Background
Hypothesis
Methods
Design
Sample
Intervention area (10 Wards) | Control area (9 Wards) | |
---|---|---|
Population | 249,813 | 217,500 |
Gender | 120,731 (48.3 %) Male | 105,147 (48.3 %) Male |
129,082 (51.6 %) Female | 112,353 (51.6 %) Female | |
Persons aged 0–24 | 91,641 (36.6 %) | 68,210 (31.3 %) |
Ethnicity | 193,612 (77.5 %) White British | 175,946 (80.8 %) White British |
26,715 (10.6 %) Asian/Asian British | 18,344 (8.4 %) Asian/Asian British | |
14,073 (5.6 %) Black/Black British | 13,570 (6.2 %) Black/Black British | |
11,873 (4.7 %) Multiple Ethnicity | 8,340 (3.8 %) Multiple Ethnicity | |
3,540 (1.4 %) Arab/Other | 1,300 (0.5 %) Arab/Other |
Measures
Structured Clinical Interview for Positive and Negative Syndrome Scale (SCI-PANSS)
DUP and component delays
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or:
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*The cluster required at least one of the symptoms positive 1, positive 2 or positive 3 to qualify as onset of psychosis.
Delay in help-seeking
Delay within MHSs
Delay in accessing EIS
Pathways to care interview
The intervention
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The youth access pathway into MHSs (‘YouthSpace’) was launched in July 2011. Following promotion of YouthSpace by clinical staff to all GP surgeries in the intervention area, the new service was embedded within two of the Trust’s largest Community mental health teams (CMHT’s) located in a specified area in the south of the city. The operational principles of YouthSpace provided direct access to EIS for those presenting with symptoms of psychosis, offering: prompt clinical assessment in a youth appropriate setting; rapid access and expert assessment based on formulation principles; home visits in cases of repeat non-attendance (‘Did not attend’: DNA); provision of a brief CBT based intervention, where appropriate, as a default; situating the GP as ‘default prescriber’, with expert support from a consultant psychiatrist; implementation of clearly defined interface roles between the clinical service and primary care (‘collaborative care’); and prompt response in cases of crisis via established channels [18, 19].
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To provide a snapshot of the typical numbers of cases presenting with possible first-episode psychosis symptoms referred to the Birmingham mental health service (Birmingham & Solihull Mental Health Trust) and their subsequent care pathway, live monitoring was conducted throughout the intervention period, using the Trust electronic case recording systems.
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Six months following the introduction of YouthSpace, our public health campaign was launched in the intervention area, with the aim of improving community knowledge and awareness of first-episode psychosis and reducing help-seeking delays. The development and implementation of the campaign followed the ‘Precede-Proceed’ public health model framework [27] and included on-going assessments of context and setting to ensure a responsive, stratified ‘knowledge-transfer’ approach. Initial findings from the ‘precede’ phase of our programme enabled comprehensive assessment, planning, piloting and target-setting of the campaign and included both patient and public involvement, with regular consultations with an advisory board of young people (the ‘YouthBoard’), users of the mental health services and their families.
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The framework was further underpinned by two theoretical models which addressed the cognitive and contextual determinants of health behaviour change, the Trans-theoretical/Stages of Change model [28] and the MINDSPACE framework [29], the latter arising from behavioural economics and widely employed by UK policymakers [30].
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Our previous research into DUP in Birmingham [16] included qualitative interviews with young people referred to EIS who had experienced long DUP (>6 months) and their carer’s. These interviews highlighted the key roles that parents and family networks play in initiating help-seeking for psychosis and directly informed the rationale of our campaign, ensuring a ‘family-focused’ approach. The campaign comprised the following components:
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This methodology was vital in clarifying the process of behaviour change with regard to improving help-seeking behaviour and community response to public health initiatives. It also highlighted the key roles that parents/carers play in initiating the help-seeking process culminating directly in the development of a ‘family-focused’ campaign, comprising of the following components:
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Publicity & community engagement
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All promotional material used for publicity included a link to our website, www.youthspace.me which served as the central information hub for the campaign.
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YouthSpace posters (example: Fig. 1) were displayed in high-use community settings including local bus services and shopping centres, supermarkets, employment offices, community and youth groups, leisure centres, coffee shops and fast-food outlets.×
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YouthSpace advertisements were placed in monthly, bi-monthly and quarterly newspapers and magazines delivered free to homes and appeared on 6 community websites, 10 library web-pages and in local GP surgeries.
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YouthSpace leaflets and postcards were distributed on high streets and in shopping centres and mail shots of these leaflets delivered to individual homes in ‘difficult-to-reach’ areas with no formal community hub.
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A variety of community, educational and NHS events were attended by research staff, clinicians and youth advisors.
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Psychosis Information Line
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A telephone information line was also included on all campaign material. This provided families and young people with an alternative method of seeking help and information about psychosis. This daily service was staffed by trained researchers who followed a clear protocol developed in collaboration with the YouthSpace clinical team, regarding referral procedures and governance issues.
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Youth Advisors
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Our youth advisors (‘Youthboard’), are young people with experience of MHSs. Throughout the campaign they provided great insight and expertise in designing and developing the YouthSpace website and campaign resources including photography, films and blogs. They also attended several community events with the research team.
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Psychosis Awareness Training
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Bespoke training events designed specifically for the individual needs of emergency services, youth, community groups and employment and education agencies were delivered by the campaign team with the aim of outreaching into the community, improving knowledge and awareness of early warning signs of psychosis and creating a broad network of organisations and individuals with which to increase the scope of the campaign.
