Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 https://doi.org/10.1186/s12913-021-06205-w RESEARCH ARTICLE Open Access Perception of the primary health care response capacity by patients with and without mental health problems, and health professionals: qualitative study Eva Rodríguez-Eguizabal1, Bárbara Oliván-Blázquez2,3,4*, Valle Coronado-Vázquez5,6, Mª. Antonia Sánchez-Calavera2,3,7,8, Mª. Josefa Gil-de-Goméz9, Sergio Lafita-Mainz2,7, África Garcia-Roy2,7 and Rosa Magallón-Botaya2,3,7,8 Abstract Background: The objective of this study is to deepen our understanding of perceptions towards Primary Health Care Response Capacity by specifically using patients with and without mental disorders, as well as family doctors and a manager, in order to compare and endorse perspectives. For it, a qualitative study was performed. In-depth interviews were conducted with 28 patients with and without mental health disorders and focus groups were held with 21 professionals and a manager. An inductive thematic content analysis was performed in order to explore, develop and define the emergent categories of analysis. Results: The fundamental domains for patients are dignity, communication, and rapid service. People with mental health problems also highlight the domain of confidentiality as relevant, while patients who do not have a mental health problem prioritize the domain of autonomy. Patients with mental health disorders report a greater number of negative experiences in relation to the domain of dignity. Patients do not consider their negative experiences to be a structural problem of the system. These findings are also endorsed by health care professionals. Conclusions: It is necessary to take these results into account as responsive systems can improve service uptake, ensure adherence to treatment, and ultimately enhance patient welfare. Keywords: Responsiveness, Primary Health care, Mental health Background once in their life, and with mood disorders and depres- Globally, mental health diseases are a major problem. In sion being the most frequent [1–5]. From a health care fact, according to the WHO, 450 million people suffer perspective, Primary Health Care (PHC) is considered from a mental or behavioral disorder, with every 1 in 4 the most effective in the management and treatment of people suffering from a mental disorder (MD) at least these mental disorders [1]. Several studies have con- firmed that 25–35% of patients receiving PHC services * Correspondence: bolivan@unizar.es; barbaraolivan@gmail.com have a psychiatric condition, with over 80% of these pa- 2 Health Research Institute of Aragon (IIS Aragón), Edificio CIBA, Avda. San tients experiencing depression or anxiety disorders. In Juan Bosco, 13, Zaragoza 50009, Spain 3 Research network on preventive activities and health promotion (Red de fact, 53.6% of the patients in primary health care settings Investigación en Actividades Preventivas y Promoción de la Salud) (RedIAPP), present one or more psychiatric disorders, with the most Gran Via de les Corts Catalanes, 587, Barcelona 08007, Spain prevalent being affective (35.8%), anxiety (25.6%), and Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 2 of 12 somatoform (28.8%) disorders. There were 30.3% of pa- system, apart from expectations for improvements in tients who had more than one mental disorder at the health or wealth”. It may be defined as the way in which time of the study and 11.5% presented comorbidity be- people are attended to and the environment in which tween affective, anxiety, and somatoform disorders [6]. they are treated. It values the personal experience of the Furthermore, it is widely known that General Practi- patients when in contact with the health care environ- tioners (GPs) only refer approximately 5–10% of their ment [13] and is different from patient satisfaction with psychiatric patients, whose disorders were detected in the care they receive. HSRC is measured through eight Primary Care, to Mental Health Services [7]. This is due domains which are in accordance with the framework of to PHC being considered the main health platform human rights, and which are classified into two main where mental health patients are treated. categories: the domains that relate to respect for a per- Since the declaration of Alma-Ata, Primary Care has son (which include dignity, confidentiality, communica- been considered a fundamental part of the health sys- tion, and the autonomy of individuals; and the structure- tem, as it is seen as the most accessible level of care to oriented domains (which include rapid service, basic the individual and community. It is based on effective quality of facilities, access to social support networks, methods and technologies and is provided at an afford- and choice of care provider) [14]. These domains, shown able cost to society [8]. Furthermore, it is the level of in Table 1, were established for both the hospital setting care closest to the health determinants of the individuals and primary care services. However, the domain of social and the community it serves [9]. This allows for it to ad- support refers only to the interaction with hospital care, dress the multi-causality of diseases and maintain a bio- so would not apply to primary health care. Understand- psycho-social approach, intersectorality, and comprehen- ing the opinions and perceptions of health care service sive care. However, changes in society have also brought users regarding the quality of care is essential for pro- out changes in the position of the general population re- moting changes and implementing effective measures garding their care and decision-making about their own for improvement. health [10]. Given the percentage of patients who suffer from a Another aspect to take into account is the quality of mental health disorder, and who are attended to the healthcare given, with reference to both clinical and mainly by primary health care services, it is relevant non-clinical care [11]. Regarding the latter, the WHO’s to analyze the patient perception of the Primary report ‘The world health report 2000 - Health