Using the capabilities approach to understand inequality in primary health-care services for people with severe mental illness

Maya Lavie-Ajayi,Rotem Porat,Galia S Moran,Gilad Gal,Itzhak Levav,Tal Reches,Margalit Goldfracht

doi:10.1186/s13584-018-0236-x

Abstract

BackgroundEpidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. This observation includes countries with universal health insurance. However, there is limited in-depth data regarding the barriers preventing equality of physical health-care provision for this population. This study applied the capabilities approach to examine the interface between general practitioners and patients with severe mental illness. The capabilities approach provides a framework for health status which conceptualizes the internal and external factors relating to the available options (capabilities) and subsequent health outcomes (functioning).MethodsSemi-structured in-depth interviews were conducted with 10 general practitioners and 15 patients with severe mental illness, and then thematically analyzed.Results: We identified factors manifesting across three levels: personal, relational-societal, and organizational. At the personal level, the utilization of physical health services was impaired by the exacerbation of psychiatric symptoms. At the relational level, both patients and physicians described the importance of a long-term and trusting relationship, and provided examples demonstrating the implications of relational ruptures. Finally, two structural-level impediments were described by the physicians: the absence of continuous monitoring of patients with severe mental illness, and the shortfall in psychosocial interventions.ConclusionThe capability approach facilitated the identification of barriers preventing equitable health-care provision for patients with severe mental illness. Based on our findings, we propose a number of practical suggestions to improve physical health-care for this population: 1. A proactive approach in monitoring patients’ health status and utilization of services. 2. Acknowledgment of people with severe mental illness as a vulnerable population at risk, that need increased time for physician-patient consultations. 3. Training and support for general practitioners. 4. Increase collaboration between general practitioners and mental-health professionals. 5. Educational programs for health professionals to reduce prejudice against people with severe mental illness.

Highlights

Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness
The active role includes the need to be aware of one’s health condition and needs; to seek timely medical health-care; to actively address related administrative procedures; to understand and follow the recommendations of one’s general practitioners (GPs), and so on. Both parties indicated that the ability of patients with severe mental illness (SMI) to take on such multi-level tasks may be compromised due to the severity of their psychiatric symptoms, the occurrence of acute episodes, and their functioning levels
Symptom severity negatively affected the patients’ ability to keep to meetings and respond constructively to incidents of discrimination and stigma, which had a negative effect on their health and mental health states

Summary

Introduction

Epidemiological studies show disparities in the provision of physical health-care for people with severe mental illness. People with severe mental illness (SMI) are more likely to have poorer physical health and are at increased risk for premature death associated with comorbid somatic conditions such as diabetes and cardiovascular disease [1,2,3,4,5,6] Despite this heightened risk, studies have shown medical care disparities for these patients [5]. The transition from psychiatric hospitalization to community services places general practitioners (GPs) in a central position – and primary care as the first and ongoing point of contact – for many individuals with SMI This makes the interaction between GPs and patients with SMI an important locus for the study of physical health-care provisions for this population [14]. Another study reported on barriers associated with the patients (e.g. socioeconomic and psychological barriers), GPs (e.g. knowledge and personal values) and the health system (e.g. models of primary care delivery) [18]

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