Impact of a governmental intervention to improve access to child psychiatric services in Japan

ABSTRACT

BACKGROUND

Caregivers of children with mental health problems have difficulty selecting an appropriate institution for consultation because of a lack of information and poor collaboration between public health centers and child specialists. The Japanese government launched an intervention in 2009 to improve access to child mental health services, including training for healthcare providers, family education using leaflets and homepage services, and promoting cooperation among facilities. The purpose of this study was to assess the effects of the intervention using pre- and post-intervention surveys.

METHODS

We conducted a pre-intervention survey in 16 specialist hospitals in 2008. After the governmental intervention was implemented in eight of the 16 specialist hospitals, we also conducted a post-intervention survey in the same hospitals in 2010. We compared changes in the time between the recognition of a child’s mental health problem and the first visit to a child psychiatrist and the caregivers’ perceived difficulty in selecting an appropriate institution before and after the intervention.

RESULTS

We received 4,323 and 869 answers to the pre- and post-intervention surveys, respectively. The intervention had no significant influence on the time between recognition of symptoms and visiting the specialist hospital. However, there was a significant improvement in caregivers’ perceived difficulty in selecting an appropriate medical institution after the intervention (p < 0.001).

CONCLUSIONS

The governmental intervention was effective in reducing the difficulty of selecting an appropriate institution.

INTRODUCTION

The prevalence of child mental health problems is increasing in Japan [1–3]. A previous study showed that the proportions of children who needed to be examined by a doctor because of mental health problems in nursery, elementary, and junior high school were 4.6%, 2.9%, and 4.2%, respectively [2]. However, only a small number of children were actually assessed by a child psychiatric specialist [2], and some caregivers of children with mental health problems found it difficult to decide which institution they should be attending for consultation [2].

A systematic review of mental healthcare access for children reported that difficulty in accessing psychiatric specialists is common throughout the world [3]. Sayal suggested a model to improve mental healthcare access for children with psychiatric disorders [3], which consists of four parts: parental perception of the problem, primary care use, management in primary care, and specialist health service use. Furthermore, Sayal proposed three filters: the decision to consult primary care, recognition of the problem, and referral to specialist services. One of the factors affecting access to care is that the majority of parents of children with mental disorders do not recognize that their child has a problem. Investigations are needed to assess the effectiveness of strategies to improve parental recognition of problems and to examine whether public education can improve access to care. In addition, the lack of an established network between primary care clinicians and child psychiatrists, and a lack of information about appropriate facilities where caregivers can seek help with their child’s mental health problems, also affect access to care [3].

In 2008, the Ministry of Health, Labour, and Welfare in Japan conducted an intervention, which included training (clinical training of child mental health doctors and training workshops for administrative officers), promotion of the diffusion of information about child mental disorders and developmental delay using leaflets and homepage services, and promotion of cooperation among child mental health facilities. This intervention involved eight leading hospitals in Japan that specialize in child psychiatric services, known as the “Child Mental Health System.” Before wider dissemination of this intervention, its effectiveness must be confirmed. Thus, we conducted pre- and post-intervention surveys in 16 leading hospitals in Japan that specialize in child psychiatric services, including the eight intervention hospitals and eight non-intervention hospitals. The purpose of this study was to assess the effects of the governmental intervention.

METHODS

GOVERNMENTAL INTERVENTION

The Ministry of Health, Labour, and Welfare launched an intervention in eight leading hospitals (two in Tokyo Prefecture and one each in Kanagawa, Shizuoka, Mie, Osaka, Tottori, and Saga prefectures) in Japan that specialize in child psychiatric services. The intervention, which was implemented in 2009, included training for child mental health doctors, nurses, and administrative officers; promotion of the diffusion of information about child mental disorders and developmental delay using leaflets and homepage services; and promotion of cooperation among child mental health facilities.

STUDY DESIGN

We conducted an observational study to assess the governmental intervention using pre- and post-intervention survey questionnaires in the eight hospitals that were subject to the intervention and the eight that were not (in Miyagi, Chiba, Saitama, Nagano, Aichi, Hyogo, Kagawa, and Hiroshima prefectures).

PARTICIPANTS

For the pre-intervention survey, we included caregivers of children with mental health problems who visited one of the 16 leading hospitals in Japan that specialize in child psychiatric services between September 2008 and February 2009 (details have been published elsewhere [4]). After the governmental intervention at eight of the 16 special hospitals, we included caregivers between January and March 2010 in a similar post-intervention survey. We disseminated 9,152 questionnaires and received 4,323 answers (response rate: 47%) for the pre-intervention survey. For the post-intervention survey, we disseminated 2,301 questionnaires and received 919 answers (response rate: 40%). We excluded 50 post-intervention survey replies because they were completed more than one year after the intervention. Ultimately, we included 4,323 pre-intervention survey responses and 869 post-intervention survey responses.

