title: Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study.
abstract: BACKGROUND
  Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions.
  
  
  METHODS
  We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data.
  
  
  RESULTS
  Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement.
  
  
  CONCLUSIONS
  We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model.
  
  
  BACKGROUND
  Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.
authors.affiliation: Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL, UK. cfd@liv.ac.uk.
authors.forename: Christopher
authors.initials: C
authors.lastname: Dowrick
authors.affiliation: NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
authors.affiliation: Primary Care and Health Sciences Research Institute, Keele University, Keele, Staffordshire, ST5 5BG, UK.|West Midlands Collaboration for Leadership in Applied Health Research & Care, Birmingham, UK.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.affiliation: School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Karina
authors.initials: K
authors.lastname: Lovell
authors.affiliation: College of Medicine, Grove Building, Swansea University, Swansea, SA2 8PP, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Edwards
authors.affiliation: NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Lamb
authors.affiliation: Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL, UK.
authors.forename: Katie
authors.initials: K
authors.lastname: Bristow
authors.affiliation: Institute of Psychology, Health and Society, Waterhouse Building, University of Liverpool, Liverpool, L69 3GL, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Gabbay
authors.affiliation: Primary Care and Health Sciences Research Institute, Keele University, Keele, Staffordshire, ST5 5BG, UK.
authors.forename: Heather
authors.initials: H
authors.lastname: Burroughs
authors.affiliation: School of Nursing, Midwifery and Social Work, Jean MacFarlane Building, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Beatty
authors.affiliation: NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Waquas
authors.initials: W
authors.lastname: Waheed
authors.affiliation: NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Hann
authors.affiliation: NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Gask
mesh_terms: D000368:Aged; D004739:England; D005260:Female; D006297:Health Services Accessibility / Q000592:standards*; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008603:Mental Health; D008605:Mental Health Services / Q000592:standards*; D008962:Models, Theoretical; D011320:Primary Health Care / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards; D012107:Research Design; D035862:Vulnerable Populations / Q000706:statistics & numerical data