Gap in health care provision among adults with mental problems,


In most cases, health services are under-utilized, especially for patients with emotional, mental, and behavioral disorders due to the social stigma associated with the disorder. The treatment of mental disorders is mostly offered by the government where the public do not incur charges except for drugs purchase. In Georgia, the disorders are prevalent because of the occurrence of wars several times in the 1990s and 2008, causing trauma, displacement, and other life stressors. This paper seeks to critique the research work- “Health service utilization for mental, behavioral and emotional problems among the conflict-affected population in Georgia” by Chikovani et al., to analyze the strengths and weaknesses of the research; and to assess its trustworthiness, importance, and applicability.


The study aims at identifying the gap in health care provision among adults with mental, behavioral, and emotional problems, especially in war-affected areas in Georgia, measure health utilization rate, and identify reasons why some did not seek mental health care. The disorders are common in war-affected communities due to exposure to trauma, daily stressors caused by the war, and inadequate and poor health infrastructure in these areas. The wars in 1990 and 2008, in the Republic of Georgia, left about 200 000 people displaced, ending up living in collective centers, and 60 percent living in private residents. Poor living conditions characterize the IDPs lifestyle, increased rate of unemployment, inadequate finances to acquire medical care, living below the poverty line, and less interaction with dominant communities (Chikovani et al., 2015).

The study used a sample size of 3600 respondents, both men and women above 18 years old, employing a cross-sectional survey design that constituted randomization and stratification. Stratification was done in accordance to the participants region of residence and displacement status.For the investigation to provide reliable results, the respondents were divided into three equal groups depending on the place of residence after both conflicts. The groupings included the 1990s IDPS, 2008 IDPs, and victims who returned to their original homes after the war (did not change location). The list of interviewees was acquired from the Governor of ShidaKartli region’s office; hence was accurate and updated (Chikovani et al., 2015).

Data collection involved direct interviews in respondents’ homes where one person was randomly selected to be interviewed by the trained fieldworkers. All the respondents provided consent to be interviewed before the activity through written forms, and confidentiality of private information was assured. The investigators rejected the people who had severe intellectual conditions and those who were unable to communicate effectively.On health service utilization, respondents were asked whether they have had any emotional and behavioral problems for the last year. They were asked whether they had sought any health practitioner like a pharmacist, GP, neurologist, psychiatrist, or any other mental health specialist. Respondents who said they had any of the problems but did not seek medical care were questioned on the reasons for not seeking care (Chikovani et al., 2015).

The measure of mental disorder was done using tools like TSQ, PHQ-9, and GAD-7, which helped identify the prevalence of trauma, anxiety, and depression. TSQ consisted of ten yes/no questions to measure trauma over the past one week. PHQ-9, measured symptoms of depression using nine interview questions that focused on respondents’ experience in the past two weeks. GAP-7 preference to measure generalized anxiety disorder due to its ability to detect current anxiety symptoms using seven questions. The three instruments showed a high level of credibility and reliability from the Cronbach’s alpha scores. Translators were used to translating English to Georgian with a keen oversight from Georgian medical health experts to gain clarity and consistent information (Chikovani et al., 2015).

The analysis of the study embarked on the application of Chi-square tests using the SPSS 18.0 to compare the three groups on health service utilization. Multivariate regression was executed to get an insight into the relationship between different variables (Chikovani et al., 2015). The first stage of the regression involved analysis in blocks of socio-demographic and health-related variables.The results of the study outlined that the majority were women representing 65 percent, most of the respondents were married, 69.6 percent of the population had completed secondary education, and 56 percent had insurance coverage. 23.5, 14.4, and 10.9 percent represented the mental health of respondents concerning PTSD, depression, and anxiety symptoms, respectively. The study also indicated that 30.5 percent of the respondents had at least one mental disorder, 12.7 percent had more than one, while 5.6 percent represented for those with more than three. On service utilization, 24.8 percent of the sample population had sought medical attention during the prior year. Out of the 39 percent of those reported to have any of three disorders, 33.1 percent said such a problem did not seek care, while 27.4 percent did not report and did not seek care. In a broader sense, 790 individuals were screened to have any of the disorders; 365 individuals did not seek medical attention (Chikovani et al., 2015).