MEASURES

The caregivers received questionnaires from the child psychiatrists who were in charge of the examination and treatment of the patients; the caregivers were asked to complete the questionnaires anonymously and return them by mail to the National Center for Child Health and Development. In the questionnaire, we queried the demographic characteristics of the patients, including the date of birth and gender of the child, the age of the child when the parents first had concerns about mental health problems, the levels of education of both parents, and the annual household income. We also assessed the difficulties with daily living when first visiting the specialized child psychiatrist using a six-point Likert scale.

The time between the recognition of a child’s mental health problem and the first visit to a specialized child psychiatrist, and the perceived difficulty in finding an appropriate institution (using a five-point Likert scale), were adopted as the primary outcomes.

STATISTICAL ANALYSIS

We compared the differences in the means of the time until the first visit to a specialist and the difficulty in determining an appropriate medical institution between the pre- and post-intervention surveys using a t-test. We also used multivariate regression models and a logistic model to adjust for covariates, including sex, maternal and paternal educational level, and income. Furthermore, to establish the effectiveness of the intervention, we calculated p values for our outcome variables for each interaction term between the pre- and post-intervention surveys, as well as between the intervention and control groups. The outcome variables were analyzed as both continuous and categorical variables; for categorization, we defined responses of 1 (very difficult) and 2 (somewhat difficult) on the five-point Likert scale as having difficulty in finding an appropriate institution after recognizing symptoms. The analyses were performed using the software package Stata version 13 (StataCorp, College Station, TX, USA). We used a two-tailed significance level of p < 0.05 in all analyses.

ETHICS COMMITTEE APPROVAL

Study approval was obtained from the Ethics Committee (the Institutional Review Board) at the National Center for Child Health and Development.

RESULTS

Table 1 shows the change in patient characteristics in the intervention and control hospitals both pre- and post-intervention. The mean ages of the children were 13.0 and 9.9 years for the pre- and post-intervention surveys, respectively. The mean ages of the children when parents first recognized symptoms were 7.1 and 7.2 years for the pre- and post-intervention surveys, respectively. The majority of the children were male in both the pre- and post-intervention surveys (66.8% and 60.0%, respectively). In both the pre- and post-intervention surveys, the most frequent symptom experienced by children before their first hospital visit was problems interacting with peers (47.1% and 39.7%), followed by behavior problems (44.8% and 33.5%), developmental delay (35.2% and 31.2%), obsessiveness (29.6% and 18.8%), and not attending school (24.4% and 21.4%). There were no significant differences between the intervention and control hospitals, except for in paternal educational level.

Table 1Patient characteristics in both intervention and non-intervention hospitals pre- and post-intervention