systems: Health Care Response Capacity (PHCRC). This is due improving performance’ [12], measures how well a to an efficient response capacity being able to con- health care system meets the legitimate expectations of tribute to improving health, fostering promotion and the population with regards to the non-health-enhancing prevention, and facilitating interaction and communi- aspects of the health system. The report was the first to cation with healthcare providers in a more efficient develop the concept of ‘Health Systems’ Response Cap- way [15]. Furthermore, as stated by WHO in its acity (HSRC), which is defined as the “ability of the ‘Mental Health Action Plan 2013-2020’ [16], health health system to meet the population’s legitimate expec- systems have not yet adequately responded to the tations regarding their interaction with the health burden of mental disorders and, therefore, the gap Table 1 Definition of the domains of the response capacity of the WHO DOMAIN DEFINITION Dignity To be treated respectfully by the personnel of the health service. Maintain privacy during physical examinations and treatment Confidentiality To carry out visits in a manner that ensures privacy. Respect the confidential nature of the information about the illness. Autonomy Involve the patient, if they so wish, in the decisions regarding care and treatment and allow the patient to reject these, unless suffering from a deterioration of their mental faculties. Seek permission before applying any tests or treatments. Rapid Service Ensure rapid service in cases of emergency. Short waiting times for visits, tests, treatments and hospital admission. Availability of health personnel when hospitalization is required. Clear Provide patients with information about their problem in understandable terms. Maintain close dialog between patients and Communication providers. Listen attentively. Allow patients and their families enough time to ask questions. Choice Free choice of providers and services. Social support Family and friends can take hospital patients their favorite meals and soaps. Allow interaction with family and friends. Allow patients to observe religious practices. Quality of Basic Availability of generous spaces. Clean environment. Appropriate furniture, sufficient ventilation, clean restrooms. Services Source: Own Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 3 of 12 between the need for treatment and the provisions by the WHO Multi-country Survey Study on Health and provided is considerable all over the world. Health System’s Responsiveness (MCSS) in Spanish [24]. In addition to being an intrinsic goal, responsiveness is Both participating patients and GPs were recruited also a process involving multiple interactions within from PHC centers in the city of Zaragoza (Spain). Due health systems and has an integral value within health to the universal nature of the health system in Spain and systems. Improved responsiveness, while itself being a the absence of other primary health care providers, the health systems goal, also contributes towards equitable data obtained in the study is considered to be represen- improvements in population health. Responsive systems tative of the population that met the criteria for inclu- can improve service uptake, ensure adherence to treat- sion in the study. The Spanish health care system has ment, and ultimately enhance patient welfare [17]. full coverage of the registered population and is funded People, especially the most vulnerable (and people with by public taxes. The health system patients do not need mental disorders are among this vulnerable population), to pay any sum of money to receive health care or diag- are more likely to use services if health systems are re- nostic tests. This characteristic is common in many sponsive to their expectations. Conversely, people are European and world health care systems. unlikely to use services within unresponsive systems Participating patients´ inclusion criteria were outlined [18]. Yet, of the four intrinsic goals of health systems, as the following: being over 18 years old and having re- that is, improving health, ensuring fairness in financing, ceived care from the primary care health professionals efficiency, and responsiveness, it is responsiveness that is (general practitioners or nurses) during the previous 12 the least studied [17]. Besides, to our knowledge, there months at the time of the study. A subsample of partici- are few studies that analyze the opinions of patients with pating patients was required to have suffered from at mental health disorders towards the HSRC [19–22], and least one psychiatric illness (generalized anxiety disorder, furthermore, those that do, do not focus specifically on depression, schizophrenia, addictions, and/or personality PHC. disorder), as classified by the ICPC-2 classification framework. They needed to have said illness also regis- tered in their electronic medical records. They had to Methods have received pharmacological and/or psychological The objective of this study is to deepen our understand- treatment, too. The exclusion criteria were the following: ing of opinions towards PHCRC by specifically using pa- not being able to respond to the interviewer, presenting tients with and without mental disorders, as well as cognitive impairment from any cause (which appears in family doctors and a manager, with the goal of assessing the patient’s medical history), residing in the area for less the most effective domains for patients in terms of re- than 3 months during the year, and receiving palliative sponsiveness and assessing their satisfaction in each do- care. main. Another objective of this study is to analyze the In the sample, 28 patients were used, 17 (46.4%) being similarities and differences between the perspectives of women, and 11 (53.6%) men, with an average age of physicians regarding their patients with mental health 52.04 years (SD:14.14). Of these 28 patients, 15 suffered problems and the perspectives of patients with and with- from a mental health disorder and 13 did not suffer any. out mental health