Trust is a vital factor when it comes to evaluating health centres for socially disadvantaged people. This is a basic recommendation of the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) in Vienna (Austria), which has published the results of a large-scale international study of this topic. The study compared 19 relevant evaluations from seven countries. It was initiated by neunerhaus, a social organisation that supports the homeless and people at risk of poverty in Vienna. The organisation opened a health centre in 2017. neunerhaus commissioned the LBI-HTA to carry out the study – over the past 13 years the institute has developed an excellent reputation for its analysis of social-medicine interventions, and has built up an outstanding network of contacts at the European level.
An estimated 100,000 people living in Austria do not have health insurance; many of them are homeless. Such people find it difficult to access health-related services. Facilities such as neunerhaus in Vienna (Austria) offer support to socially disadvantaged people, and since 2017 the organisation has even been operating a health centre of its own. In order to gain a better insight into the assessment of such low-threshold outpatient centres, in 2018 neunerhaus asked the LBI-HTA to prepare an international overview of evaluation methodologies. The findings have now been published, supplemented by specific recommendations, such as building trust between evaluators and patients.
WIDE AND VARIED
“Overall, we found that health centres for the socially disadvantaged are evaluated in a variety of different ways,” explains Dr Roman Winkler, an academic at the LBI-HTA. His colleague Inanna Reinsperger adds: “Due to the contrasting thematic backgrounds and aims of the various facilities, we found that a range of different evaluation methodologies are used.” The LBI-HTA team analysed 12 evaluation studies in English and seven in German from a total of seven countries. One point that stood out was that the evaluations in the English-language studies were mainly summative, with a focus on the quality of the results achieved by the centres, while the German-language reports also included an assessment of the centres’ internal processes (formative). The researchers found that various methods were used in parallel in many of the evaluations. For instance, qualitative and quantitative methods were both employed, and data were collected by means of interviews and questionnaires.
In the next phase, the researchers compared indicators that served as criteria in the individual evaluations of low-threshold outpatient health centres. These included patients’ health, recourse to health and social services, and sociodemographic data. However, patients’ levels of satisfaction with the range of services offered was also adopted as an indicator in the evaluations.
By contrast, other indicators were only rarely used. “Interestingly, only a few of the evaluations made use of health-economic indicators,” comments Dr Roman Winkler. “These would include data on the cost effectiveness of the services offered.” There were also few indications of the use of standardised measurement tools. Information from patients themselves remained the most common means of obtaining details on their mental health.
LOW THRESHOLD AND TRUST
The LBI-HTA team derived specific recommendations from their analysis of the 19 studies and reports. The most important included a recommendation to build trust between evaluators and patients. This is vital to the success of an evaluation of low-threshold outpatient health centres, because it is effective in keeping patients “on board” for the duration of an evaluation. However, a low-threshold design is also essential for the evaluations themselves and the methods employed. Homeless and uninsured people should definitely be involved in structuring such studies – and the design of the evaluation should make this possible.
On the whole, the LBI-HTA report showed once again why the institute is a sought-after partner thanks to its expertise in assessing social-medicine interventions. As a result, the institute is playing its part in highlighting the efficiency of such cost-effective interventions – in an age in which high-tech medicine is becoming more and more cost-intensive.
Winkler, R., Reinsperger, I. Evaluierungsmethoden zur Nutzenbewertung niederschwelliger, ambulanter Gesundheitszentren für vulnerable Personengruppen – Zielgruppen-Fokus: obdachlose, wohnungslose und nicht-versicherte Personen(Evaluation methods for assessing the benefits of low-threshold outpatient health centres for vulnerable groups – target group focus: homeless and uninsured individuals). LBI-HTA project report no. 114; 2019. Vienna: Ludwig Boltzmann Institute for Health Technology Assessment.