Access to primary mental health care for hard-to-reach groups: From ‘silent suffering’ to ‘making it work’

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Abstract

Equitable access to primary care for people with common mental health problems in the UK remains problematic. The experiences of people from hard-to-reach groups offer important insights into barriers to accessing care. In this study, we report on secondary analysis of qualitative data generated within seven previously-reported studies. Thirty-three of ninety-two available transcripts were re-analysed using a new heuristic of access, generated to frame narrative-based comparative case analysis. The remaining transcripts were used to triangulate the findings via a process of collaborative analysis between a secondary researcher, naïve to research findings of the original studies, and primary researchers involved in data generation and analysis within the original studies. This method provided a rich body of ‘fine grain’ insights into the ways in which problem formulation, help-seeking, use of services and perceptions of service quality are interlinked in a recursive and socially embedded matrix of inequitable access to primary mental health care. The findings indicate both extensive commonalities between experiences of people from different ‘hard-to-reach groups’, and considerable diversity within each group. An idiographic generalisation and aggregation of this variety of experiences points to one main common facilitator (communicated availability of acceptable mental health services) and two main common barriers (lack of effective information and multiple forms of stigma) to equitable access to primary mental health care. We conclude that there is a need to provide local care that is pluralistic, adaptive, holistic, resonant and socially conscious in order to ensure that equitable access to mental health services can become a reality.

Research highlights

► Access is about problem formulation, help-seeking, use and experience of services. ► There is a lot of commonalities between people from various hard-to-reach groups. ► Main barriers to access are lack of effective information and multiple stigma(s). ► The main facilitator to access is communicated availability of acceptable services. ► Improving equity of access to primary mental health care is a complex and dynamic task.

Introduction

Adequate and timely support for common mental health problems within primary care is less likely to be accessed by certain groups of individuals (Borowsky et al., 2000). Some people, such as those with medically unexplained symptoms or with advanced cancer, have problems in obtaining appropriate primary mental health care (Aabom and Pfeiffer, 2009, Ring et al., 2005), while others, such as people from racialised minorities (Brubaker, 2004) have problems in gaining equitable access to health care in general (Commander, Sashi Dharan, Odell, & Surtees, 1997). Given that the UK’s National Health Service (NHS) has an explicit equity-driven health policy framework (DH., 2005, DH., 2008), it is necessary to understand how and why inequity of access to professional help for common mental health problems is sustained.

This paper contributes to understanding why people from ‘hard-to-reach groups’ have difficulties in accessing mental health support in primary care and how these difficulties could be overcome. We present findings from a secondary analysis of qualitative data, conducted within a research and development programme to improve equity of access to primary mental health care (Dowrick, Gask, Edwards, Aseem, Bower, Burroughs et al. 2009). The term ‘hard-to-reach-group’ is used in this paper to describe population clusters who, in comparison to the average population of primary care users, are less likely to receive mental health support within primary care when needed. We explore this phenomenon by comparing the experiences of people from five exemplar groups known to be at risk of inequitable access:

  • people with advanced cancer (Aabom & Pfeiffer, 2009),

  • people with medically unexplained symptoms (MUS) (Peters, Rogers, Salmon, Gask, Towey, Clifford et al. 2009),

  • people from Black and minority ethnic (BME) groups (Commander et al., 1997),

  • people on prolonged sickness absence from work (Edwards & Gabbay, 2007), and

  • elderly people (Burroughs et al., 2006).

