Synthesizing the Impact of Community-Level Characteristics on Healthcare Access and Utilization Among Individuals with Serious Mental Illness

Background and Purpose: Individuals with serious mental illnesses (SMI), such as schizophrenia and major affective disorders, have high rates of physical comorbidities yet face barriers that impede access to needed mental and physical healthcare. These barriers increase acute care use and contribute to premature death. An emerging body of research has shown that community-level characteristics may impact healthcare outcomes. For example, economic and social aspects of communities impact the demand for healthcare by influencing the health of individuals. Community-level characteristics are also linked to the availability of physical and mental healthcare services. Individuals with SMI disproportionately reside in communities with low economic and social resources, yet the incorporation and measurement of community-level drivers of healthcare access and utilization among this population has been inconsistent. The current study seeks to identify commonalities and knowledge gaps in the published research by a) examining the relationship between community-level economic and social characteristics and healthcare access and utilization among individuals with SMI and b) examining how community-level characteristics are being defined and operationalized across studies.

Methods: The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) were followed for this review and a study protocol was registered with PROSPERO. A comprehensive search string and strategy was developed in consultation with a university reference librarian. Six computerized bibliographic databases were searched, resulting in a total of 7,763 potentially eligible studies. Title and abstract screenings, as well as full text reviews, resulted in the inclusion of 33 manuscripts in this review. Study quality was assessed using the JBI Critical Appraisal Checklist for Analytic Cross-Sectional Studies. A narrative synthesis of the results was presented.

Results: Thirty-one studies included a measure of community-level socioeconomic status (SES). Fifteen studies used 11 distinct multidimensional measures of community-level SES and 17 studies used eight distinct single-item indicators of community-level SES. Nineteen of the 31 studies examining community-level SES found significant associations with healthcare access and utilization. Lower community-level SES was associated with increased risk of MH relapse, inpatient readmission and length of stay, emergency department utilization, and disengagement of early intervention services.

A total of eight studies examined community-level social capital or social fragmentation via eight distinct indicators. Higher levels of community-level social capital were associated with longer duration of untreated psychosis. Higher levels of social fragmentation were associated with fewer mental health service visits and lower odds of inpatient follow-up visits.

Conclusions and Implications: Though the measurement of community-level social and economic factors varied greatly between studies, these factors were found to impact a wide range of mental healthcare outcomes. The development and use of a standardized set of community-level social and economic indicators would help strengthen research in this area as well as help direct resources and programming aimed at meeting the treatment needs of individuals with SMI.