Associations between health-related quality of life and financial barriers to care among women veterans and women non-veterans

The authors of this study examined the association between health-related quality of life and financial barriers to care, defined as not getting the needed care due to cost considerations. To better understand health-related quality of life among women veterans, the authors compared women veterans to women non-veterans. The authors conducted cross-sectional analyses using data from the 2009 Behavioral Risk Factor Surveillance System survey. The authors assessed four health-related quality of life measures: (1) general health; (2) physical health; (3) mental health; and (4) functional status. The authors performed multinomial logistic regressions to examine the relationship between financial barriers to receiving healthcare and health-related quality of life measures after controlling for other independent variables. The authors included women veterans not in active military duty (N = 3,747) and a matched sample of women non-veterans (N = 3,747), selected using a propensity score method so that they would have distributions of demographic and socioeconomic characteristics similar to those of the veterans. Overall, 14% of women reported financial barriers. Women who reported financial barriers to receiving healthcare were more likely to have poor health-related quality of life in all four dimensions than those who did not report such barriers. Compared to women non-veterans, women veterans did not differ in reported financial barriers but were more likely to report poor health-related quality of life. Reporting financial barriers to receiving needed healthcare was significantly associated with poor health-related quality of life among women. Veteran status was also significantly associated with poor health-related quality of life. These findings suggest the need for healthcare policy makers and practitioners to align emerging new models of healthcare delivery to improve health-related quality of life for women veterans.     

Behaviour of medical students in seeking mental and physical health care: exploration and comparison with psychology students

CONTEXT: Doctors are often reluctant to seek health care through the usual channels and tend to self-diagnose and prescribe. Medical students learn attitudes and values from clinician role models and may also adopt behaviour patterns that lead them to seek help for physical and mental health problems from informal sources. OBJECTIVES: This study aimed to explore the behaviour of students in seeking health care for physical and mental health problems, comparing medical with psychology students, and to understand what barriers to conventional routes of seeking health care may affect this. METHODS: We administered a questionnaire asking for demographic details and responses to 2 vignettes in which a student from the respondent's discipline was experiencing firstly symptoms of a mental health problem and secondly symptoms of a physical health problem. Data were analysed with spss and univariate anovas to examine differences between respondents. RESULTS: A total of 172 students at the psychology and medical schools at James Cook University in Australia participated. We identified a number of barriers affecting student behaviour in seeking help, which included worries about knowing the doctor they could consult at the university health centre or having future dealings with him or her, and cost of treatment. There were differences between the 2 groups of students. DISCUSSION: There are several barriers for both psychology and medical students to accessing appropriate professional mental health care. Medical students also experience barriers to attaining appropriate physical health care when needed. Psychology and medical students were more likely to seek advice informally from friends and/or family with regard to mental health care.     

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.     

Providing family planning and reproductive healthcare to Canadian immigrants: perceptions of healthcare providers

Cultural impacts on health experiences and behaviours are profound in the area of reproductive health and family planning. Explored through interviews with family planning healthcare professionals, this paper evaluates their experiences in providing family planning and reproductive healthcare to immigrants in the Greater Toronto and Hamilton area of Ontario, Canada. Results reveal the complexity of delivering care to members of this group, particularly when dealing with language barriers, situations when professional and non‐professional interpreters are used, and instances where healthcare professionals realize that they themselves have misconceptions and misunderstandings about other cultures. The paper concludes by discussing future research options and implications for the delivery of reproductive health family planning services to this population.     

Supporting family engagement with child and adolescent mental health services: A scoping review

A key challenge facing the mental health field is connecting children and families to services when symptoms first appear. Multiple barriers inhibit timely access to treatment, and interventions to resolve barriers to care are not common among health and social care organisations. To address this research‐to‐practice gap this study undertook a scoping review of the empirical literature aimed at identifying key factors in the social ecology of families which influence family engagement with child and adolescent mental health services, then identifying and describing models of intervention designed to help facilitate access to care. Forty studies published between 1 January 2000 and 28 February 2019 were reviewed. Key factors associated with child and adolescent mental health service engagement included family attitudes towards mental illness and help seeking, the flexibility and availability of needed services, community attitudes and stigma surrounding mental illness and mental health treatment, and the degree of coordination and integration across systems of health and social care. Models of intervention to facilitate engagement with mental health services included family outreach, telephone and digital health strategies, and integrated care approaches. Empirical support is strongest for family outreach and integrated care, although telephone and digital health strategies are underexplored with children and families and a potentially promising avenue for future research. To support family engagement with child and adolescent mental health services health and social care organisations should be prepared to identify barriers in their local practice settings and integrate efficacious engagement approaches into their continuum of available services.     

