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The World Health Organisation (WHO) concept of responsiveness has been defined as a measure of how well the health system responds to the population's legitimate expectations of non-health aspects of health care provision. It comprises eight domains: dignity, prompt attention, autonomy, choice of health care provider, clear communication, confidentiality, quality of basic amenities, and access to social support networks. The concept is of particular relevance to mental health care systems because of the specific dependency and vulnerability of their users. We tested its applicability to mental health care with five focus groups of experienced mental health care users in Hannover, Germany. The focus groups revealed 492 statements about users' expectations in mental health care. Most concerned attention (115), dignity (108) and autonomy (86). The quotations were assigned to the eight responsiveness domains. In addition, the domain of prompt attention was extended and renamed attention, and the new domain continuity was created. The findings correspond with the literature on health care expectations of non-mental health patients, but differ slightly from the results of a WHO study on overall health care responsiveness. The need for widening the concept of continuity and extending the attention domain reflects the nature of mental health care of providing predominately long-term care. Our analysis indicates the feasibility of the responsiveness concept (if altered as proposed) as a tool for assessing the quality of mental health service from the users' point of view. It should also be further developed to quantitatively evaluate mental health care systems and to benchmark system performance. Keywords: Responsiveness; Mental health care; Health system performance; Patient's expectations; Patient orientation; Respect for persons; Germany

Abstract Background Suicide and non-fatal suicidal behaviour are significant public health issues in Europe requiring effective preventive interventions. However, the evidence for effective preventive strategies is scarce. The protocol of a European research project to develop an optimized evidence based program for suicide prevention is presented. Method The groundwork for this research has been established by a regional community based intervention for suicide prevention that focuses on improving awareness and care for depression performed within the European Alliance Against Depression (EAAD). The EAAD intervention consists of (1) training sessions and practice support for primary care physicians,(2) public relations activities and mass media campaigns, (3) training sessions for community facilitators who serve as gatekeepers for depressed and suicidal persons in the community and treatment and (4) outreach and support for high risk and self-help groups (e.g. helplines). The intervention has been shown to be effective in reducing suicidal behaviour in an earlier study, the Nuremberg Alliance Against Depression. In the context of the current research project described in this paper (OSPI-Europe) the EAAD model is enhanced by other evidence based interventions and implemented simultaneously and in standardised way in four regions in Ireland, Portugal, Hungary and Germany. The enhanced intervention will be evaluated using a prospective controlled design with the primary outcomes being composite suicidal acts (fatal and non-fatal), and with intermediate outcomes being the effect of training programs, changes in public attitudes, guideline-consistent media reporting. In addition an analysis of the economic costs and consequences will be undertaken, while a process evaluation will monitor implementation of the interventions within the different regions with varying organisational and healthcare contexts. Discussion This multi-centre research seeks to overcome major challenges of field research in suicide prevention. It pools data from four European regions, considerably increasing the study sample, which will be close to one million. In addition, the study will gather important information concerning the potential to transfer this multilevel program to other health care systems. The results of this research will provide a basis for developing an evidence-based, efficient concept for suicide prevention for EU-member states.

Abstract Background Health systems increasingly try to make their services more responsive to users' expectations. In the context of the World Health Report 2000, WHO developed the concept of health system responsiveness as a performance parameter. Responsiveness relates to the system's ability to respond to service users' legitimate expectations of non-medical aspects. We used this concept in an effort to evaluate the performance of mental health care in a catchment area in Germany. Methods In accordance with the method WHO used for its responsiveness survey, responsiveness for inpatient and outpatient mental health care was evaluated by a standardised questionnaire. Responsiveness was assessed in the following domains: attention, dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care provider, continuity, and access to social support. Users with complex mental health care needs (i.e., requiring social and medical services or inpatient care) were recruited consecutively within the mental health services provided in the catchment area of the Hanover Medical School. Results 221 persons were recruited in outpatient care and 91 in inpatient care. Inpatient service users reported poor responsiveness (22%) more often than outpatients did (15%); however this was significant only for the domains dignity and communication. The best performing domains were confidentiality and dignity; the worst performing were choice, autonomy and basic amenities (only inpatient care). Autonomy was rated as the most important domain, followed by attention and communication. Responsiveness within outpatient care was rated worse by people who had less money and were less well educated. Inpatient responsiveness was rated better by those with a higher level of education and also by those who were not so well educated. 23% of participants reported having been discriminated against in mental health care during the past 6 months. The results are similar to prior responsiveness surveys with regard to the overall better performance of outpatient care. Where results differ, this can best be explained by certain characteristics that are applicable to mental health care and also by the users with complex needs. The expectations of attention and autonomy, including participation in the treatment process, are not met satisfactorily in inpatient and outpatient care. Conclusion Responsiveness as a health system performance parameter provides a refined picture of inpatient and outpatient mental health care. Reforms to the services provided should be orientated around domains that are high in importance, but low in performance. Measuring responsiveness could provide well-grounded guidance for further development of mental health care systems towards becoming better patient-orientated and providing patients with more respect.