Some of the limitations of the study included the usage of different timeframes while investigating the prevalence of disorders (1 and 2 weeks). The study employed the symptoms of the diseases rather than the diagnosed cases. The research was subject to biasness since it measured only the past 12 months and did not investigate the patients’ experiences during health care (Chikovani et al., 2015).

In conclusion, from the study findings, limited use of health services for patients with mental health disorders in Georgia was caused by hinder ants like the cost of treatment and drugs. The study also reveals that neurologists and the G.P.s were mainly consulted on mental health issues. This shows the need by the government to equip mental health facilities in primary care as a way of intervention on the matter to increase treatment patients with mental health disorders.

Research Critique

The article was retrieved from the U.S. National Center for Biotechnology Information (NCBI)official website and will be critiqued with a qualitative critique framework to analyze the strengths and weaknesses of the research; and to assess its trustworthiness, importance, and applicability.

Chikovani et al. (2015) conducted a qualitative study to investigate health services utilization for adults with mental, emotional, and behavioral problems in Georgia where wars were persistent in the 1990s and 2008. Conflicts have been identified as one of the major causes of mental health disorders due to exposure to risk-factors like trauma and other stressors, thereby causing adverse outcomes and a range of emotional, mental, and behavioral problems like depression and anxiety. Smith et al. 2015, argues that behavior problems can be transmitted to children from adults depending on the surrounding environment with further investigation, outlining that positive and negative emotional expressions are directly associated with external behavior and social competence.This investigation is of great importance since it helps learn more about the rate of health service utilization, type of mental health patients seek and identify the reasons why respondents with health disorders did not seek medical care. Service utilization in this context is defined as the visitation of any health practitioner because of behavioral, mental, and emotional problems in a formal health facility (Chikovani et al., 2015).

In this case, cross-sectional study design of the qualitative approach was applied to draw research findings. A cross-sectional study design enables the investigator to identify the relationship between variables (outcomes and exposures) in the study at the same time. This type of research design is mainly employed in population-based surveys and while estimating the prevalence in clinical-based researches like diseases. A cross-sectional study is preferable because of its speed and ease in seeking relationships, relatively low cost, and is practically useful while planning, monitoring, and evaluating public health projects (Dermatol, 2016).

Researchers prefer the application of this approach while inquiring about collecting or analyzing data due to the benefits as mentioned above associated with this designwhile conducting qualitative research. However, the design is sometimes faulty, causing limitations like difficulty while drawing casual relationships of variables in the analysis, and causes a certain degree of biases (Dermatol, 2016). Cross-sectional study design maps the aim of the study due to the need to relate semi-demographic variables to health-related variables in the research, which include PTSD, depression, and anxiety by executing multivariable regression(Chikovani et al., 2015). Multivariate regression is an analysis used to examine the relationship between more than two variables, both independent and dependent. Researchers employ this model while analyzing data due to its ability to determine the relative influence of a predictor variable(s) to the criterion value, and identify outliers and anomalies in a set of data. The model at times may be misleading, especially while using incomplete data, making the researcher conclude that the correlation is causation while it is false (Weedmark, 2018).

Data collection involved face-to-face structured interviewswith 3600 respondents, both male and female, above 18 years old. Respondents were grouped into three categories; the 1990s IDPs, 2008 IDPs, and the ‘returnees'(Chikovani et al., 2015). Structured interviews make use of pre-determined questions and format to all the respondents by the interviewers, ensuring that the questions are posed similarly through written or spoken form. The face-to-face interview involves a one-on-one conversation between respondents and interviewers while information is collected.This method of qualitative data collection is useful, especially in health services, due to the depth and breadth of understanding concepts, while there is room for questioning to seek clarity (Rapport et al., 2018). The respondents were asked whether they had experienced any feelings of anxiety, depression, or other problems in the past year. They were also asked where they seek care with categories of practitioners provided; GP, policlinic, neurologist, and psychiatrist. Practitioners at the international level play a vital role in promoting human wellbeing, ensuring equality in service delivery to all. Health practitioners encourage sound behavior and healthy lifestyles and are committed to treating both mental and neurological conditions. International practitioners are governed by policies and statutes like human rights and code of conduct during practice (APA, 2012). Respondents who did not seek medical even after the realization of abnormal behavior were questioned further to provide the reasons. According to Lake & Turner, 2017 mental health patients fail to seek professional medical attention due to the limited mental health facilities, financial inadequacy, and social stigma associated with the disorder.Besides, they argue that mental disorders being a global crisis should be addressed to avoid adverse impacts like increased suicide among people aged 15 to 29 due to depression and stress (Lake & Turner, 2017).