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Statistical analysis
Principal analysis
Secondary analyses
Mental health care pathway monitoring
Website hits, information line calls and campaign activity
Results
Control area (n = 98) | Pre-intervention area (n = 80) | |
---|---|---|
Gender | 29 (29.5 %) Female | 18 (22.5 %) Female |
69 (70.4 %) Male | 62 (77.5 %) Male | |
Mean age | 22.2 years | 22.5 years |
Ethnicity | 52 (53 %) White British | 45 (56.2 %) White British |
21 (21.4 %) Asian Pakistani | 13 (16.2 %) Asian Pakistani | |
6 (6.1 %) Black (other) | 5 (6.2 %) Black Caribbean | |
3 (3 %) Asian Indian | 4 (5 %) Black African | |
3 (3 %) Black African | 3 (3.7 %) Asian Indian | |
3 (3 %) Black Caribbean | 3 (3.7 %) Mixed heritage (White & Black Caribbean) | |
3 (3 %) Mixed heritage (White & Black Caribbean) | 2 (2.5 %) Mixed heritage (White & Black African) | |
2 (2 %) Asian (other) | 1 (1.2 %) Mixed heritage (White and Asian) | |
1 (1 %) Mixed heritage (other) | 1 (1.2 %) Black (other) | |
1 (1 %) White Irish | 1 (1.2 %) Asian Bangladeshi | |
1 (1 %) Asian Bangladeshi | 1 (1.2 %) White Irish | |
1 (1 %) White (other) | 1 (1.2 %) White(other) |
Help-seeking delay | Delay within MHSs | Delay in reaching EIS | DUP |
N = 178 | ||
---|---|---|---|---|---|---|
Control area | Mean |
41.07
|
109.40
| 338.55 |
213.27
| 98 |
Median | 0 | 2.5 | 90 | 31.5 | ||
St Dev | 132.81 | 389.46 | 583.65 | 459.03 | ||
Pre-Intervention area | Mean |
95.40
|
118.36
| 396.75 |
284.54
| 80 |
Median | 4.00 | 19.00 | 93.50 | 71.00 | ||
St Dev | 238.43 | 272.01 | 772.87 | 482.13 |
Control area (n = 74) | Intervention area (n = 77) | |
---|---|---|
Gender | 28 (38 %) Female | 25 (32 %) Female |
46 (62 %) Male | 52 (68 %) Male | |
Mean age | 21.6 years | 22.5 years |
Ethnicity | 29 (39 %) White British | 37 (48 %) White British |
1 (1 %) White Irish | 0 (0 %) White Irish | |
1 (1 %) Asian Bangladeshi | 3 (4 %) White – Other | |
2 (3 %) Asian-Indian | 2 (3 %) Asian Bangladeshi | |
5 (7 %) Asian –Other | 2 (3 %) Asian-Indian | |
18 (24 %) Asian Pakistani | 3 (4 %) Asian –Other | |
2 (3 %) Black African | 5 (6 %) Asian Pakistani | |
2 (3 %) Black Caribbean | 1 (1 %) Asian British Pakistani | |
4 (5 %) Mixed White & Black Carribbean | 4 (5 %) Black African | |
3 (4 %) Other Ethnic Group | 4 (5 %) Black Caribbean | |
7 (9 %) Missing | 6 (8 %) Mixed White & Black Carribbean | |
2 (3 %) Mixed – Other | ||
1 (1 %) Mixed White Asian | ||
7 (9 %) Missing |
Help-seeking delay | Delay within MHSs | Delay in reaching EIS | DUP |
N = 151 | ||
---|---|---|---|---|---|---|
Control area | Mean |
116.97
|
124.19
| 162.30 |
216.43
| 74 |
Median | 11.50 | 21.00 | 44.00 | 79.50 | ||
St Dev | 229.02 | 216.45 | 242.84 | 335.86 | ||
Intervention area | Mean |
41.49
|
42.32
| 130.57 |
103.82
| 77 |
Median | 1.50 | 6.50 | 40.50 | 39.00 | ||
St Dev | 105.93 | 86.74 | 225.89 | 155.00 |
The samples
Baseline data
Incident cases
Pathway | Pre-intervention (N = 48) | Control (N = 109) |
---|---|---|
Crisis team | 7 (15 %) | 38 (35 %) |
Community mental health team | 15 (31 %) | 42 (39 %) |
CAMHS | 9 (19 %) | 0 |
Primary Care | 4 (8 %) | 0 |
A youth support team | 2 (4 %) | 5 (5 %) |
Transfer from out-of-area EIS team | 5 (10 %) | 3 (3 %) |
Early detection team | 0 | 8 (7 %) |
Hospital | 4 (8 %) | 0 |
Other | 2 (4 %) | 13 (12 %) |
Principal analysis
Care pathways to early intervention teams: intervention vs control areas
Pathway | Intervention area (n = 77) | Control area (n = 74) |
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Crisis team | 28 (36 %) | 24 (32 %) |
Assertive Outreach Team | 0 | 1 (1 %) |
Casualty | 0 | 1 (1 %) |
Generic mental health team | 16 (21 %) | 27 (36 %) |
A youth support team | 3 (4 %) | 6 (8 %) |
YouthSpace | 17 (22 %) | 0 |
Child & Adolescent Mental Health Team | 4 (5 %) | 3 (4 %) |
Primary Care | 3 (4 %) | 2 (3 %) |
Psychiatric Hospital | 3 (4 %) | 7 (9 %) |
Early detection team | 0 | 1 (1 %) |
Other | 3 (4 %) | 2 (3 %) |
Help-seeking Delay | Delay within MHSs | Delay in reaching EIS | DUP |
N = 17 | |
---|---|---|---|---|---|
Mean |
42.25
|
68.46
| 125.68 |
149.25
| |
Median | 0.5 | 34 | 31.5 | 91.5 | |
St Dev | 109.56 | 84.74 | 199.43 | 161.58 |