problems. The study also intends to Of the 15 participating subjects with a mental health dis- analyze whether there is a difference in the perception of order, 5 were male. This sampling was used in order to PHCRC according to the gender of the interviewees. analyze differences in both groups of patients in regard A qualitative design was carried out in order to collect to the topic of the study. In the sample, 21 family doc- information from an intentional sample of PHC patients tors from different urban health centers, belonging to with and without mental disorders, GPs, and from a different population profiles, were also recruited with 1 member of a PHC management team. In-depth inter- being a member of a management team. Of the family views and discussion groups were used to collect sub- doctors, 12 were women (57.1%) and 9 were men jective data and to access understanding for the (41.9%), with an average age of 54.24 (SD:9.48). The processes involved in generating expectations [23]. The average years of experience was 25.67 (SD:10.75). individual interviews and the discussion groups were Participating patients, with and without mental health held by two interviewers, both of them psychologists disorders, were invited to participate in the study ac- and researchers, with previous experience in the subject cording to the order in which they appeared on the par- field, and who had no prior contact with the partici- ticipating family doctor’s consultation list. Their sex and pants. This study is complementary to a quantitative age were analyzed as they were included in the study to study whose objective is to analyze the PHCRC, specific- ensure that there were no significant differences in both ally in each of its domains, by assessing people with groups (p-value: 0.448 with regard to sex, p-value: 0.085 mental disorders, using the brief questionnaire provided with regard to age). The patient’s age (< 40; 41–60;> 60), Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 4 of 12 sex, and mental health pathology were taken into ac- towards their experiences with health services (focus count. The participating family doctors ages (< 40; 41– group instrument) [25], and which was translated and 60;> 60), sex, and years of experience (< 15; 15–30;> 30) back-translated from English to Spanish to ensure the were also taken into account with the purpose of obtain- quality of the questions. The patients were asked to de- ing the widest variety of information possible. tail whether they had ever needed to consult a health All patients, family doctors, and managers initially care center (and if so, whether it was because of mental agreed to be interviewed, and all of them partook in said health problems). In the case that the patients had not interviews. Table 2 shows the main characteristics of the further detailed their experience, they were asked about 49 participants (28 patients and 21 professionals, of how they felt in that situation, how long ago that experi- which 20 were GPs and 1 was a member of management ence happened, how the doctors/nurses treated them, from a primary care team and was also a GP). Two focus what they thought of the place where they received med- groups were carried out with the participation of the 20 ical care, and if they could change anything about this GPs and an individual interview with the member of the experience, apart from their health being better or not, management team. The interviews were conducted from what would they change. These questions were related January to July 2019. to positive and negative experiences during their use of A standardized protocol was designed to guide individ- PHC services (if the patient reported a negative experi- ual and group interviews. It included the preparation of ence, they were subsequently asked for a positive one a topic list to be addressed, with previously tested, open and vice versa). The WHO document is intended for suggestions that could have been of interest. The topic focus groups, but in our study, we opted for its use in in- list was based on the guide created by the WHO for dividual interviews in order to maintain confidentiality, qualitative assessment to study patient perception since several of the participants belonged to the same health center and the inclusion criterion of a subsample Table 2 Characteristics of participating patients and health care was to have a diagnosis of mental disorder. In addition, professionals open questions were prepared based on the domains Variables Patients outlined in the Multi-country Survey Study on Health (n = 28) and Health System’s Responsiveness (MCSS) question- Age naire [24]. The questions in the MCSS were formulated 20–40 years 6 (21.4%) to be answered on an ordinal scale (how often or how 41–60 years 15 (53.6%) would you rate), while the interviews were formulated with open-ended questions to avoid yes/no answers and > 60 years 7 (25%) referring to health personnel (doctors, nurses, and ad- Sex ministrative staff). Table 3 shows the list of topics and male 11 (39.3%) questions. The individual interviews with the patients female 17 (60.7%) were carried out first, followed by the group interviews Group with family doctors, and lastly the interview with a With mental disorder 15 (53.6%) member from the management team. Interviews were continued until all possible information was collected. Without mental disorder 13 (46.4%) The objectives of the study were indirectly addressed Variables Health care professionals (n = 21) and questions asked about the topics were answered in an open and progressive way. The interviewers and/or Age moderators were introduced to the participants as re- 20–40 years 3 (14.3%) search psychologists and assumed the minimal role of 41–60 years 14 (66.7%) orientating, limiting their interventions to addressing the > 60 years 4 (19%) topics in the script. The environment for data collection Sex was a neutral room in the different health centers in male 9 (41.9%) which the patients were registered, without the presence of non-participants in order to ensure the confidentiality female 12 (57.1%) of their responses. In-depth interviews lasted between 20 Years of experience and 60 min and the discussion groups lasted 40–75 min. < 15 years 3 (14.3%) All sessions were digitally audio-recorded and a verbatim 15–30 years 12 (57.1%) transcription was made in order to obtain the final set of > 30 years 6 (28.6%) qualitative data for analysis, which was revised by some Health care professional includes GPs and a member from a PC participants and added to the field notes made during management team and after the interviews/groups. Participants agreed to Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 5 of 12 Table 3 Topic list and questions Topic list Questions for patients Before the interview 1. Greetings, words of thanks and introduction of the interviewer and observer. 