		Pre-intervention (N = 4,323)				Post-intervention (N = 869)				p for interaction term
		IH (N = 2,558)		Non-IH (N = 1,765)		IH (N = 536)		Non-IH (N = 333)
		Mean or N	SD or %	Mean or N	SD or %	Mean or N	SD or %	Mean or N	SD or %
Current age of child, years		13	5.8	13	5.1	10	3.7	10	3.8	0.47
Age of child when symptoms were recognized, years		7	4.7	7	4.5	7	4.3	8	4.2	0.67
Sex	Male	1,724	67.9	1,140	65.2	334	62.4	184	55.6	0.3
	Female	814	32.1	608	34.8	201	37.6	147	44.4
Duration of follow-up at specialist hospital	First visit	369	14.6	128	7.3	483	90.1	284	85.3	0.37
	<3 months	214	8.4	132	7.5	46	8.6	42	12.6
	3–12 months	414	16.3	295	16.8	7	1.3	7	2.1
	1–2 years	335	13.2	291	16.6	0	0.0	0	0.0
	2–4 years	443	17.5	378	21.6	0	0.0	0	0.0
	>4 years	761	30.0	528	30.1	0	0.0	0	0.0
Maternal educational level	High school or below high school	1,159	47.3	891	53.0	251	48.6	159	50.8	0.27
	Junior college	756	30.9	485	28.8	156	30.2	88	28.1
	College graduate or above	533	21.8	306	18.2	109	21.1	66	21.1
Paternal educational level	High school or below high school	1,000	42.8	784	48.8	237	47.6	142	46.9	0.03
	Junior college	133	5.7	97	6.0	42	8.4	14	4.6
	College graduate or above	1,202	51.5	726	45.2	219	44.0	147	48.5
Income (USD/year)	<40,000	659	27.8	444	27.0	164	32.2	92	30.3	0.17
	40,000–59,999	550	23.2	443	27.0	143	28.1	87	28.6
	60,000–79,999	502	21.2	334	20.3	112	22.0	53	17.4
	>80,000	656	27.7	423	25.7	90	17.7	72	23.7
Symptoms of children before hospital visit	Developmental delay	999	39.1	524	29.7	175	32.7	96	28.8	0.15
	Problem with interaction with peers	1,256	49.1	779	44.1	227	42.4	118	35.4	0.56
	Obsessiveness	814	31.8	464	26.3	118	22.0	45	13.5	0.11
	Behavior problems	1,184	46.3	752	42.6	191	35.6	100	30.0	0.52
	Not attending school	589	23.0	465	26.4	106	19.8	80	24.0	0.7
	Physical symptoms due to mental health problem	332	13.0	317	18.0	68	12.7	63	18.9	0.67
	Excretory problem	155	6.1	98	5.6	31	5.8	16	4.8	0.76
	Eating behavior problem	212	8.3	158	9.0	34	6.3	26	7.8	0.63
	Mutism	76	3.0	65	3.7	20	3.7	15	4.5	0.95
	Problem with habit (e.g., tic)	184	7.2	152	8.6	37	6.9	31	9.3	0.64
	Extreme anxiety	346	13.5	287	16.3	64	11.9	38	11.4	0.25
	Depressive mood	407	15.9	291	16.5	45	8.4	36	10.8	0.34
	Delinquency	64	2.5	41	2.3	5	0.9	5	1.5	0.4
	Suicidal thoughts	267	10.4	193	10.9	34	6.3	19	5.7	0.6
	Sleep problems	201	7.9	106	6.0	26	4.9	15	4.5	0.55
	Child abuse	81	3.2	72	4.1	14	2.6	8	2.4	0.47
	Trauma	241	9.4	205	11.6	42	7.8	38	11.4	0.48
	Hallucinations	117	4.6	91	5.2	13	2.4	11	3.3	0.66
	Delusions	107	4.2	68	3.9	18	3.4	4	1.2	0.096
	Drug abuse	5	0.2	8	0.5	1	0.2	0	0.0	N/A
	Other problem	213	8.3	149	8.4	47	8.8	22	6.6	0.27
Difficulties with daily living on first visit to the specialist hospital	range 1 (not difficult) to 6 (very difficult)	4	1.4	4	1.4	3	1.2	3	1.1	0.34

Abbreviations: IH, intervention hospitals; SD, standard deviation.

Table 2 shows the time between the recognition of symptoms and visiting the specialist hospital and the perceived difficulty in choosing an appropriate institution for care. There was no significant difference between the intervention and control hospitals in the time between the recognition of symptoms and visiting the specialist hospital; the interaction term of pre–post and intervention was also not significant (coefficient 0.086; 95% confidence interval [CI] −0.33 to 0.51; p = 0.69). In the intervention hospitals, the difficulty in determining an appropriate medical institution (the range was from 1 [very difficult] to 5 [not at all]) improved from pre- to post-intervention (mean ± standard deviation [SD], 2.2 ± 1.3 to 2.4 ± 1.3; p < 0.001). However, in non-intervention hospitals, the difficulty worsened (mean ± SD, 2.3 ± 1.4 to 2.1 ± 1.2; p = 0.03). The interaction term of pre–post and intervention was also significant (coefficient 0.40; 95% CI. 0.20 to 0.60; p < 0.001). This result was consistent with that of a sensitivity analysis that treated values of difficulty as a categorical variable. In the intervention hospitals, the proportion of parents feeling difficulty in identifying appropriate care institutions decreased between the pre- and post-intervention surveys (69.5% to 62.4%; p = 0.002); in non-intervention hospitals, the proportion increased (66.4% to 73.2%; p = 0.017). The interaction term was also significant (odds ratio 0.53; 95%CI. 0.38 to 0.73; p < 0.001). All three multivariate models of the time from recognizing symptoms to visiting the specialist hospital and difficulty in determining appropriate medical institution, which adjusted for covariates including sex, maternal and paternal educational level, and income, showed similar results to those of the univariate analyses (Tables 3, 4, and 5).