Reporting mental health problems of undocumented migrants in Greece: A qualitative exploration

Background: Mental health problems are highly prevalent amongst undocumented migrants (UMs), and often part of their consultations with general practitioners (GPs). Little empirical data are available of how GPs and UMs engage around mental health in Greece, a country with a lack of balance between primary and secondary care and limited healthcare provisions for UMs.

Objectives: To acquire insight in the barriers and levers in the provision of mental healthcare for UMs by GPs in Greece.

Methods: This was a qualitative study using semi-structured interviews with 12 GPs in Crete, Greece with clinical expertise in the care of UMs. All interviews were audio-taped and transcribed verbatim and were analysed using thematic content analysis.

Results: Greek GPs recognized many mental health problems in UMs and identified the barriers that prevented them from discussing these problems and delivering appropriate care: growing societal resistance towards UMs, budget cuts in healthcare, administrative obstacles and lack of support from the healthcare system. To overcome these barriers, Greek GPs provided UMs with free access to care and psychotropic drugs free of charge, and referred to other primary care professionals rather than to mental healthcare institutions.

Conclusion: Greek GPs experienced substantial barriers in the provision of mental healthcare to UMs and political, economic and organizational factors played a major role.     

Attending to physical health in mental health services in Australia: a qualitative study of service users’ experiences and expectations

Evidence is unequivocal: the premature death of people with severe mental health problems is attributable primarily to cardiovascular disease, and healthcare provided is often suboptimal. With the overarching aim of improving outcomes, policies and guidelines oblige mental health services and psychiatrists to monitor cardio‐metabolic health of patients and intervene as appropriate. Practice is highly variable; however, with ongoing debate about resourcing and responsibilities dominated by clinicians who have identified disinterest among patients as influencing practice. Seeking to balance discussion, we posed the question ‘what do patients experience and expect of mental health services in relation to their physical health?’ To answer it, we interviewed a convenience sample of 40 service users recruited from a mental health service in Australia, early in 2015. Data were analysed using the framework approach. With few regarding themselves as healthy, participants were commonly concerned about side effects of medication, weight and fitness but rarely mentioned tobacco smoking. Participants’ accounts reinforce extensive research demonstrating variability in attention to physical health in mental health services. Reports by some participants of comprehensive care are encouraging, but widespread uncertainty about reasons for various assessments and denial of requests for management of medication side effects, including weight gain, gives cause for concern. Although participants in this study wanted to improve their health and health‐related quality of life, they acknowledged that their motivation and ability to do so fluctuated with mental health. They expected clinicians to work proactively, especially when symptoms compromised capacity for self‐care, and mental health services to provide or enable access to health‐promoting interventions. Attention should be given, as a matter of priority, to creating conditions (culture and infrastructure) needed to support sustained attention to physical health within services and, importantly, to full engagement of service users in management of their physical health.     

Joint working in community mental health: prospects and challenges

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional 'seepage' and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government's Green Paper, 'Developing Partnerships in Mental Health'.     

Nurses’ perceptions of mental healthcare in primary-care settings in Kenya

Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n?=?20), private urban (n?=?20), and public rural (n?=?20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya.     

Deportation of non-citizen military veterans: A critical analysis of implications for the right to health

Military personnel are commonly exposed to health-harming conditions during their service, resulting in higher rates of physical and mental health conditions compared with the general population. In an era of mass deportations, it is notable that non-citizen military veterans are not exempt from deportation. We utilised a human rights framework to conduct a critical analysis of potential health consequences of deportation for U.S. military veterans, identifying three ways in which veterans’ rights to health may be constrained through deportation. First, honourably discharged deported veterans may be denied access to free or subsidised Veterans Affairs health services to which they would likely otherwise be entitled. Second, availability of and access to healthcare may be limited for reasons including barriers to enrolling in public insurance schemes, challenges navigating unfamiliar health systems and stigma and discrimination towards deported migrants. Finally, quality of available care may be sub-optimal due to limited expertise in service-related health issues and lack of evidence-based treatment for some health conditions (e.g. substance abuse/dependence). Binational multi-sectoral efforts are necessary to ensure that the rights to health of deported military veterans are adequately protected.     

Knowledge and expertise in care practices: the role of the peer worker in mental health teams

Our research examines how different forms of knowledge and expertise are increasingly important in caring for people experiencing mental illness. We build on theoretical developments regarding multiple ontologies of knowing about illness. We examine how experiential knowledge of mental health problems, learned by being subject to illness rather than through objective study, is enacted in mental healthcare teams. We focus on Peer Workers (PW), individuals who have lived experience of mental health problems, and who contribute knowledge and expertise to mental health care within multidisciplinary healthcare teams. Our longitudinal study was undertaken over 2 years by a multidisciplinary team who conducted 91 interviews with PW and other stakeholders to peer support within a comparative case study design. We show how workers with tacit, experiential knowledge of mental ill health engaged in care practice. First, we show how subjective knowing is underpinned by unique socialisation that enables the development of shared interactional spaces. Second, we point to how the situated nature of subjective knowing is uniquely embedded in time and space and allows for the alignment of embodied knowledge with trajectories of care. Third, we provide insight into how subjective forms of expertise might be incorporated into multidisciplinary care.     