2. General information about the topic to be discussed and the purpose of the session. 3. Explanation of ethical aspects: confidentiality and informed consent and permission to record. 4. Explanation of the dynamics of the interview (We will ask some questions to find out about your experiences. We are interested in your opinion. Before we continue, do you have any questions, do you have any doubts? Do you agree to participate?) 1. Perception of the response capacity given Could they describe a situation when they went to see a health professional (either a doctor or a by the primary care unit. nurse) at their health center about a mental health problem? How did they feel in that situation? How long ago did the incident they are describing happen (if they are recounting a negative situation or incident)? How did the doctors/nurses treat them? What do they think about the place where they received care? If they could change anything about this experience, apart from it being better or not, what would they change? If it was a negative experience, ask them to talk about a positive experience and vice versa. What would they expect their health center to be like? Could the health center change anything in the way they are treated? 2. Specific perception of each domain. After explaining the concept of responsiveness and each domain, ask specifically about their perceptions of the last year, when they have needed attention from their doctor or nursing staff at their health center, and their opinions in the context of each of the domains. 3. Most important domains for patients on Which of these domains do they consider most important? Why? responsiveness. * Questions for health care professionals only focus on the second point. Patients with a mental health disorder, who also presented another chronic pathology, were specifically asked in their mental health-related consultations participate in the study and signed a consent form. None loss of dignity can occur which, although not fre- of the interviews were repeated. quent, tend to be more common in hospital care than With the intention of assessing the scope of discourse, in Primary Care. Nevertheless, family doctors an inductive thematic content analysis was carried out in recognize that these situations regarding loss of dig- order to explore, develop, and define the emergent cat- nity and autonomy can occur with these patients. Al- egories of analysis which derived from the individual though some patients report some negative interview and group data [26]. This analysis was per- experiences in relation to dignity and communication, formed by two researchers independently and was patients without mental health problems generally express agreed upon between the two where there were discrep- that their negative experiences are centered on rapid ser- ancies in the analyses. Subsequently, these emerging cat- vice. When the participants were asked what they would egories were recoded based on the theoretical change, none considered it to be a structural problem. Ra- framework developed with consideration to the WHO, ther, they considered it to be a problem with certain pro- HSRC, and previous studies. All analysis was performed fessionals. Those who have had relevant problems in this iteratively using Maxqda-2007 software in agreement be- respect have solved them by changing professionals. On tween two researchers, and the interpretations made the other hand, the professionals consider that it is im- from the data were discussed with interviewers and par- portant to take these non-medical aspects into account ticipants to obtain their consent [27]. This methodo- and to act accordingly during consultations. However, it is logical triangulation was able to increase consistency often the very organization of the system and the very na- and rigor by combining multiple techniques and maxi- ture of the profession (dealing with the health and illness mizing the breadth and depth of the interpretations car- of people who each have their own context) that make it ried out. complicated to implement non-medical aspects. In the analysis, no differences were observed in the Results perception of the PHCRC from the professionals ac- Regarding patients’ experiences in their use of Pri- cording to their gender. However, in the group of mary Care (PC) services, both negative and positive patients, women, regardless of whether or not they experiences fell into the categories of dignity, commu- suffered from a mental health disorder, reported nication, and rapid service. Patients relate dignity and more negative experiences in terms of communica- communication very closely in their discourse. Sub- tion. As for participants with MD, only one male re- jects with mental health disorders report more nega- ported negative experiences regarding clear tive experiences regarding dignity, including also communication and dignity, while women with MD recording experiences with management staff. In pa- reported more negative experiences regarding dignity tients with a mental health disorder, extreme cases of and clear communication. Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 6 of 12 "Well, I kept crying and they sent me to hospital be- “For me, it was very good. I also have to say that I, cause I was too nervous, and once they tied me to... too, am well mannered”. to the stretcher" (Patient, female, 70 years old, with SMD) (Patient, female, 29 years old, with SMD) "Sometimes, due to the circumstances surrounding "We make decisions consulting with the police. Noth- the consultation, and perhaps on a particular day, ing is further from autonomy than to force someone there may be a feeling of pressure; that everything is into a hospital or to immobilize them..." going too fast, that the professional does not conduct (Family doctor, male, >30 years experience) the consultation well... There may be a certain mo- ment when the doctor is no longer fully in command "one thing is your personal behavior and another is of their ability to attend in a calm and attentive how the system allows you to act. I believe that the manner. If at that moment a specific patient who system has many flaws in terms of autonomy, confi- also requires special attention for mental health rea- dentiality, dignity... I, as a professional, can be very sons, for social conditions, or for any other reason much in favor of this, but sometimes the system does particular to their personality, etc., etc., there may not allow me, or is not inclined to allow me to act in be an interaction that may not result in being the a certain way". most appropriate ... Things happen in a more stag- (Family doctor, female, >30 years experience) nant and difficult way which may result in the pa- tient or the professional not being satisfied..." (Family doctor, male, >30 years experience) Domain of dignity When analyzing the questions relating to each of the “yes, yes, regardless of the health problem, the treat- domains, with respect to dignity, there is a majority ment of the patients always, generally speaking, but perception by patients that they are treated with dig- this is also supported by all the satisfaction surveys, nity. However, there are some patients with mental is always in principle, very satisfactory”. health disorders who specifically comment on some (Manager, male, 15–30 years experience) negative experiences with respect to this domain. This fact could be complementary to the perspective of the professionals. They report that if the patient Domain of confidentiality displays aggression or anxiety, has some personality Regarding confidentiality, all patients, regardless of disorder, and/or communicates guilt to the profes- whether they have a mental disorder or not, recognize sional, the professional should maintain control of the importance of confidentiality with no reports having the consultation. However, some circumstances, such been made about having problems in this regard. Ac- as working under pressure, can make the situation cording to the professionals, the most challenging aspect more difficult and not satisfactory for either the pro- is inter-consultation with other professionals. They be- fessional or the patient. Patients also regard this as a lieve they have established mechanisms to improve con- two-way street, that is, patients consider that if they fidentiality but there are still aspects to improve. In address the health professional with respect, the pro- their discourses, family doctors reported some nega- fessional must treat them with respect and vice tive experiences when recording confidential matters versa. Another aspect that emerged in the discourse regarding the patients (for example, an issue of gen- of both users and professionals is that the presence der violence), which were being seen to by the health of residents and medical students, with whom they center and in consultation with a specialist interven- do not have close contact and who are often present ing in an action already underway at the PC. There during exams, etc., is violent to them. However, in are also problems of confidentiality with users who this respect doctors say that they usually ask the pa- suffer from a mental health disorder who are also tient if they agree with the presence of doctors in seen to by private health care providers since infor- training. Finally, the difficulty in maintaining privacy mation is not shared. In the groups of professionals, during clinical exams also appears in the discourse. there is no agreement as to whether certain types of Due to small consultation rooms, the positioning of pathology with a strong social stigma, for example, available furniture, or consultation spaces shared severe mental health disorders, HIV, social problems, with nursing staff, even if screens are used, interrup- etc., would have to be reported to all professionals or tions can complicate efforts to maintain privacy dur- reserved to only some, with there being opinions for ing exams. and against the matter. Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 7 of 12 “I think so. I don't have any proof to the contrary." centers that have a mental health unit integrated note (Patient, female, 72 years old, no SMD) that by having more fluid communication with special- ists, patient attention can be faster. There are tools such "We have so much information and it passes through as minimum waiting time specifications. With regard to so many channels, that the truth is that absolute waiting for additional tests, which are generally blood confidentiality is entirely impossible, right? In fact, a tests, rapid service is well perceived. detail that just sums up what happens is just how many times a patient tells us ‘hey, I've been sent to “Some countries are establishing quick consulta- god knows who and it says here that I have this tions... They have a system set up where the patient health problem and I don't want that to appear on talks to, and is responded to, by the doctor through a my record’. Patients come to you and they tell you computer. I don't think that's the solution, I think these things. I think it's so difficult. For most people there needs to be adequate time, and not quick con- the intention is, supposedly, to maintain confidenti- sultations that don't solve the problem”. ality, but it is exhausting to try to guarantee 100% (Family doctor, male, >30 years experience) confidentiality with these systems.” (Family