Table 2Time before first visit to the specialist hospital and difficulty in consultation when symptoms were recognized

		Pre-intervention (N = 4,323)				Post-intervention (N = 869)				p for interaction term
		IH (N = 2,558)		Non-IH (N = 1,765)		IH (N = 536)		Non-IH (N = 333)
		Mean or N	SD or %	Mean or N	SD or %	Mean or N	SD or %	Mean or N	SD or %
Time from recognizing symptoms to visiting the specialist hospital	years	2.5	2.8	2.3	2.9	2.4	2.4	2.1	2.3	0.69
Difficulty determining appropriate institution (continuous)	range: 1 (very) to 5 (not at all)	2.2	1.3	2.3	1.4	2.4	1.3	2.1	1.2	<0.001
Difficulty determining appropriate institution (categorical)	“Very difficult” or “Somewhat difficult”	1,739	69.5	1,142	66.4	329	62.4	240	73.2	<0.001
	“Not sure,” “Not too difficult,” or “Not at all”	764	30.5	578	33.6	198	37.6	88	26.8

Abbreviations: IH, intervention hospitals; SD, standard deviation.

Table 3Multi-variable regression analysis for time between recognizing symptoms and visiting the specialist hospital

Variables		Coefficient	95% Confidence interval	p value
Hospital category	Non-intervention hospital	Reference
	Intervention hospital	0.26	0.08–0.44	0.005
Intervention term	Pre-intervention	Reference
	Post-intervention	−0.18	−0.52–0.17	0.314
Interaction term*		0.17	−0.27–0.60	0.458
Sex	Female	Reference
	Male	0.54	0.37–0.71	<0.001
Maternal educational level	High school or below high school	Reference
	Junior college	−0.02	−0.37–0.33	0.903
	College graduate or above	0.32	0.12–0.52	0.001
Paternal educational level	High school or below high school	Reference
	Junior college	−0.16	−0.36–0.04	0.123
	College graduate or above	−0.25	−0.49–−0.01	0.038
Income	<400	Reference
	400–<600	0.14	−0.09–0.37	0.228
	600–<800	0.00	−0.24–0.24	0.994
	800+	−0.12	−0.37–0.12	0.327

* The interaction term is defined as the interaction between the hospital category and the intervention term.

Table 4Multi-variable regression analysis for difficulty determining appropriate institution (continuous)

Variables		Coefficient	95% Confidence interval	p value
Hospital category	Non-intervention hospital	Reference
	Intervention hospital	−0.13	−0.21–−0.04	0.004
Intervention term	Pre-intervention	Reference
	Post-intervention	−0.15	−0.31–0.01	0.075
Interaction term*		0.33	0.12–0.54	0.002
Sex	Female	Reference
	Male	0.17	0.09–0.25	<0.001
Maternal educational level	High school or below high school	Reference
	Junior college	0.00	−0.17–0.17	0.997
	College graduate or above	−0.02	−0.12–0.07	0.619
Paternal educational level	High school or below high school	Reference
	Junior college	0.02	−0.08–0.11	0.742
	College graduate or above	0.11	−0.01–0.22	0.064
Income	<400	Reference
	400–<600	−0.04	−0.14–0.07	0.508
	600–<800	−0.05	−0.17–0.07	0.392
	800+	−0.10	−0.22–0.01	0.083

* The interaction term is defined as the interaction between the hospital category and the intervention term.

Table 5Multi-variable logistic analysis for difficulty determining appropriate institution (categorical)

Variables		Odds ratio	95% Confidence interval	p value
Hospital category	Non-intervention hospital	Reference
	Intervention hospital	1.19	1.03–1.37	0.017
Intervention term	Pre-intervention	Reference
	Post-intervention	1.38	1.04–1.83	0.025
Interaction term*		0.56	0.40–0.80	0.001
Sex	Female	Reference
	Male	0.77	0.67–0.88	<0.001
Maternal educational level	High school or below high school	Reference
	Junior college	1.03	0.78–1.36	0.843
	College graduate or above	1.03	0.88–1.20	0.694
Paternal educational level	High school or below high school	Reference
	Junior college	1.04	0.89–1.21	0.640
	College graduate or above	0.88	0.73–1.06	0.178
Income	<400	Reference
	400–<600	1.07	0.90–1.28	0.444
	600–<800	1.09	0.90–1.31	0.382
	800+	1.29	1.06–1.57	0.010

* The interaction term is defined as the interaction between the hospital category and the intervention term.

DISCUSSION

In this study, we found that the governmental intervention to improve access to child mental healthcare did not shorten the time between the recognition of symptoms and visiting a specialist hospital. However, the intervention did significantly improve caregivers’ self-reported difficulty in choosing an appropriate medical institution.

