Barriers In Accessing Health Care For Individuals with Severe Mental Illness: A Qualitative Study

Purpose: The purpose of this study was to understand the barriers faced by individuals with severe mental illness in accessing health care service. Individuals with severe mental illness have higher mortality rates and on average die 25 years earlier than the general population (Colton, & Manderscheid, 2006). Medical co-morbidity is exacerbated by lifestyle and risk factors including smoking, obesity, high cholesterol, side effects of psychotropic medications, substance abuse conditions (Compton et al., 2006) They have a higher propensity to have fatal outcomes because of physical illnesses and poorer quality of life. (Lawrence et al. 2000; Pandiani et al., 2005). Systemic barriers include a fragmented health care system where primary and mental health services are provided through different channels and locations (Horovitz-Lennon, et al. 2006; Druss, 2007), lack of insurance (Druss et al., 2001); substandard care because of time and knowledge related challenges on the part of primary care physicians and mental health providers (Newcomer et al. 2004). Utilization of emergency room services is higher for individuals with mental illness to access medical care and to circumvent other systemic barriers (Salsberry, et al. 2005). Stigma is an all-pervasive barrier that prevents this population from accessing health and mental health care (Golberstein, et al. 2008). With this backdrop and the complex health care needs of this population, a qualitative pilot study was conducted to achieve a comprehensive understanding of the needs and barriers experienced by this community. This pilot study was a prelude to developing an intervention that aims to mitigate some of the identified barriers and enhance health care access.

Methods: The qualitative component included three focus groups that involved a total of 21 mental health consumers at 2 separate sites of a community mental health agency. Participants had a diagnosis of severe mental illness and their cognitive functioning ranged from low to very high functioning. The focus group included open-ended questions with follow-up probes. The focus groups were led by a trained facilitator.

The focus groups were taped and the tapes were transcribed verbatim and content analyzed. Data analysis included reading and re-reading of transcriptions and the creation of codes. Data were sorted according to emerging themes and sub-themes regarding barriers encountered while accessing health care services. Triangulation was used to increase inter-rater reliability

Results and Conclusions: Barriers at 4 levels emerged from the focus groups. 1.System level barriers included lack of insurance, inadequate insurance and transportation. 2. Provider level barriers included problems faced in getting services, lengthy clinic and hospital waits, poor quality of services and problems in getting medication. 3. Environmental factors included poverty and inadequate resources 4. Individual level barriers included cognitive impairments, co-morbid substance abuse and homelessness Stigma was a pervasive theme, acting as a barrier through all the levels. The participants reported feeling discriminated against, dismissed, and left out of medical decisions. This study goes to the heart of the multiple barriers this marginalized community experiences as it negotiates everyday life.