PMA
|
|
|
|
|
|
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|
|
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|
|
|
|
|
|
|
|
2.4
|
Educate GPs
|
TF + SO
|
|
|
|
M
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2.5
|
Distribute Evaluation / Survey via a
stigma scale
|
PM & PMA
|
|
|
|
|
|
|
|
|
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|
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|
|
|
|
|
|
Open
dialogue between GPs & patients - increasing referrals
|
|
|
|
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|
|
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|
|
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|
|
Increase
acceptance and reduce stigma of GP
|
|
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3
|
Action / Implementation
|
|
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|
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|
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|
|
3.1
|
Information distribution to patients
|
PM & PMA
|
|
|
|
|
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|
|
|
|
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|
|
|
|
|
3.2
|
Filling out Questionnaires
|
P (GP+S)
|
|
|
|
|
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|
|
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|
M
|
|
|
|
|
3.3
|
Conversation between patient & GP
regarding mental health
|
GP & P
|
|
|
|
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|
3.4
|
Referrals psychologists
|
GP
|
|
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|
|
Return of
filled out question.
|
|
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|
Table 1 Gantt Chart
(continued)
|
|
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|
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|
|
|
|
|
TASKS
|
RESPONSIBE
|
2016
Q1
|
2016
Q2
|
2016
Q3
|
2016
Q4
|
2017
Q1
|
2017
Q2
|
2017
Q3
|
2017
Q4
|
2018
Q1
|
2018
Q2
|
2018
Q3
|
2018
Q4
|
2019
Q1
|
2019
Q2
|
2019
Q3
|
2019
Q4
|
|
Mental
and physical treatment equality
|
|
|
|
|
|
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|
4
|
Monitoring & Control
|
|
|
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|
|
|
|
|
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|
|
|
|
|
|
4.1
|
Completed monitoring and controlling
assessment
|
LBI & TF
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
4.2
|
Meetings
|
StS
|
|
|
|
|
|
|
|
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|
|
|
|
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4.3
|
Risk Management
|
TF
|
|
|
|
|
|
|
|
|
|
|
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4.4
|
Updating project plan
|
TF & StS
|
|
|
|
|
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|
|
|
|
|
|
|
|
|
M
|
|
Get
target samples feedback
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Re-evaluate
project plan, if necessary
|
|
|
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|
5
|
Evaluation
|
|
|
|
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|
|
|
|
|
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|
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|
|
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|
|
5.1
|
Feedback
|
SGP & SP & TF & LBI
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.2
|
Project management evaluation
|
TF
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.3
|
Holistic program evaluation
|
TF & LBI
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5.6
|
Collecting of significant data generating
concrete results
|
TF
& LBI & St
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M
|
|
Evaluate
data and generate definite results
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Compile
gathered statistics for further research
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
6
|
Rollout
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.1
|
Development of sustainability Plan
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.2
|
Introduction of tablets
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.3
|
Broaden the regions / Acquire new
countries
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.4
|
Acquire further funding possibilities
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.5
|
Institute a new media plan
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
6.6
|
Encourage further research
|
TF & StS
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Ensure
sustainability
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Table 2 Project Structure Plan
1.
Ludwig Boltzmann Institute (LBI)
HealthCheck acts as a
task force of the Ludwig Boltzmann Institute (LBI), specifically, for the
“Health promotion research institute” focusing on mental health. The task force
requires a well-regarded organization that is respected and has the capacity
for strong quantitative analysis. With this strong base, the initiatives will
have a greater scope for implementation and acceptance. This is essential for
the success and sustainability of the HealthCheck pilot project. This venture
will need to draw from the skills and resources of the LBI in order to attain a
solid analytical foundation so that its performance can be showcased. As the
institute is known for its research abilities and capacities, the results
obtained by HealthCheck will secure further funding and ensure sustainability.