The instruments used to measure the prevalence of disorders through examination for the possibility of symptoms used a questionnaire approach. TSQ was used to measure the incidence of Post-Traumatic Stress Disorder (PTSD). TSQ is designed for use by survivors of a tragic impact that may cause traumatic stress. Screening is recommended to execute three to four weeks after the incident to allow for recovery and normalcy (DVA, n.d.). PTSD is associated with symptoms, which include nightmares, intense feelings of distress, upsetting memories, loss of interest in social life, and numbness, among others. PHQ-9 is used to measure the prevalence of depression. Some of the depression associated with depression include loss of interest, increased fatigue,anxiety, and sleep problems, among others.GAD-7 is used to measure anxiety disorder(Chikovani et al., 2015). The TSQ, PHQ-9, and GAD-7 showed reliability on the Cronbach’s alpha scores, which is a measure to show consistency on how related and close items are. The score is not a statistical test tool but a measure of the coefficient of reliability (UCLA, n.d.).

To ensure the effectiveness and confidentiality of the respondents, the researchers undergo training to get familiar with the interview protocol. This included the procedure of obtaining consent from respondents before the interview through writing to show acceptance and coordination. Confidentiality of the client’s information is regarded as an ethical issue that protects confidential information and includes a responsibility to ensure recorded patient’s information is secure and private. The policy that protects patient informationreport states that the data should be protected and not accessed by third parties, including other patients, families, employees without the consent of the patient (NHS Digital, n.d.).

In statistical analysis, Chi-square tests compare the three groups about health services utilization, the types of services used, and reasons for not seeking medical care. Multivariate analysis executed to explore the relationship between the different variables on health services utilization(Chikovani et al., 2015). Chi-square tests statistic is used to show the relationship between categorized variables, both numeric and non-numeric. It shows the difference in counts and how much counts you would expect if there was no relationship between variables.

The study findings showed that limited use of formal health services for patients with mental, behavioral, and emotional problems was associated with inadequate financial access for drug purchase and cost involved during treatment. The social stigma was another reason that made patients avoid mental health facilities causing them to seek professional care elsewhere.

Application to Practice

Mental disorders are prevalent globally with research outlining an upward trajectory of the illnesses, with the rate becoming noticeable among younger people with as low as 15. When mental health care is not sought in the early stages, the disorder may be severe, causing suicide. To reduce such catastrophic impacts of mental disorders, the research brings on board ideologies and facts which can be used by the government while tackling the disease. It provides an insight demographically on the categories of people and regions that require mental health services.

The study can be used to identify other regions in the world that match Georgia characteristically, where effects of wars are still felt, to help war victims recover from traumatic scenarios.

Strengths and weaknesses

            In a qualitative research paradigm,close observation and explanation are requiredto identify crucial elements in the research to make aunique and preciseconclusion. The qualitative design mainly focuses on the process rather than the outcomes of the study. Most researchers assume that the process defines the result hence descriptive. Qualitative research involves fieldwork where the researcher goes out to the people, or site making an observation or asking questions while recording behavior in that particular setting (Ochieng, 2009). Human behavior is highly influenced by the natural setting or the surrounding environment, and thus the researchers must attach the two factors for reliable and credible information.

Generally, some of the strengths associated with the qualitative research paradigm include; simplicity in managing data without tampering with its complexity and context, it gives a proper response to most of the research needs, and it is often error-free considering it mostly deals with words rather than figures. Some of the limitations with qualitative study are inability to extend the research to a wider population with certainty, ambiguities causes due to language barriers (Ochieng, 2009).