Access to health and welfare services has been researched within different conceptual and methodological approaches. On one side, health services research traditionally examines access from the point of entrance to the formal system of care. Key concepts such as demand, availability, utilisation and patterns of use are developed in a functionalist view of the relationship between service provision and use where access is conceptualised as an interaction between supply and demand rationalised by professionally-defined need for services (for an overview see Dixon-Woods, Cavers, Agarwal, Annandale, Arthur, Harvey et al. 2006). On the other side, behavioural and social sciences traditions, within the ‘help-seeking’ literature, focus mainly on ‘out-of-services’ perspectives i.e. on processes that happen before the point of entrance into formal systems of care. Broadhurst's (2003) review of this literature identifies a three-stage model of help-seeking, summarizing variations in a) problem definition, b) deciding to seek help and c) actively seeking help. Liang, Goodman, Tummala-Narra, and Weintraub (2005) extend this further to incorporate bidirectional, dialectical relations between the stages and a set of individual, interpersonal and societal influences that effect behaviour in each of the help-seeking stages. However, literature aiming to integrate these two distinctive perspectives is emerging (e.g. Dixon-Woods et al., 2005, Dixon-Woods et al., 2006).

We identify three particularly useful concepts in relation to researching access: candidacy, concordance and recursivity. Candidacy refers to the processes by which people’s eligibility to use a particular service is formulated in locally situated interactions between health services and themselves (Dixon-Woods et al., 2005, Dixon-Woods et al., 2006). Concordance indicates the importance of a match between users’ and practitioners’ narratives and resources for successful access to medical attention and intervention (Stevenson & Scambler, 2005). Recursivity refers to interdependency between a user’s experiences of health services and her/his future actions in regards to health and help-seeking (Rogers, Hassell, & Nicolaas, 1999). The relevance of these concepts rest in their capacity to connect two traditionally separate streams of academic inquiry which split people’s experiences of access into compartments of help-seeking (addressed mainly in behavioural and social sciences literature) and use of services (addressed mainly in health services research literature). Acknowledging the recurring nature of help-seeking behaviour and use of health services, the concept of recursivity is particularly relevant in adding a diachronic dimension to the phenomenon of access and ultimately bringing the notion of quality and outcomes of care into the scope of academic inquiry of access.

However, empirical research which employs these concepts is still scarce (Koehn, 2009). Additionally, the literature on barriers and facilitators to professional mental health support explores problems of access within individual hard-to-reach groups, or tends to focus on between-group difference rather than areas of commonality. Our work seeks to address these gaps. We explore access to primary mental health care as a complex social phenomenon shaped by links between help-seeking behaviour of individuals, processes underpinning the use of health services, and quality and outcomes of care. This was achieved by comparing barriers and facilitators to care experienced by people from a range of hard-to-reach groups. This paper presents an integrative methodological approach to undertaking that comparison. Further, we present identified areas of commonality between the groups, suggesting potential foci for developing policy and research.

Section snippets

Method

This paper is based on a collaborative comparative secondary analysis of qualitative data conducted as a part of a wider programme of research exploring stakeholders’ perspectives on access to mental health services in primary care and aiming to develop interventions to improve access within the same programme of work (Dowrick et al., 2009). Secondary analysis is considered a suitable method of increasing utility of qualitative data, particularly for generating knowledge about people from

Findings and discussion

In this paper, we present only identified commonalities between the observed hard-to-reach groups. In the first part of findings (‘Fine grain’), we present the outcome of the first stage of reflection on what was common to all groups in respect to research sub-questions emerging from our analytical model. We then present ‘Large grain’ findings with the messages coming from the third and final stage of reflection on more generic commonalities (see Table 1, Summary of findings).

Conclusions and recommendations

Presented ‘fine grain’ insights demonstrate the ways in which problem formulation, help-seeking, use of services and experience of service quality are interlinked in a recursive and socially embedded matrix of inequitable access to mental health support in primary care. Despite the diversity of insights available from this detailed analysis, three core issues stand out with important implications for addressing existing inequities. Eliminating compounding effects of multiple stigma(s) and

Acknowledgments

We are grateful to Derek Hibbert, Dan Heartly, two anonymous peer reviewers and the AMP Study Group for helpful comments and suggestions. We would also like to thank Heather Burroughs, Helen Sanderson and Aisha Waquas who contributed to generation of some of the data. The research presented in this paper was a part of the AMP Programme which received the Department of Health’s financial support from the NIHR Programme Grants for Applied Research funding scheme (NIHR RP-PG-0606-1071). The views

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