A qualitative study: barriers and facilitators to health care access for individuals with psychiatric disabilities

The model of access to speech-language pathology services

PURPOSE

Within Australia, some families face challenges in accessing paediatric speech-language pathology services. This research sought to investigate the factors that impact access to paediatric speech-language pathology services within Western Australia.

METHOD

Researchers used constructivist grounded theory to investigate the construct of access, as experienced and perceived by service decision-makers, namely caregivers of children with communication needs and speech-language pathologists who provide communication services. Eleven speech-language pathologists and 16 caregivers took part in 32 semi-structured in-depth interviews. Researchers used layers of coding of interviews transcripts and the constant comparative method to investigate data.

RESULT

Findings outline the factors that impact access to speech-language pathology services, as organised into the seven categories of the Model of Access to Speech-Language Pathology Services (MASPS). The categories and properties of this model are grounded within experiences and perspectives that participants contributed to the dataset.

CONCLUSION

MASPS provides a theoretical structure that has been constructed using inductive and abductive reasoning. This model can be used by service designers and decision-makers to reflect upon and improve experiences of service for a range of consumers. MASPS can also be used as a basis for further investigation into aspects of service access.

Understanding Barriers and Facilitators of Primary Care Use Among Assertive Community Treatment Teams Via Qualitative Analysis of Clients and Clinicians

Individuals with severe mental illness and substance use disorders face complex barriers to achieving physical health. This study aims to explore the barriers and facilitators of primary care access among an Assertive Community Treatment (ACT) team. Semi-structured qualitative interviews were conducted with 14 clients and 7 clinicians from an ACT team at a community mental health center in Connecticut. Data analysis followed a grounded theory approach, with codes and themes emerging iteratively during the interview process. The study identified multifaceted barriers to accessing primary care, including economic challenges, homelessness, and the prioritization of mental health and substance use symptoms over healthcare. The conceptual framework consists of nine dominant themes: clients' attitudes, knowledge, mental health, and motivations ("Client-Level Barriers and Facilitators"); ACT team-directed care coordination and relationship-building as well as primary care provider communication ("Provider-Level Barriers and Facilitators"); and clients' experiences with medical care and socioeconomic status ("Systemic-Level Barriers and Facilitators"). This research provides valuable insights into the various barriers faced by ACT clients in accessing primary care. Improving primary care access for individuals with severe mental illness and substance use disorders is crucial for reducing health disparities in this vulnerable population.

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA

The aim was to identify which factors facilitate providing integrated behavioral health care for Iraqi refugees in nationally recognized community health center in Northern USA. The social-ecological model (SEM) framework guided this qualitative case study exploring the experience of 11 professional staff. Data were collected from June through August 2021 through individual interviews. Eight themes emerged based on the SEM levels: Intrapersonal-gender-driven engagement; interpersonal-the need for discretion and trusting relationship; community-collaboration with community resources and integrator from the community; organizational-holistic care, and long-term care; and policy-insufficient educational preparation. The results highlight components for clinical practice and policymakers regarding a population that is a big consumer of mental health care. Future research should explore other vulnerable populations, the effect of social groups, and the incorporation of community resources as part of the integrated care team.

Facilitators and barriers for implementing the integrated behavioural health care model in the USA: An integrative review

The integrated behavioural health care (IBHC) model incorporates mental health services with primary care. This service model is widely advocated due to its increasing access to health care and cost-saving. By connecting individuals with mental illnesses with a primary care provider, this model of care promotes collaboration between interdisciplinary teams, and therefore, increases health equity, decreases stigma, and increases patient satisfaction. This integrative review aimed to examine and synthesize available literature on facilitators and barriers related to the IBHC model implementation in the United States. An integrative review methodology by Whittemore and Knafl was utilized, and data evaluation was based on the JBI Critical Appraisal Checklist. The social-ecological model guided the review. Twenty-two articles were analysed, and nine themes were identified, which were further organized according to the five levels of the social-ecological model and consisted of intrapersonal level - patient-centered care; interpersonal level - relationships; community level - physical accessibility; organizational level - operation and infrastructure, team approach, training in behavioural health, electronic medical record, and staffing; and policy level - funds and health insurance. Most facilitating factors were on the organizational level and related to infrastructure, team approach, patient-centered care, and the most noted barrier was poor relationships. Nurses can increase engagement in integrated care by assuming roles that oversee patient care, foster professional collaborations, and improve relationships. Future research should focus on vulnerable populations this model serves, patients' perspectives, and the effect of telehealth.