doctor, woman, >30 years experience) Domain of clear communication With regard to clear communication, in general, the Domain of autonomy patients interviewed, at the time of the study, consid- With respect to the domain of autonomy, both patients ered that they had good communication and were lis- and professionals note patient involvement, when will- tened to well by the health professionals. There were ing, in decisions about their care or treatment, and that patients who reported that when they did not have their permission should be requested before tests or good communication, they opted to change profes- treatments are performed. However, it also appears that sionals. Patients also reported negative experiences in patients often do not want to be involved, regardless of terms of communication with administrative staff. On whether they suffer from a mental health disorder or the other hand, the professionals consider that pa- not. tients are provided with information about their prob- lem in an understandable manner, have close “There has been a paradigm shift in Medicine, espe- dialogue, and are listened to carefully. However, these cially in Family Medicine. We have gone from pater- professionals also comment that often that there is nalism to a model of autonomy”. not enough time to provide this level of service. Pro- (Manager, male, 15–30 years experience) fessionals also believe that this domain with patients with a severe mental health disorder is more compli- “Everything is explained to them... Sometimes they cated for several reasons. For example, explaining are not told "do you agree?", but there is an implicit both the prognosis and its implications is more com- request of... “Do you want me to do this to you?”... or plicated and requires more time, especially for those “this should be done”...” with severe disorders. Another reason is that the pa- (Family doctor, female, 15–30 years experience) tient may already have a limited capacity of under- standing (they come to the consultation without their “Patients often don't want to get involved... There is legal guardian, or in the acute phase of a psychotic a certain delegation of responsibility to the doctor.” episode, etc.). (Family doctor, female, >30 years experience) "the one at the front desk screeching at me, as if she Domain of rapid service were the teacher scolding a child. It was practically With regard to rapid service, except at specific times of the same thing!" the year, waiting times are short. Usually, there is an ap- (Patient, female, 55 years old, with SMD) pointment on the same day for the family doctor if there is no possibility of continuous care. It does appear re- “The time we give to explain things to the patient peatedly in all patient discourse that there is a delay with comes at the expense of our own health...” the time of entry to the consultation, but they often at- (Family doctor, female, 15–30 years experience) tribute this to the fact that the time per consultation is scarce and, therefore, it is normal that there are delays. “I think the biggest problem is the lack of time we Professionals emphasize the need for sufficient time in have to talk to patients and families with mental consultations to provide adequate assistance and reso- health problems because there are patients which lution capacity. With respect to mental health disorders, you have for six minutes or ten minutes and you Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 8 of 12 know you need to be there for at least an hour!” “Before they weren’t any..., it is clear that there have (Family doctor, woman, >30 years experience) been cuts”. (Patient, female, 51 years old, with SMD). Domain of choice With regard to the domain of choice, 25% of the pa- “There is no respect, there are people who don't pay tients interviewed had changed their family doctor at any attention to anything”. some time and had not had any problems in making (Patient, male, 55 years old, with MD). this change and choosing another doctor. The main reason why people had changed doctors was because Relevance of the domains of problems with dignity and communication. The Regarding the importance of the domains in patients geographical distribution of resources must also be with mental health disorders, the domains, appearing in taken into account, as it is different to exercise order of highest to lowest importance, are dignity, rapid choice in an urban health center where there are service, confidentiality, and clear communication, with several professionals, than in rural centers in small 80% accounting for the first two; dignity and communi- municipalities where there is only one doctor. An- cation. For people who do not have a mental health dis- other fact to highlight is that patients are able to order, dignity is also the most important domain (also change their family doctor depending on the under- around 80%), but the domains that follow are confidenti- standing, trust, and doctor-patient relationship they ality, autonomy, and rapid service. The latter is not so have, but in mental health units located in the much of a priority for control participants, while auton- health centers, they cannot choose a mental health omy is. Only 13% of subjects with a mental health dis- specialist. There is also no possibility of choice with order place autonomy among the most prominent respect to the administrative staff, and patients have domains. The domains that are considered less relevant reported negative experiences with this part of the are quality of services and choice. This is also shared by health center staff. professionals and management. The interrelationship be- tween domains also appears in the discourses with there “In general, in those centers where it is possible, there being mention of a relationship between clear communi- is no problem”. cation, autonomy, dignity, and the latter with (Manager, male, 15–30 years experience) confidentiality. Domain of quality of services “Dignity is fundamental and goes hand in hand with With regard to the quality of services, in general, there is