A Mixed-Method Study of the Health Care Experiences of Hispanics with Serious Mental Illness

Background and Purpose.   Compared to non-Hispanic whites with serious mental illness (SMI, e.g., schizophrenia), Hispanics with SMI have higher rates of obesity and diabetes, placing them at elevated risk for cardiovascular disease (CVD).  Hispanics with SMI are also less likely to engage and receive high quality medical care, even against the backdrop of the poor quality of care received by people with SMI.  The aims of this federally funded study were to use a combination of qualitative and quantitative methods to examine the experiences of Hispanics with SMI receiving primary care services in an urban environment and to explore the relationships between interpersonal aspects of care, quality of chronic illness care, and self-management behaviors.  

Methods.  A purposive sample of 40 Hispanic adults with SMI and at least one CVD risk factor (e.g., smoking, hypertension) were recruited from a public outpatient mental health clinic.  Structured interviews that included a series of standardized instruments (e.g., Patient Activation Scale, Perceived Discrimination/Stigma Scale, Chronic Disease Self-efficacy Scale, Patient Assessment of Chronic Illness Care) were conducted with each participant in their preferred language (English or Spanish). Chart abstractions were used to examine participants’ medical and psychiatric needs. A sub-set of participants (n = 24) participated in focus groups to discuss their experiences receiving medical care and managing their medical issues.  All focus groups were audio taped and transcribed.  Bivariate analyses were used to analyze quantitative data.  Grounded theory was used to analyze qualitative data.  A concurrent mixed-method approach that utilized triangulation and examination of convergence was used to integrate quantitative and qualitative data and results.

Results.  Half of our participants were male and mostly of Dominican and Puerto Rican descent. The majority (78%) had a diagnosis of schizophrenia, schizoaffective or bipolar disorders and taking second-generation antipsychotics (65%).  On average, participants had 4.2 medical conditions with high cholesterol (68%), hypertension (60%), and diabetes (40%) being the most frequent conditions.  A grounded model of health care experiences emerged from the triangulation of our data. The model captures how participants’ health care experiences are embedded in a stressed health care system characterized by structural barriers (e.g., language barriers, overburdened clinics) and high levels of perceived discrimination/stigma associated with being Hispanic, having a mental illness and limited English proficiency.  These barriers were buffered by the nature of the interpersonal relationship participants had with primary care providers. Positive relationships were characterized as warm, friendly, and trustworthy, while negative relationships were characterized as impersonal, detached, rushed, and disrespectful. Bivariate analyses show that the nature of the relationship was positively associated with participants’ assessment of chronic illness care (e.g., goal setting), self-efficacy in communicating with providers, and patient activation, an indicator self-management.

Conclusions and Implications. Study findings revealed the central role that interpersonal aspects of primary care play in the health care experiences of Hispanic adults with SMI by moderating barriers to care and influencing the quality of chronic illness care and self-management behaviors. Implications for using this grounded model for developing and implementing culturally appropriate health care interventions will be discussed.