Healthcare professionals' perceptions and experiences of physiotherapy for people with mental illness: a protocol for a systematic review and meta-ethnography

INTRODUCTION

There is a high global prevalence of patients presenting with physical and mental health comorbidities. Physiotherapeutic interventions, such as exercise, can have positive benefits for physical and mental health. However, poor accessibility and negative experiences of healthcare services for those with mental illness (MI) have been consistently observed within literature with recent research identifying poor experiences of physiotherapeutic interactions and processes such as referrals and discharges. One way to help improve physiotherapy services for this population is to understand the personal experiences and perceptions of healthcare professionals (HCPs) toward physiotherapy for patients with MI. Qualitative-based evidence syntheses are suited to bring this data together with the aim of improving physiotherapy services for patients with MI. This review will systematically search and synthesise existing evidence around HCP experiences and perceptions of physiotherapy for people with MI.

METHODS AND ANALYSIS

A systematic search and seven-phase meta-ethnography will be undertaken. A comprehensive search of electronic databases (CINAHL plus, MEDLINE, Pubmed, Embase and Psycinfo) and search engines as well as grey literature (unpublished primary research such as theses) will be completed. Searches are planned to take place in July 2022. Eligibility criteria include: (a) qualitative data, (b) perceptions identified from HCP, including physiotherapists, assistants and HCP referring into physiotherapy, about physiotherapy for patients with MI and (c) are primary studies.

ETHICS AND DISSEMINATION

This work is exempt from requiring ethical approval due to review methodology with data accessed from published works. This systematic review is expected to provide insight into experiences and perceptions of HCP around benefits and barriers to accessing physiotherapy for patients with mental health illness. Findings will be used to inform further research and co-develop recommendations to overcome barriers and optimise facilitators to care for this population. Findings will be disseminated via peer-reviewed journal, conference presentations and to key stakeholder groups.

PROSPERO REGISTRATION NUMBER

CRD42021293035.

A clinician-monitored 'PTSD Coach' intervention: findings from two pilot feasibility and acceptability studies in a resource-constrained setting

Background: The high prevalence of trauma exposure and consequent post-traumatic stress disorder (PTSD) is well documented in low- and middle-income countries, and most individuals with PTSD have limited access to treatment in these settings. Freely available internet-based interventions, such as PTSD Coach (web-based and mobile application), can help to address this gap and improve access to and efficiency of care. Objective: We conducted two pilot studies to evaluate the feasibility, acceptability, and preliminary effectiveness of PTSD Coach in a South African resource-constrained context. Method: Pilot 1: Participants with PTSD (n = 10) were randomized to counsellor-supported PTSD Coach Online (PCO) or enhanced treatment as usual. Pilot 2: Participants (n = 10) were randomized to counsellor-supported PTSD Coach Mobile App or self-managed PTSD Coach Mobile App. Feasibility and acceptability were assessed by comparing attrition rates (loss to follow-up), reviewing participant and counsellor feedback contained in fieldnotes, and analysing data on the 'Perceived helpfulness of the PTSD Coach App' (Pilot 2). PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), changes between treatment and control groups were compared, the reliable change index (RCI) was calculated, and clinically significant changes were determined. Results: Three participants in Pilot 1 and two participants in Pilot 2 were lost to follow-up. Fieldnotes indicated that PTSD Coach Mobile App addressed identified computer literacy challenges in Pilot 1 (PCO); and a shorter duration of intervention (from 8 to 4 weeks) was associated with less attrition. The RCI indicated that four participants in Pilot 1 and eight participants in Pilot 2 experienced significant improvement in PTSD symptom severity. Conclusions: The preliminary results suggest that both platforms can alleviate PTSD symptoms, and that the involvement of volunteer counsellors is beneficial. The use of PTSD Coach Mobile App may be more feasible than the online version (PCO) in our setting. HIGHLIGHTS Research on supported PTSD Coach interventions is limited in resource-constrained settings.Both volunteer counsellor-supported PTSD Coach Online and the PTSD Coach Mobile App showed preliminary reliable and clinically significant changes.The use of PTSD Coach Mobile App seems more feasible than the volunteer counsellor-supported PTSD Coach Online.

Registry-Managed Care Coordination and Education for Patients With Co-occurring Diabetes and Serious Mental Illness

OBJECTIVE

Longitudinal changes in health outcomes of patients with serious mental illness and co-occurring diabetes were examined after introduction of an intervention involving electronic disease management, care coordination, and personalized patient education.

METHODS

This observational cohort study included 179 patients with serious mental illness and diabetes mellitus type 2 at a behavioral health home in Chicago. The intervention employed a care coordinator who used a diabetes registry to integrate services; patients also received personalized diabetes self-management education. Outcomes included glucose, lipid, and blood pressure levels as assessed by glycosylated hemoglobin, low-density lipoprotein, triglycerides, and systolic/diastolic values from electronic medical records and completion of specialty visits confirmed with optometrists and podiatrists. Interrupted time-series segmented random-effects regression models tested for level changes in the eight study quarters following intervention implementation compared with eight preimplementation study quarters, controlling for clinic site and preimplementation secular trends.