confidentiality... Then, there would also be rapid ser- the consensus that all is correct and adequate in terms vice. Clear communication would come before au- of facilities and their hygienic conditions, however, there tonomy because it would be difficult for the patient also appear to be opinions from patients who feel that to choose between different options if I am not able cleaning is not correctly done or that it has worsened to make clear what they are to them”. after the economic crisis. Yet, it has also been mentioned (Manager, male, 15–30 years of experience) the notion that the responsibility for the care and clean- liness of the facilities also falls back on the patients “Dignity, confidentiality and rapid service”. themselves and there are people who do not take on this (Family doctor, female, >30 years of experience) responsibility to care for the common facilities. The opinion of the professionals and the health care manager “Clear communication is also the basis for autonomy is that it depends on the health centers. There are health and dignity. Dignity is also related to confidential- centers where there are no complaints about this during ity”. the assessment of the facilities in the satisfaction surveys, (Family doctor, male, >30 years of experience) but there are also others which receive many complaints. The domains’ prioritization and their interrelationship is shown in Fig. 1. “There’s room for improvement with this because after going through a period of economic crisis with Discussion insufficient funding in Primary Care it’s mmm wors- The HSRC measures the patients’ experiences regarding ened, or at least put on the backburner with respect non-medical health problems and their legitimate expec- to other needs. So, logically there has been some de- tations when they come into contact with the health sys- terioration in the state of the spaces”. tem, evaluating their objective experience with these (Manager, male, 15-30 years experience). services, regardless of whether they are satisfied or not Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 9 of 12 Fig. 1 Importance and relationship among domains obtained in the discourses with the attention they receive [13, 28]. Mental health difficult by the fact that a collaboratively negotiated diag- care is especially relevant since patients with a mental nosis and treatment is needed, taking account of the pa- disorder are especially vulnerable to not being treated as tient’s preferences, expectations, understanding, and they wish due to the characteristics of their illness and social context. This collaboratively negotiated diagnosis the associated stigma [29, 30]. The qualitative method and treatment is difficult to provide with limited time used in this study is based on the recommendation to and resources, something for which university education use a qualitative research method in order to investigate does not prepare [39]. Besides, this difficulty in commu- experiences with non-medical care and individualized nication could be due also to the stigma of mental disor- disease, and the providers´ experiences in regards to re- ders that also exists among healthcare professionals [40]. lationships between patients and providers [31]. Regarding the domain of dignity, there is a majority Regarding the results obtained, dignity, communica- perception by patients that they are treated with dignity, tion, and rapid service are the domains highlighted as but both patients and health professionals express that important by patients with a mental disorder. The close treatment must be respectful on both sides. Therefore, relationship between dignity and communication was authors such as Ziedonis et al. [41] advocate for a sup- also commented on. These domains were also identified portive and respectful physician-patient alliance as a as relevant in the qualitative study that Forouzan carried means of ensuring this dignity. out in Iran with mentally ill patients [32], as well as in Regarding confidentiality, the majority of patients have the study by Murante et al. [33]. These findings are also had positive experiences; results which are endorsed in consistent with the fact that people in mental health other studies [20, 21, 42, 43]. In general, patients know units are less likely to report that staff treat them with that confidentiality is the duty of all professionals in- dignity and respect than those in primary and secondary volved in medical care in the health field [44]. Patients care [34]. with mental health problems consider this domain to be Regarding communication, it should be emphasized more relevant compared to patients who do not have that women have higher expectations regarding commu- mental health problems. This may be related to the nication [35] and are more likely to prefer a collabora- stigmatization of mental health [40, 45]. A substantial tive style of communication with their physicians by desire to maintain privacy during consultations also taking an active role in the process of their medical care emerged in statements regarding the physical layout of [36]. Research also suggests that both health profes- the facility. The physical layout of the facility also sionals and patients with a severe mental disorder have emerged in the assessment of dignity at the center as difficulty in communicating effectively about symptoms, well as in the study by Njeru et al. [42]. drug treatments, side effects, and about how to reach a Regarding the domain of autonomy, it appears to be a mutual understanding on the topics of diagnosis, prog- significant domain for all, but specifically for patients nosis, and treatment [37]. Regarding the training in without mental health disorders. Patient participation is communication skills, a seminal paper published in the increasingly recognized as a key component in the re- Lancet in 1980 highlighted the potential benefit of teach- design of health care processes and is upheld as a means ing communication skills in undergraduate medical pro- to improve patient safety [46]. However, on many occa- grams [38]. Since the time of the study, programs