The LBI can only benefit from this cooperation as our task force is contesting
an area, mental health, which the institute is currently not focusing on. So,
the LBI stands to gain valuable data with which it may conduct research and
publish results. Through this collaboration the LBI will also have a team
directly engaged in the area of mental health, which it is currently not (Ludwig
Boltzmann Institute, 2015).
2. Bilateral ETZ
program Austria-Slovenia
The
bilateral agreement ETZ is focused on the boarder regions between Austria and
Slovenia, which make up the poorest and most affected regions of the respective
countries. HealthCheck will collaborate with the existing program between the
two countries specific regions and extend it to cover all of Slovenia. Due to
the arrangements and already strong connections between the European regions,
HealthCheck would like to strengthen this partnership as well as increase
investments in Slovenia, which will hopefully lead to an expansion of its
economic and social status so as to be more in line with ideal European Union
standards. Through this cooperation, the program also offers a gateway for
leading experts, policy makers and health economists to ensure a smooth
entrance into the region (Regionalmanagement Graz und Graz-Umgebung, 2015).
3. Federal Ministry of
Health (Austria)
As
seen below in Point 4.
4. Ministry of Health
(Government of the Republic of Slovenia)
HealthCheck
is focusing on the development of a new strategy for early intervention and
prevention of mental health disorders. This cooperation with the ministries
offers them a great capacity for future budgetary savings. The ministries will
help organize seminar facilities, develop educational material for the medical
staff and help to promote and back the program in order to generate the support
of the communities, while reducing the barriers in regards to the acceptance of
the program. New programs in the medical universities will be developed,
focusing more intensely on the subject of mental health, and will increase the
awareness and importance of this aspect of medicine by making it “more equal”
to physical health. (Bundesministerium
für Gesundheit, 2015; Republic of Slovenia, Ministry of Health, 2015)
5. The Austrian Medical
Association
As seen below in point 6.
6. Slovenian Medical
Chamber
The Austrian Medical Association and Slovenian Medical
Chamber are both highly influential.
HealthCheck would require the seminar-training program to be included,
and preferably mandatory, in the choice of further education programs that
practitioners need to complete yearly in Austria and every 7 years in Slovenia.
It would also be beneficial to require Slovenian practitioners to attend
seminars on a yearly basis. HealthCheck will be offering free educational
seminars to the practitioners in each country. With this cooperation, the
medical practitioners will be gaining valuable free education (Österreiche Ärztekammer,
2015; Zdravniška zbornica Slovenije, 2015).
7. ENMHP (European
Network for Mental health Promotion)
HealthCheck would
benefit by collaborating with ENMHP due to the expertise that ENMHP has in
regards to education. HealthCheck would utilize the experience in education for
the development, facilitation and presentation of the seminars for the benefit
of doctors. This is mutually prosperous because this enhances the promotion of
mental health through educational seminars (European Network of Mental Health
Promotion, 2015).
8.
Austrian Federation Association for Psychotherapy
As seen below in point
9. (Slovenian Psychologists’ Association, 2015)
9.
Slovenian Psychologists’ Association
With the structure of
the pilot program, there will be an increased demand for psychologists. It
would be a great asset if the association were to develop accreditations for
students of psychology to attain licenses in the field other than those of
“life coach”, “psychotherapist” and “psychologist”, but rather something in
between as well; a license that would allow for more counseling possibilities
for
those
suffering from a mental illness. Through this cooperation, HealthCheck will
benefit from educational material, experts in the field as well as being able
to establish a greater connection between GP’s and psychologists (ÖBVP, Österreichischer
Bundesverband für Psychotherapie. 2015).
10. Austrian Insurance
Associations
As
seen below in point 11.
11. Slovenian Insurance
Associations
HealthCheck
will develop a business relationship with both countries insurance associations
for networking purposes. This will allow HealthCheck to lobby for the
questionnaire to be covered financially through the annual medical check up as
well as to increase the number of allocated psychologist visits. This will
support the future sustainability of the program (Hauptverband der österreichischen
Sozialvericherungsträger, 2015; Government of the Republic of Slovenia, 2015).
