Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from ‘hard to reach’ groups

Abstract

Knowledge about depression, access and help-seeking has increasingly been influenced from a range of disciplines including clinical and applied social science. A range of interventions can improve outcomes of depression and anxiety. However, many in need do not seek help, or their interaction with care-givers does not address their needs. We carried out a systematic search for qualitative articles focusing on the experiences of eight exemplar groups with exceptional problems in access (the homeless, long-term unemployed, adolescents with eating disorders, depressed elderly people, advanced cancer sufferers, patients with medically unexplained symptoms, asylum seekers and people from black and minority ethnic groups). Twenty articles representing these groups were selected, findings were then developed using qualitative meta-synthesis, this suggested a range of mechanisms accounting for poor access among these groups. Many regarded their mental health problems as rooted in social problems and employed a variety of self-management strategies to maintain function. These strategies could involve social withdrawal, focusing available resources on close family relationships and work roles. Over-investment in these roles could result in a sense of insecurity as wider networks were neglected. Material disadvantage affected both the resources people could bring to performing social roles and influenced help-seeking. A tacit understanding of the material, psychological and social 'costs' of engagement by patients and health professionals could influence decisions to seek and offer help. These costs were felt to be proportionally higher in deprived, marginalized and minority communities, where individual resources are limited and the stigma attached to mental ill-health is high.

Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study

“…Engagement with services may also inhibit recovery if it reinforces responses that confirm illness identity. 220 Our evidence pointed towards a need for the development of resources for self-help, coping skills and resilience, designed to help members of underserved communities improve their mental well-being without direct primary care involvement. Initial consultations indicated that this was highly congruent with current priorities in both Liverpool and Manchester and in wider health policy.…”

“…Details of our findings from this analysis have been published in the paper by Lamb et al, 220 of which the key features are as follows.…”

“…For deprived communities the perceived personal 'costs' and 'benefits' for the patient or his or her family of engaging in treatment may involve different parameters from those in operation in more affluent communities. 220 Improving access for underserved groups could involve addressing any of the barriers in the pathway from patients recognising that they may need help to them seeking, negotiating and engaging in treatment. The nature, scale and impact of different barriers at the local level, as well as how we might best address them, could be understood only by engaging with the communities.…”

Mental ill health in the elderly: medical students’ social representations in the United Kingdom

“…Primary care constitutes the first point for seeking help for mental health problems (6) . This setting is particularly relevant in the management of mental health problems in later life for two reasons: older adults express more willingness to reveal mental health problems in primary care; secondly, primary care facilitates service provision to marginalised and "difficult-to-reach" groups such as older adults with depression (7,8) .…”

“…They state that older adults tend to resist medical classifications and treatment in order to protect their identity from discriminatory practices (25) . Illness may affect one's sense of self and the way one interacts with the social world (8) . In this case, the experience of being diagnosed and complying with mental health care is seen as threatening an older person's identity and social relationships.…”