or sions, physicians do not evaluate accurately the patients’ subjects on communication have been implemented in preferences [47]. Furthermore, the autonomy domain is undergraduate training in health care degrees. However, also closely related to clear communication [28] and this communication between primary health care personnel communication is more deficient with patients with and patients with mental health problems is made mental health disorders [37]. This may explain why Rodríguez-Eguizabal et al. BMC Health Services Research (2021) 21:285 Page 10 of 12 patients with mental health problems do not place au- Conclusions tonomy as a preferred domain. The fundamental domains for patients, with or without Our study has important strengths but also has its lim- a mental health disorder, are the domains of dignity, itations. Among the strengths, it can be noted that, com- communication, and rapid attention, with dignity being paring with patients without mental health problems, a closely related to communication. People with mental very relevant issue has been addressed for the attention health problems also highlight the domain of confidenti- of health service providers in relation to populations suf- ality as relevant, while patients who do not have a men- fering from health problems which are highly-prevalent tal health problem prioritize the domain of autonomy. worldwide, such as mental health problems. Another Patients with mental health disorders report a greater strength is the methodology we employed, since it number of negative experiences in relation to the do- allowed us to deepen our understanding of patient per- main of dignity. These findings are also endorsed by ception of response capacity. Moreover, it allowed for health care professionals. the number and profile of the participants, collecting of Abbreviations the patient perspectives (service users), health care pro- GPs: General Practitioners; MD: Mental disorder; HSRC: Health Systems’ fessionals (service providers), and administrators (man- Response Capacity; MCSS: Multi-country Survey Study on Health and Health agers), and was in line with the principles of the System’s Responsiveness; PHC: Primary Health Care; PHCRC: Primary Health Care Response Capacity stakeholder theory. This fact allows us to analyze dis- course, collecting the opinions from all profiles involved Acknowledgements in the health care. However, this study also has limita- We wish to thank the Research network on preventive activities and health promotion" (RedIAPP); Research Group B21_R17 of the Department of tions such as the very nature of the concept of respon- Research, Innovation and University of the Government of Aragon (Spain); siveness in the health system and in the domains, since Health Institute Carlos III (grant number PI07/02274 and PI18/01336), and the patients are not usually familiar with the notion. An- Feder Funds "Another way to make Europe", for their support in the development of the study. other limitation of this study is that it is necessary to consider its results in the context of the health system in Authors’ contributions which they occur and according to the sample size. Sev- BOB, VCV, ERE were responsible for the conception and design of the study. BOB, MASC, AGR and SLM were responsible for carrying out the interviews eral studies [33] suggest that HSRC varies substantially and data collection. VCV, MJGG, RMB and BOB were responsible for data between countries due to variations between health sys- analysis and contributed to the interpretation of data. ERE and BOB wrote tems in each country. On the other hand, although 28 the manuscript, which was critically revised by all the other authors. All authors have approved the final version of the manuscript. patients and 21 professionals were interviewed, this is a small number to take into account with respect to its ex- Funding ternal validity. In addition, the aspect of the perception This work was supported by the Health Institute Carlos III (Ministry of Science, Innovation and Universities of Spain). Grant number: PI17/02274 and of the PHCRC according to gender and especially in the PI18/01336. The funder has no role in study design, data collection and group of patients with mental health problems should be analysis, decision to publish, or preparation of the manuscript. further investigated, since the results cannot be consid- Availability of data and materials ered conclusive in this respect and further research The data that support the findings of this study are available from the would be necessary. It is also necessary to reinforce the corresponding author, (B.O.B)], upon reasonable request. perspective given from managers. Declarations In all medical specialties, including Primary Health Care and Mental Health Care, evidence is growing that there is Ethics approval and consent to participate a gap between what is considered optimal care and what All procedures contributing to this work were carried out complying with the ethical standards of the Clinical Research Ethics Committee of Aragón is actually provided [19]. Therefore, it is relevant to evalu- (belonging to the Department of Health of the Government of Aragon, ate and compare the performance of health services and Spain) and with the Helsinki Declaration of 1975, as revised in 2008. The specifically mental health attention, by using a universal Study Protocol was approved by the Clinical Research Ethics Committee of Aragón (Spain) (17/194). Every participant subject provided an informed indicator, which does not need any adjustment for specific consent form. risks, such as the response to the domains found in health services [19]. In addition, it is important to incorporate Consent for publication Not applicable. patients in the generation of knowledge about health sys- tems, and to involve them in health care planning with a Competing interests view to co-production in health with contextualized, biop- The authors declare that they have no competing interests. sychosocial and salutogenic care models. 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