To display more precise and detailed
planning, the stakeholders and their position will be presented in the
following chapter. The chart gives a good overview of their influence and
participating roles in the project.
Furthermore, the finance plan explains
in detail the expenditures and investments of the provided budget. The first
chart provides the financial planning for the first year 2016, including the
planning stage and the first half a year of the implementation stage. The
second chart of the finance plan explains the expenditures of the subsequent
three years from 2017 - 2019. It also includes the total spending taking an
inflation rate of 2% into account.
Table 3 Stakeholder Analyses
Table 3
Stakeholder Analyses (continued)
Table 4 Finance Plan (for 2016)
Table 4 Finance Plan continued (for 2017-2019)
Since monitoring
and evaluation is a crucial tool to assess the quality of a program, gather
adequate data in regards to the program as well as setting priorities to
develop further strategies, this chapter will provide an effective strategy for
monitoring and evaluation (Bulanda
et al. 2014). The HealthCheck program uses program evaluation in order to
encompass routine monitoring and to, furthermore, evaluate and assess the
process, results and impact of the interventions (Bertrand & Escudero 2002).
While monitoring and process evaluation determines the scheduled realisation as
well as the quality and coverage of the program, outcome and impact evaluation
identifies changes in outcomes, such as variation in behaviour, attitude or
interactions (Adamchak et.al. .2000). The evaluation plan distinguishes between
program-based (input, process and output measures e.g. information received
through program sources by statistics, surveys or other program records) and
population based (outcome e.g. data provided by government documents or surveys
with nationally representative samples) measurements (Bertrand und Escudero 2002).
Baseline
information: Based on surveys prior to the intervention, data collection from Nongovernmental
Organisations (NGO’s), national health facilities, mental health agencies or
research centres the current status quo of the target region and population
addressed can be described and analysed. This baseline information will be
collected in cooperation with stakeholders and represents an essential factor in
the outcome and impact evaluation HealthCheck undertakes further on (Adamchak
et.al. 2000).
One standardised
international measure of stigmatization of various psychoses is the Maristán
Stigma Scale. This Scale consists of 38 statements respondents can agree or
disagree with. These statements target stigma in personal, family and social
life, attitudes of health professionals as well as stigma in the public sphere
and work. The survey is based on a Likert scale from 1 (complete disagreement)
to 7 (complete agreement) and is analysed by means of SPSS (Saldivia et al.
2014).
These indicators
determine the process and especially the purpose of the program and focus on
project management tools, education and training of participating GP’s,
successful return of questionnaires and long-term cost reductions. For more
detailed indicators, see Logical
Framework on page 27-28. Quarterly stakeholder reports will provide
permanent monitoring of the program and potential challenges and threats can be
recognised and adjusted accordingly in the program.
These indicators
can be categorised in short-, intermediate- and long-term indicators and
provide essential approaches to measure the effectiveness of the program (Link et al. 2004).
The monitoring
of the implementation process will be ensured by the measuring, on a regular
and on-going basis, the realisation of the programs activities (e.g. through
quarterly board meetings or staff reports).
For the majority
of the indicators, already existing data and surveys were identified as adequate
source of data. Furthermore, evaluation and monitoring will be carried through
the use of both, quantitative and qualitative indicators as well as staff and
outside evaluators. Additionally, participatory evaluation involving most
important stakeholders will be an essential element of this HealthCheck
E&M-plan (Adamchak et al. 2000).
Qualitative research will be used in process evaluation to measure
stakeholder satisfaction, developing needs assessments, record local challenges
and resistors or participant reactions to the intervention. HealthCheck
methodologies therefore are focus groups, interviews with participants and key
figures or observations.
Quantitative research enables the project team to measure results and
impact of the program on the one hand and to incorporate the benefit of
implemented activities for further dissemination of HealthCheck on the other hand
(Bertrand und Escudero 2002).