Challenges to sanctuary: the clergy as a resource for mental health care in the community

The transfer of psychiatric care from the institution to the community has presented community structures including faith-based organisations (FBOs) with an additional burden of care. In recent years there has been an increasing policy interest among government departments, public and non-statutory agencies for the inclusion of FBOs as partners in health and welfare services. However, despite their long historical involvement in healing and healthcare, clergy are seldom viewed by mental health professionals as partners in healing and restitution but with suspicion [Koenig, 1988. Handbook of Religion and Mental Health San Diego: Academic Press; Larson, Hohmann, & Kessler, 1988. The couch and the cloth: The need for linkage. Hospital and Community Psychiatry, 39, 1064-1069]. This may be compounded by ignorance about mental health care provision within FBOs in the UK and the preparedness, confidence and willingness to undertake such care. This paper is based on a study which examined clergy contact with people with mental illness. Thirty-two interviews were conducted with male clergy (Christian ministers, rabbis, and imams) most of whom were London-based. We examine barriers and dilemmas for clergy in caring for people with mental illness. We found that they play an important but often confined role the scale and impact of which is not recognised by their central organisation and training bodies. Low confidence about managing psychiatric problems, underscored by anxiety, fear and stereotyped attitudes to mental illness restrain their willingness to formalise their function. We argue that any proposed extension of clergy involvement in mental health will require further research and thorough deliberation by mental health services and religious organisations.     

Economic barriers to better mental health practice and policy

Mental health systems in many countries are seriously under-developed, yet mental health problems not only have huge consequences for quality of life, but--particularly in low- and middle-income countries--contribute to continued economic burden and reinforce poverty. This paper discusses economic barriers to improving the availability, accessibility, efficiency and equity of mental health care in low- and middle-income countries. Six sets of barriers are identified: an information barrier, resource insufficiency, resource distribution, resource inappropriateness, resource inflexibility and resource timing. Overcoming these barriers will be a major task, although there is no shortage of suggestions for action. The paper discusses broadening the evidence base, improving mental health literacy, tackling stigma, improving financing mechanisms, prioritizing and protecting mental health care budgets, emphasizing mental health promotion through the development of resilience, exploring routes to improved equity, experimenting with new arrangements for purchasing and delivering services, improving coordination between agencies and professionals at both macro- and micro-levels, building alliances between public and private sectors, and training and mobilizing primary care services to improve identification and treatment of mental health problems.     

The impact of vouchers on the use and quality of health care in developing countries: A systematic review

Abstract

One approach to delivering healthcare in developing countries is through voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health care. Using inclusion/exclusion criteria, a search of databases, key journals and websites review was conducted in October 2010. A narrative synthesis approach was taken to summarise and analyse five outcome categories: targeting, utilisation, cost efficiency, quality and health outcomes. Sub-group and sensitivity analyses were also performed. A total of 24 studies evaluating 16 health voucher programmes were identified. The findings from 64 outcome variables indicates: modest evidence that vouchers effectively target specific populations; insufficient evidence to determine whether vouchers deliver healthcare efficiently; robust evidence that vouchers increase utilisation; modest evidence that vouchers improve quality; no evidence that vouchers have an impact on health outcomes; however, this last conclusion was found to be unstable in a sensitivity analysis. The results in the areas of targeting, utilisation and quality indicate that vouchers have a positive effect on health service delivery. The subsequent link that they improve health was found to be unstable from the data analysed; another finding of a positive effect would result in robust evidence. Vouchers are still new and the number of published studies is limiting.     

‘Every single minute and hour is scrutinised’: neoliberalism and Australian private mental health care

There is little understanding of how recovery-oriented approaches fit within contemporary mental healthcare systems, which emphasise biomedical approaches to care, increased efficiency and cost-cutting. This article examines the established models of service delivery in a private, youth, mental health service and the impacts of the current system on staff. It explores whether the service is prepared or capable of adopting recovery-oriented approaches to care. Qualitative interviews were undertaken with staff and thematically analysed to understand the everyday practices on the unit. Data suggest that economic efficiencies and biomedical dominance largely shaped how health care was organised and delivered, which was perceived by staff as inflexible to change. Additionally, findings suggest that market-oriented principles associated with neoliberalism restricted the capacity of individuals to transform services in line with alternative models of care and lowered staff morale. These finding suggest that, while neoliberal ideologies and biomedical approaches remain dominant in organisations, there will be challenges to adopting alternative recovery-oriented models of care and promoting healthcare systems that understand mental health issues in broader socio-political contexts and can flexibly respond to the needs of service users.     

