Evaluation definitions and conceptual framework

Historically, evaluative research in psychiatry originated in the mid-nineteenth century as the tabulation of admissions, discharges, and deaths in mental hospitals, and developed through the established more patient-orientated statistics, to recent increasingly sophisticated studies of community forms of care. (2,3)

The Oxford Little Dictionary and Thesaurus(4) gives the following definitions and synonyms of 'evaluation': evaluate v.tr 1. assess, appraise; 2a. find or state the number or amount of; 2b find a numerical expression for.

evaluation n. 1. appraisal, valuation, assessment; 2. estimate, estimation, approximation, rating, opinion, ranking, judgement, reckoning, figuring, calculation, computation, determination. [Etymology back-form. f. evaluation f. F évaluation f. évaluer (as e-, value)]

As can be seen, the etymological root of the word refers directly to 'value', although in common usage the emphasis has moved to a more technical, quantitative connotation. This reflects our view that evaluation necessarily requires both the precise measurement of aspects of treatment or service performance, and the consequent contextualization of the measurement, so that the value of the results may be given meaning. Thus one of the challenges that must be faced in the next few years is to identify agreed 'standards' of quality to be used as a basis on which to judge the performance of services.

Within health service research, the purpose of evaluation is often more specific. As Sartorius (5) has put it, 'In its most classical form, evaluation denotes a comparison between results and goals of activity.' This moves the definition on from the description of measurements per se to a purposeful exercise in which measurements are tools to answer defined specific questions. We shall show in this chapter that, in relation to the research on the wide range of 'community care arrangements', (6) it is exactly the lack of (i) clear definitions on the nature of the interventions defined and (ii) precise questions that has led to such confusion in the interpretation of the research findings.

We have recently proposed a conceptual model that may be used as a framework not only for planning and providing, but also for evaluating mental health services. (7)

This 'matrix model' has two dimensions (see Table 1 of Chapter 7.5). The first dimension is geographical and has three levels (country/regional, local, and patient).

The second dimension is temporal and also has three levels (input, process, and outcome). The 3 * 3 matrix resulting from the use of the two dimensions brings into focus critical issues of mental health service evaluation, and helps to distinguish the content of this chapter (the evaluation of psychiatric services at the local level) from assessments made at the national/regional level, as well as from those made at the individual patient level. The second benefit of using the matrix model is that it allows the measurement of outcomes (the results obtained by treatments or services in terms of functioning, morbidity, or mortality) in relation to both inputs (those resources which are put into the mental health care system) and processes (those activities which take place to deliver mental health services).

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