There have been several studies investigating the pathway to child and adolescent psychiatric clinics [5, 6]. Pedrini et al. showed that most patients were referred to child and adolescent psychiatric clinics by schoolteachers or health professionals, and only 17% of the parents sought help by themselves [5]. Ivert et al. analyzed the following four different pathways: family referrals, social/legal agency referrals, school referrals, and health/mental health referrals [6]. They demonstrated the existence of important ethnic and social differences in the pathways to child and adolescent psychiatric clinics [6]. However, effective interventions to improve access to hospitals specializing in child mental health have not been established. Thus, the current study adds to the literature by showing the effectiveness of this governmental intervention, at least in improving caregivers’ access to hospitals specializing in child mental health in Japan.

This governmental intervention can improve parents’ knowledge of where they should go for consultation, especially through promotion of the diffusion of information about child mental disorders, and cooperation among child mental health facilities. However, the time between the recognition of a child’s mental health symptoms and attendance at a specialist hospital did not change. Two possible reasons exist for this finding: 1) the specialist hospitals were too busy and it was difficult for the parents to be seen promptly, and 2) the governmental intervention was effective, but the sample size was not sufficient to detect a significant difference. Previous research about barriers to access for child psychiatric clinics found that the most common parent-reported treatment participation barrier was experiencing a lot of stress in their life, and the second barrier was the therapist not calling enough [7]. Evidence is lacking, but high therapist workloads are one of the possible barriers to access. A governmental intervention can be one of the most powerful interventions for health services. Many studies have shown that governmental intervention can result in significant improvements in access to immunization [8, 9]. However, in the current study, the governmental intervention was not shown to be effective.

To reduce the time between recognizing a child’s mental health symptoms and visiting a specialist hospital for evaluation, raising awareness of child mental disorders among parents and promoting cooperation among child mental health facilities may be beneficial. This is consistent with Sayal’s findings of a lack of knowledge among parents about child mental disorders, a lack of established networks between primary care and child psychiatrists, and a lack of available information about child mental disorders [3].

Several limitations of this study should be acknowledged. First, recall bias was inevitable because this was a retrospective study. Second, the response rates to the questionnaires were relatively low (47% and 40% for the pre- and post-intervention surveys, respectively). Participants may have had significant reasons for not responding to the questionnaires, such as caring for a child with symptoms too severe to take the time to complete the questionnaire. In such cases, the effectiveness might be underestimated, since respondents could be expected to have children who were less severely ill than non-respondents. Finally, the intervention hospitals were not selected randomly, so unmeasured confounders could affect the results.

CONCLUSION

The Japanese government conducted an intervention in 2009 that included training for child mental health specialists, promotion of the diffusion of information about child mental disorders, and promotion of cooperation among child mental health facilities. The intervention reduced parents’ perceived difficulty in accessing appropriate child mental healthcare. To reduce the time between the recognition of symptoms and visiting a specialist hospital for evaluation, the intervention may need to be strengthened.

SOURCE OF FUNDING AND CONFLICT OF INTEREST STATEMENT

This research is supported by Research on Healthcare System for Children with Mental Problems and Development of Child Psychiatrist, in Research on Children and Families, Health and Labor Sciences Research Grants from Ministry of Health, Labour, and Welfare.

No conflicts of interest are disclosed

Supplemental TableActual questionnaire items (Originally in Japanese, translated by the authors into English)

“difficulties with daily living when first visiting the specialized child psychiatrist” Please select one of the following that applies to your first visit to this hospital. 1. Home and school life is going well. 2. Occasionally there is a slight difficulty in a part of home or school life, but it cannot be seen from the outside. 3. There are continued difficulties in home and school life, but they can be resolved through normal measures. 4. There are considerable difficulties in home and school life, and special assistance is required (use of resource rooms, mother gives up work, etc.). 5. There are difficulties in home and school life, which can sometimes be dangerous to the child and their surroundings. 6. There are remarkable difficulties in home and school life, and they are always impossible to manage.

“length of time from the recognition of a child’s mental problem to the first visit to a specialized child psychiatrist” How long did it take to recognize this child’s symptoms and consult this hospital? ___ years ___ months ___ days

“the perceived difficulty in finding an appropriate institution” When you noticed your child’s symptoms, how difficult was it to find out which agency to consult? 1. Very difficult 2. Somewhat difficult 3. Not sure 4. Not too difficult 5. Not at all difficult

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