Project members
of the mental health task force of Ludwig Boltzmann Institute will perform the
evaluation. Since the program is not merely a research study, the project team will
not use a specific comparison group. The network of HealthCheck can use the
evaluated data for further research and adaptation for an optimal dissemination
approach. However, within the framework of four years, only short- and
intermediate-term indicators will be possible to evaluate.
In the
following, three pages, a logical framework for the program is shown including
relevant indicators. Furthermore, the economic burden was calculated with the
following assumptions - out of the 1.631 public general practitioners in the
target area:
-
60%
of the total number of GP’s in the target area will participate
-
60%
of the patients attending the GP’s office will fill out the questionnaire
-
25%
of patients fill out the questionnaire in the GP’s office will have a mental
health issue
-
60%
of patients having a mental health issue will actually use the referral and
seek professional help
-
12.5%
of (2) suffer from a form of depression
Table 5 Logical framework
|
OBJECTIVES
|
Measurable
INDICATORS
|
Means of
VERIFICATION
|
Important
RISK / ASSUMPTIONS
|
|
GOAL:
Reduce stigmatization through:
-
Increasing
awareness regarding mental illness
-
Early detection
& prevention
-
Empowerment
of citizens affected
-
Integration
of MH into accepted health concept
|
-
Intermediate:
Increased number of referrals to psychologists and number of those making use
of the referral among GP patients in the target region by 20% by 2018
-
Long term:
Increased knowledge/awareness about mental health/illness among population in
the target region by 2025
-
Number of
publications and on-going presence in respective local and international
media during and after implementation
|
-
Comparison of
data with pre-test and post-test surveys (e.g. Maritan Stigma Scale)
-
Analysis of
existing studies and data regarding stigmatization
-
Interviews
regarding brand awareness and knowledge about Mental Health
-
Regular press
conferences, publication of press releases and citation of project
deliverables by external experts; analysis of press articles
|
-
Effective and
efficient implementation of HealthCheck through cooperation with the
HealthCheck network
-
Sustainable
funding sources and long-term accreditation as an EU-project
-
Willingness
and capability of target group to change their attitudes towards MH
-
Willingness
and financial capacity of patients to seek help and make use of the referral
|
|
PURPOSE:
-
60% of public
GP’s and staff are educated through info material and seminars addressing MH
and its effect on the population
-
Target
population in East Austria and Slovenia by using GP practices as an interface
-
GP patients
are given the opportunity to articulate
MH-issues based on questionnaire through conversation showcase any MH-issues
through a questionnaire or conversation?
-
Opening a
dialogue between GP’s and patients in regards to MH
-
Reduction of
economic burden by cost saving regarding long term MH illnesses through early
prevention
-
Creating and
developing a sustainable network for MH in the program area
-
Equating
mental and physical health by giving them same attention and value
|
Performance indicators for process evaluation
-
Short term:
Number of returned and filled out questionnaires of GP patients in the target
region by 2018
-
Number of
training sessions attended by GP’s about 60% by 2018
-
Measure
number of individuals who encountered HealthCheck by number of patients, who
annually see a GP (estimation) in the target region by 2018
-
Increase the
number of referrals and used treatments vs. how many are not referred or
refuse referral in the target region by 2018
-
Long term: Percentage
of cost reduction for insurance companies in the target area by 10% in 2018
-
Long term:
Reduction in number of sick days among GP patients in the target region by 20%
by 2020
|
-
Calculate
number of returned questionnaires using IT-Software
-
Attendance
lists for GP seminars
-
Numbers of GP
visits based on existing data from project partners
-
Calculate
number of pre and post economic burden through quantitative data - evaluation
based on surveys, statistics and research
-
Comparison of
referrals before and after implementation
-
Comparison of
data regarding predicted percentage of mentally ill people already covered
with treatment vs. the additional number due to questionnaire
|
-
Unclear
communication of MH as an integral part of holistic health
-
Individuals
with potential or already existing MH issues have to visit the GP, otherwise they
cannot be detected by the program
-
GP’s
understand the importance of the project and are willing to actively
participate (Wittchen study)
-
People must
be willing to fill out the questionnaire properly and read through the
informational material
-
Individuals
willing to make use of the referrals
-
Functioning
referral network between GP’s and psychologists - best case psychologists in
same office as GP’s
|
|
Table 6 Logical framework (continued)
|
|
-
|
-
|
|
OUTPUTS
-
60% of public
GP’s in target region (ca. 978) are distributing questionnaires to their
patients
-
Attending
GP’s understand the structure of the questionnaire and start up conversations
with patients regarding MH
-
All questionnaires
are collected and analysed for further research
-
Brand
HealthCheck and connection to mental health are recognized by 50% of GP
patients.