Understanding wellness and barriers to care among Iraqi refugee women in the United States

Iraqi refugees in the US experience a high prevalence of non‐communicable diseases. In this article, we explore how cultural and structural realities intersect to influence utilisation of preventative healthcare and cancer screening with the aim of understanding health disparities in this population. We conducted three focus group discussions with a total of 14 Iraqi refugee women living in a northeastern US city in 2016 and analysed the qualitative data using a thematic analysis. Eight themes emerged from our data: (a) ‘prevention is better than cure:' Iraqi refugee women maintain wellness; (b) physical and mental health are interrelated in causing and curing ill‐health; (c) Iraqi refugee women embrace both biomedical and other healing practices; (d) God contributes to healing; (e) cancer is caused by dangerous environments. Three of the eight themes related to barriers to care; (f) multi‐level problems within hospitals and clinics prevent the delivery of care; (g) financial barriers prevent access to care and good health; (h) competing priorities are a barrier to good health. We argue that understanding refugee health requires critical analysis of both culturally informed understandings of health and illness as well as the structural aspects of health disparities that result in limited access to life opportunities, racism and inequality for refugees and their communities.     

Voices of care for adults with disabilities and/or mental health issues in Western Canada: what do families and agencies need from each other?

Our purpose in this paper is to report on the frustrations and unmet needs of paid, formal caregivers and unpaid, family caregivers who together provide care to adults with disabilities and/or mental health issues. We conducted eight focus group interviews between November 2010 and June 2011 in two large, urban centres and one smaller centre in Western Canada. Four of our focus groups were with family members including adults with disabilities and/or mental health issues, their parents and their siblings, and four were with representatives from agencies providing support and services to adults with disabilities and/or mental health issues and their families. Data were collected from 23 family members and 24 agency representatives who responded to questions about successes and struggles in meeting, and collaborating to meet, care needs of adults with disabilities and/or mental health issues. Each focus group session was digitally recorded and transcribed; field notes were also taken and we thematically analysed data according to family versus agency perspectives of their successes and barriers in care provision and care collaboration. We found that family members desire greater and more effective support in enriching the lives of adults with disabilities and/or mental health issues and in preparing for age‐related changes. Agency representatives are keenly aware of the needs and challenges faced by families, yet grapple with being effective collaborators with families of widely varying priorities and styles of care and collaboration.     

The role and competence of midwives in supporting women with mental health concerns during the perinatal period: A scoping review

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. Despite a recognition of the significance of this issue, women often do not receive the care they need and fall between the gap of maternity and mental health services. To address this, there is a call for reform in the way in which perinatal mental healthcare is delivered. This paper responds to this by exploring the role and competence of midwives in delivering mental healthcare. Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question ‘what is the nature of the evidence relevant to the provision of mental health interventions by midwives?’ To identify studies, the databases PubMed, Maternity and Infant Care, Science Citation Index, Social Sciences Citation Index, Medline, Science Direct and CINAHL were searched from 2011 to 2018, and reference lists of included studies were examined. Studies relevant to the role of midwives in the management and treatment of perinatal mental health issues were included; studies focussed on screening and referral were excluded. Thirty papers met inclusion criteria, including studies about the knowledge, skills, and attitudes of midwives and student midwives; the effectiveness of educational interventions in improving knowledge and skills; the delivery of counselling or psychosocial interventions by midwives; and barriers and enablers to embedding midwife‐led mental healthcare in practice. Synthesis of the included studies indicates that midwives are interested in providing mental health support, but lack the confidence, knowledge and training to do so. This deficit can be addressed with appropriate training and organisational support, and there is some evidence that midwife‐led counselling interventions are effective. Further research is needed to test midwife‐led interventions for women with perinatal mental health problems , and to develop and evaluate models of integrated perinatal mental healthcare.     

Family day care educators: an exploration of their understanding and experiences promoting children's social and emotional wellbeing

This study aimed to explore family day care (FDC) educators' knowledge of child social and emotional wellbeing and mental health problems, the strategies used to promote children's wellbeing, and barriers and opportunities for promoting children's social and emotional wellbeing. Thirteen FDC educators participated in individual semi-structured interviews. FDC educators were more comfortable defining children's social and emotional wellbeing than they were in identifying causes and early signs of mental health problems. Strategies used to promote children's mental health were largely informal and dependent on educator skills and capacities rather than a systematic scheme-wide approach. Common barriers to mental health promotion were limited financial resources, a need for more training and hesitance raising child mental health issues with parents. There is a need to build FDC educators' knowledge of child social and emotional wellbeing and for tailored mental health promotion strategies in FDC.