title: Institutional discrimination in mental health services: a comparative analysis of schizophrenia and diabetes in Romania
Creators: name: Petrea, I
Publisher: name: London School of Hygiene & Tropical Medicine
Year: 2012

description: Background: This thesis aims to ascertain the extent and nature of institutional discrimination against people with mental illness in specialist health care settings in Romania. The hypothesis is that such discrimination exists. Building on the definition in EU directives, discrimination is defined, for the purposes of this thesis, as harm that is caused to individuals or groups on the basis of identifiable characteristics bearing negative connotations. Harm is defined as the receipt of care that is less good than, inequitable in comparison to that received by others with similar needs, (long-term physical and mental illness), on grounds of stigma against people with mental illness. To assess the presence of discrimination, two groups were identified suffering from disorders that, although at first sight quite different, actually have much in common. They are schizophrenia and type 1 diabetes. Methods: The research method was Rapid Assessment, involving initial assessment, study area profile, contextual assessment, and health intervention assessment. The presence of horizontal inequity was determined by means of a de jure and a de facto assessment of specialist health care for people with schizophrenia and type 1 diabetes, using a set of criteria for aspects of care that are equally applicable to the management of both conditions, namely: 1) accessibility of specialist services; 2) availability of evidence-based treatment and care; 3) delivery of care; 4) quality of facilities; 5) protection of human and civil rights. The presence of stigma was determined the by ascertaining whether those in a position of authority and influence, namely the health professionals interviewed during the fieldwork, displayed stigmatising of attitudes and beliefs, language or approaches to treatment. The research triangulated data collected using a range of methods that include systematic review and comparative analysis of laws, policy documents and other literature, interview strategies (focus groups, group interviews and semi-structured interviews) and observations of practice. Analysis of the data involved three methods: content analysis, narrative structure analysis, and critical appraisal. For the fieldwork, a total of 228 participants (service users and health professionals) were selected using multi-stage sampling, covering each condition in each specialist setting (mental health acute and chronic inpatient services and outpatient services as well as inpatient and a comparative analysis o f schizophrenia and diabetes in Romania outpatient services for type 1 diabetes) in two selected locations in Romania (Bucharest and Slatina). Data collection took place between the 19th of September 2007 and the 8th of January Findings: In assessing equity, weaknesses were found in management of both conditions, particularly poor access to medication for associated health problems and lack of follow-up after discharge, poor continuity of care. In many areas, treatment and care for people with schizophrenia was worse generally, though some aspects were equitable: access to care in community-based settings, geographical accessibility of services, access to services when needed (temporal access), access to different parts of the system, as needed (referral system), financial access to appropriate care, access to social care, availability of enough staff in all settings, involvement of service users in shaping the services, involvement of families and carers, protection of service users’ privacy and safety, decent living environment and hygiene of health facilities. Patients with schizophrenia were significantly disadvantaged in: access to a comprehensive range of evidence-based specialized services and to qualified and competent multidisciplinary staff, the quality of health facilities, access to care for other health conditions and, availability of individual treatment plans developed for each patient, empowerment of service users to care for themselves and live as independent a life as possible, and respect of all human and civil rights on health facilities and a number of patient rights. In assessing stigma, I found that all types of mental health professionals, in all settings, stigmatised people with schizophrenia, manifest through their attitudes and beliefs, language and approaches to treatment. Conclusions: This research found that people with schizophrenia suffer direct institutional discrimination in Romania, manifest inequities in both the legislation that applies to them and the specialist care delivered when compared with people with type 1 diabetes, and that these inequities arise in a context of stigmatising attitudes to people with severe mental health problems by those in a position of authority and influence (health professionals).