-
Strong cross
border network of MH between various stakeholders
|
Output indicators for effect evaluation
-
Number of
filled out and returned questionnaires of GP patients in the target area by 2018
to the task force
-
Increase of
knowledge and understanding of GP’s and staff concerning questionnaire and
program concept in the target region by 2018
-
Increased
number of illnesses detected and following referrals among GP patients by 25%
in the target region by 2018
|
-
Calculate
number of returned, filled out questionnaires using IT-Software
-
Focus
interviews with sample of GP in project region
-
Obligatory
meetings with stakeholders and project team
-
Calculation
of cost saving using cost index and compare existing calculations with
post-calculation taking implementation into account
|
-
Lack of
understanding, motivation and support by GP’s to implement program as
essential pillars
-
Lack of
support from various stakeholders i.e. governmental agencies or chambers
-
Technical
feasibility and willingness to print the questionnaire on the backside of the
already existing physical health form
-
Logistic
challenges of distribution, collecting and analysing data
-
Lack of
funding and scarcity of financial and human resources concerning sustainable
roll out
|
|
ACTIVITIES
-
Adaption,
distribution and provision of the questionnaire
-
Developing
and providing information within various channels (Flyers, Website, Poster,
Seminars)
-
Informing
GP’s and staff through seminars and info material
-
Informing
stakeholders and providing results through monitoring and evaluation
|
INPUTS
- SUMMARY OF PROJECT BUDGET:
See
Finance Plan p. 22
|
Financial turn-out report as agreed in grant
agreement
|
-
Defective
distribution of questionnaires
-
Inaccurate
wording of questionnaire or lack of educational quality in seminars
-
Language
barrier/ lack of translation program
-
In-transparent
procedures and lack of communication
-
Time needed
for controlling and evaluation
|
When
the positive outcomes of the HealthCheck pilot project have been proven through
the analysis of the received data and the subsequent evaluation process,
further funding partners will be engaged. This will help in the extension of
the region the project targets with implementation across the rest of Austria
and other eastern European member states. Main funding partners that could be
brought on board are pharmaceutical and health insurance companies due to the
benefits that can be gained by these two industries. This will help with
securing sustainable funding for the program.
In
order to optimize the communication process and minimize bureaucratic
expenditure, the questionnaire will be completed on hand-held tablets; this
will automate the process with the questionnaire. The data entered in the tablets will be
directly transferred to the GP and subsequently a referral will be sent to the
health insurance provider. This innovative communication process enables time
saving for the office staff as well as for the insurance companies. Through
streamlining this process, there is also a cost saving effect regarding printed-paper
and data entry. It will also further stimulate the reduction of the economic
burden because a greater number of suffering individuals will utilize the
referral if the process of gaining psychological treatment is simplified.
Through this program billions of Euros can be saved on mental health
expenditure. (See Economic Burden on page
29.)
With
positive outcomes, the importance of this early intervention will be showcased,
lobbied for and brought forward to the Ministries of Health who will make it
mandatory for all GP’s to screen for
mental health issues using the questionnaire and increase the coverage to
hospitals and other medical practitioners. With this reform, the economic burden
of mental health issues will be reduced as well as the stigma attached to
mental health.
The
obtained data from the pilot project can be used to enhance further research
regarding the stigmatization of mental illnesses as well as to justify the
extension of the implementation in the EU.
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