Application of face-to-face structured interview as a method of data collection, caused simplicity in the acquisition of information from respondents. The method preferably matches the research since it assist in obtaining detailed personal information about feelings, opinion, and perceptions. One-on-one interview gives the interviewer an opportunity to seek clarification and question further on the subject for better understanding and acquire reliable information. The respondents are less-likely to be self-conscious and less-likely to be affected by other people’s opinion thereby giving firsthand information that is reliable.

The use TSQ, PHQ-9, and GAD-7 which are recognized as international measures of emotional and behavioral problems provided an assurance of getting reliable data. In addition, the scores from Cronbach’s alpha score proves the credibility and validity of the measures.


The research was prone to ambiguity because of the different languages involved, English and Georgian which required professional translator and a Georgian mental health expert to review the translations. This exposed the information received from respondents to the risk of manipulation.


The research work by Chikovani et al. can be termed as credibleand reliable because of the authoritative information provided through well-organized facts. A cross-sectional study design of the qualitative approach was applied to draw the research findings through employment of face-to-face structured interviews as the data collection method. The TSQ, PHQ-9 and GAD-7 were used to measure the prevalence of PTSD, depression, and anxiety through examination for possibility of symptoms used a questionnaire approach.To ensure the effectiveness and confidentiality of the respondentsconsent from respondents prior to the interview through writing was seek to show acceptance and coordination. Practically, the research lays a foundation for ease government intervention to curb and promote treatment of mental problems. The research will be used in other war-affected regions to help war victims recover from traumatic experiences. The strengths associated with the research include use of one-on-one interviews due to the ease of acquiring information, and use of international standards instruments to measure disorder prevalence assured data reliability. Weaknesses for the research include ambiguity due to use of more than one langua


APA (2012). Global Mental Health: Finding your niches and network. American psychological Association. Retrieved from on 27 February 2020.

Chikovani, I., Makhashvili, N., Gotsadze, G., Patel, V., McKee, M., Uchaneishvili, M., Rukhadze, N., & Roberts, B. (2015). Health Service Utilization for Mental, Behavioral and Emotional Problems among Conflict-affected Population in Georgia: A Cross-Sectional Study. PLOS. Vol. 10, Iss. 4, doi: 10.1371/journal.pone.0122673.

Dermatol, I.J. (2016). Methodology series Module 3: Cross-sectional Studies. Indian Journal of Dermatology. Doi: 10.4103/0019-5154.182410, 261-264.

DVA (n.d.). PTSD: National Center for PTSD. U.S. Department of Veterans Affairs. Retrieved from on 27 February 2020.

Lake, J. & Turner, M.S. (2017). Urgent need for Improved Mental Health Care and a More Collaborative Model of Care. Doi: 10.7812/TPP/17-024.

NHS Digital (n.d.). Codes of Practice for Handling for Handling Information in Health and Care. NHS Digital. Retrieved from on 27 February 2020.

Ochieng, A.P. (2009). An Analysis of the Strengths and Limitation of Qualitative and Quantitative Research Paradigms. Problems of Education in the 21st Century, vol. 13.

Rapport, F., Hogden, A., Faris, M., Bierbaum, M., Clay-Williams, R. Long, J.C., Shih, P., Rebecca, S., & Braithwaite, J. (2018). Qualitative Research in Healthcare: Modern Methods, Clear Translation a White Paper, MarcquarieUnivesity, Australia, ISBN 978-0-85837-000-5.

Smith, L., Greenberg, J., Seltzer, M., & Hong, J. (2010). Symptoms and behavioral problems with Autism: Effects of Mother-child Relationship Quality, Warmth, and Praise. HSS Public Access.

UCLA (n.d.). What does Cronbach’s Alpha Mean? SPSS FAQ. Statistical Consulting. Retrieved from on 27 February 2020.

Weedmark, D. (2018). The advantages and Disadvantages of a Multiple Regression Model. Sciencing. Retrieved from on 27 February 2020.

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