RESULTS

Significant declines were found in levels of glucose, lipids, and blood pressure postimplementation. In addition, completed optometry referrals increased by 44% and completed podiatry referrals increased by 60%.

CONCLUSIONS

Significant improvement in medical outcomes was found among patients of a behavioral health home who had comorbid diabetes and mental illness after introduction of a multicomponent care coordination intervention, regardless of which clinic they attended.

It is time to mobilize suicide prevention for sexual and gender minorities in Canada

Suicide is a significant health issue among sexual and gender minority adults (SGMA); yet, there are no tailored suicide prevention programs for these marginalized populations in Canada. We hosted two world cafés with community leaders, health professionals, policymakers, and researchers to identify recommendations for mobilizing SGMA-focused suicide prevention programs. We identified five priorities: (1) make society safer for sexual and gender minorities; (2) decrease barriers to mental health services; (3) support community-driven and community-based interventions; (4) increase suicide knowledge and reduce stigma; (5) expand the knowledge base on SGMA suicide. In the absence of a national Canadian SGMA suicide prevention policy, these priorities provide a starting point in addressing SGMA suicide inequities by advancing SGMA-tailored interventions.

Experiences of individuals with severe mental illnesses about physical health services: A qualitative study

AIM

This study aims to understand the ideas and experiences of individuals' with severe mental illnesses regarding their access to physical health care services.

METHODS

In this study, a qualitative descriptive approach and content analysis were used. The sample comprised 14 individuals with severe mental illnesses in a psychiatric clinic.

RESULTS

Three themes emerged: i) a barrier theme related to the patient and the illness, health care professionals, and the health system; ii) a theme that comprised facilitators, for example, health care system facilitators and family support; and iii) an expectations theme, comprising patients' and health care services.

CONCLUSION

Individuals with severe mental illnesses must overcome many barriers while receiving physical health care, and nursing interventions are critical for increasing these patients' access to physical health services.

Perceived Barriers to Mental Health Services Among Canadian Sexual and Gender Minorities with Depression and at Risk of Suicide

This study examines barriers to mental health services among sexual and gender minorities (SGM) who screened positive for depression and risk of suicide. Data from an online survey of SGM (N = 2778) are analyzed. 37.5% met criteria for depression and 73.6% screened for being at risk of suicide. The most frequently cited barriers to mental health services access were inability to pay (62.3%), insufficient insurance (52.2%), a preference for 'waiting' for the problems to go away (51.5%), discomfort discussing emotions (45.7%), and feeling embarrassed and ashamed about mental health challenges (42.5%). Policy and practices implications of these findings are discussed.

Suicide Prevention From the Perspectives of Gay, Bisexual, and Two-Spirit Men

Although gay, bisexual, and two-spirit men (GBTSM) experience high rates of suicidality, there have been few empirical studies of prevention initiatives and policies that could address or reverse this major social problem. This article reports on a photovoice study of 29 GBTSM who had a history of suicidality or lost a fellow GBTSM to suicide. We focused our analysis on participants' perspectives on suicide prevention. Participants described four key considerations for GBTSM suicide prevention: (a) recognizing and addressing enduring homophobia, biphobia, and mental illness stigma; (b) provision of low-barrier, long-term, and GBTSM-affirming counseling; (c) de-isolation through peer support and community connection; and (d) fostering creativity and cultural resilience. By engaging GBTSM affected by suicide through photographs that depict their experiences and points of view, in this study, we offer concrete recommendations to reduce suicidality among GBTSM.

Mental health care professionals' accounts of actions and responsibilities related to managing physical health among people with severe mental illness

BACKGROUND

Life expectancy of people with severe mental illness (SMI) is greatly shortened compared to the general population, and despite extensive research, this issue is unsolved. Although it is widely recognised that people with SMI need support from health care services to manage health related issues, profound health inequalities exist within provision of health care. The aim of this study was to examine how mental health care professionals accounted for their actions and responsibilities related to managing physical health issues among people with SMI.

METHODS

Three focus groups were conducted with 22 mental health care professionals, employed at three mental health care locations. Participants' situated accounts were subjected to discourse analysis.

RESULTS

Participants accounted for actions and responsibilities in three typical ways; 1) by positioning people with SMI as difficult to motivate and actively resisting intervention, 2) by positioning people with SMI as so impaired that intervention was futile, and 3) by arguing they are undertreated for physical conditions and might have physical illnesses that staff are not aware of because of prominent mental illness. These discursive strategies seemed to legitimise situations where participants described not responding to physical health issues, and to downplay potential trouble in situations where participants described not succeeding in facilitating lifestyle changes or promoting compliance to treatment of physical conditions.

DISCUSSION AND CONCLUSION

Mental health care professionals need to increase their awareness of latent discriminating attitudes towards people with SMI. Such attitudes are suggested to reinforce barriers for people with SMI receiving physical health care.

Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers

Background

The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas.

Purpose

The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs).

Methods

This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC.

Results

Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care.

Conclusion

There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided.

Electronic supplementary material

The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Barriers and facilitators to the integration of mental health services into primary healthcare: a qualitative study among Ugandan primary care providers using the COM-B framework

Background

Uptake of clinical guideline recommendations into routine practice requires changes in attitudes and behaviors of the health care providers. The World Health Organization (WHO) has heavily invested in public health and health promotion globally by developing policy recommendations to guide clinical practice; however, clinical guidelines are often not applied. The success of the implementation of any guidelines depends on consideration of existing barriers and adequately addressing them. Therefore, exploring the context specific barriers and facilitators affecting the primary care providers (PCPs) in Mbarara district, Uganda may provide a practical way of addressing the identified barriers thus influence the PCPs action towards integration of mental healthcare services into PHC.

Methods

We adopted a theoretical model of behavior change; Capability, Opportunity and Motivation developed to understand behavior (COM-B). This was a cross-sectional study which involved using a semi-structured qualitative interview guide to conduct in-depth interviews with PCP’s (clinical officers, nurses and midwives).

Results

Capability - inadequacy in knowledge about mental disorders; more comfortable managing patients with a mental problem diagnosis than making a new one; knowledge about mental health was gained during pre-service training; no senior cadre to consultations in mental health; and burdensome to consult the Uganda Clinical Guidelines (UCG). Opportunity - limited supply of hard copies of the UCG; guidelines not practical for local setting; did not regularly deal with clients having mental illness to foster routine usage of the UCG; no sensitization about the UCG to the intended users; and no cues at the health centers to remind the PCPs to use UCG. Motivation - did not feel self-reliant; not seen the UCG at their health facilities; lack of trained mental health specialists; conflicting priorities; and no regulatory measures to encourage screening for mental health.

Conclusions

Efforts to achieve successful integration of mental health services into PHC need to fit in the context of the implementers; thus the need to adapt the UCG into local context, have cues to enforce implementation, and optimize the available expertize (mental healthcare providers) in the process.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3684-7) contains supplementary material, which is available to authorized users.

A Randomized Clinical Trial Investigating the Effect of a Healthcare Access Model for Individuals with Severe Psychiatric Disabilities

We conducted a randomized trial to examine a model for integrating primary care into a community mental health setting. Two hundred individuals were recruited and randomly assigned to receive primary care delivered by a nurse practitioner (n = 94) or services-as-usual (n = 106), assessed on health and mental health outcomes, and followed for 12 months. Intent-to-Treat and exposure analyses were conducted and suggest that participants who engaged with the nurse practitioner experienced gains in perceptions of primary care quality. Health benefits accrued for individuals having receiving nurse practitioner services in a mental health setting to address primary care needs.

Nursing Care for Lifestyle Behavioral Change

The purpose of this pilot study was to determine if metabolic risk factors can be stabilized or improved with weekly motivational interviewing/coaching and medical follow-up care focused on lifestyle behavioral change in individuals with serious mental illness. Individuals were followed for 18 weeks following discharge from an inpatient psychiatric service. All individuals were prescribed an antipsychotic medication and had at least two risk factors for metabolic syndrome. Weight, waist circumference, blood pressure, LDLs, triglycerides, and blood glucose levels were evaluated during the study period. In addition, each individual selected a lifestyle behavior to improve over the 18-week period. Weekly motivational interviewing, and staggered health promotion appointments were designed to keep individuals focused on health and behavior change. While some individuals showed improvement, others showed deterioration in the physiological markers for metabolic syndrome. Only a small number completed the 18-week study. The nature of current psychiatric care is focused on rapid stabilization and discharge; individuals with serious mental illness may have difficulty focusing on lifestyle behavioral change while transitioning to independent living following an acute exacerbation of mental illness.

Perceptions of barriers to physical health care for people with serious mental illness: a review of the international literature

Premature death and poorer access to quality care for physical health concerns is common for people diagnosed with serious mental illness (SMI). However, there is lack of clarity regarding the nature of barriers encountered at different points in the physical health care process, and the level of consistency of these barriers both among countries, and between consumers with SMI and health care staff. The current narrative review integrates views of consumers and health care staff on barriers to physical health care. It involved a search of CINAHL, Proquest, and Web of Science, for peer-reviewed papers published between 2005 and June 2012, for studies of perceptions of barriers to physical health care, published in English. Despite variations in health care systems among countries, there is agreement between consumers and health care staff that division between physical and mental health care and stigma of mental illness act as barriers to all phases of the physical health care process. This uniformity is grounds for international policy development (in general public health and within mental health nursing) for reforms that improve the physical health care, quality of life, and longevity of people with serious mental illness.