Disparities in access to health care in Australia for people with mental health conditions

Objective One aim of Australia’s Equally Well National Consensus Statement is to improve monitoring of the physical health of people with mental health conditions, which includes measures of accessibility and people’s experiences of physical health care services. The present analysis contributes to this aim by using population survey data to evaluate whether, and in what domains, Australians with a mental health condition experience barriers in accessing care when compared with Australians without a mental health condition. Methods The 2016 Commonwealth Fund International Health Policy Survey includes a sample of 5248 Australian adults. Access to care was measured using 39 survey questions from before to after reaching services. Multivariable logistic regression models were used to identify disparities in barriers to access, comparing experiences of people with and without a self-reported mental health condition, adjusting for age, sex, immigrant status, income and self-rated health. Results Australians with mental health conditions were more likely to experience barriers for 29 of 39 access measures (odds ratio (OR) >1.55; P < 0.05). On average, the prevalence of barriers was 10 percentage points higher for those with a condition. When measured as ratios, the largest barriers for people with mental health conditions were for affordability. When measured as percentage point differences, the largest disparities were observed for experiences of not being treated with respect in hospital. Disparities remained after adjusting for income, rurality, education, immigrant status and self-rated health for 25 of 39 measures. Conclusion Compared with the rest of the community, Australians with mental health conditions have additional challenges negotiating the health system, and are more likely to experience barriers to access to care across a wide range of measures. Understanding the extent to which people with mental health conditions experience barriers throughout the pathway to accessing care is crucial to inform care planning and delivery for this vulnerable group. Results may inform improvements in regular performance monitoring of disparities in access for people with mental health conditions. What is known about this topic? A stated national aim of the Equally Well National Consensus Statement is to improve monitoring of the physical health and well-being of people with mental health conditions through measures of service accessibility and people’s experiences of physical healthcare services. What does this paper add? This paper highlights areas in which health services are not providing equal access to overall care for people with mental health conditions. The analysis offers quantitative evidence of ‘red flag areas’ where people with mental health conditions are significantly more likely to experience barriers to access to care. What are the implications for practitioners? Systematic attention across the health system to making care more approachable and accessible for people with mental health conditions is needed. Practitioners may be engaged to discuss possible interventions to improve access disparities for people with mental health conditions

Experiences of maternity care in New South Wales among women with mental health conditions

Background: High quality maternity care is increasingly understood to represent a continuum of care. As well as ensuring a positive experience for mothers and families, integrated maternity care is responsive to mental health needs of mothers. The aim of this paper is to summarize differences in women's experiences of maternity care between women with and without a self-reported mental health condition. Methods: Secondary analyses of a randomized, stratified sample patient experience survey of 4787 women who gave birth in a New South Wales public hospital in 2017. We focused on 64 measures of experiences of antenatal care, hospital care during and following birth and follow up at home. Experiences covered eight dimensions: overall impressions, emotional support, respect for preferences, information, involvement, physical comfort and continuity. Multivariable logistic regression was used to compare experiences of women with and without a self-reported longstanding mental health condition. Results: Compared to women without a condition, women with a longstanding mental health condition (n = 353) reported significantly less positive experiences by eight percentage points on average, with significant differences on 41 out of 64 measures after adjusting for age, education, language, parity, type of birth and region. Disparities were pronounced for key measures of emotional support (discussion of worries and fears, trust in providers), physical comfort (assistance, pain management) and overall impressions of care. Most women with mental health conditions (75% or more) reported positive experiences for measures related to guidelines for maternity care for women with mental illness (discussion of emotional health, healthy behaviours, weight gain). Their experiences were not significantly different from those of women with no reported conditions. Conclusions: Women with a mental health condition had significantly less positive experiences of maternity care across all stages of care compared to women with no condition. However, for some measures, including those related to guidelines for maternity care for women with mental illness, there were highly positive ratings and no significant differences between groups. This suggests disparities in experiences of care for women with mental health conditions are not inevitable. More can be done to improve experiences of maternity care for women with mental health conditions

Evidence of functional cell-mediated immune responses to nontypeable Haemophilus influenzae in otitis-prone children

Otitis media (OM) remains a common paediatric disease, despite advances in vaccinology. Susceptibility to recurrent acute OM (rAOM) has been postulated to involve defective cell-mediated immune responses to common otopathogenic bacteria. We compared the composition of peripheral blood mononuclear cells (PBMC) from 20 children with a history of rAOM (otitis-prone) and 20 healthy non-otitis-prone controls, and assessed innate and cell-mediated immune responses to the major otopathogen nontypeable Haemophilus influenzae (NTHi). NTHi was a potent stimulator of inflammatory cytokine secretion from PBMC within 4 hours, with no difference in cytokine levels produced between PBMC from cases or controls. In the absence of antigen stimulation, otitis-prone children had more circulating Natural Killer (NK) cells (p<0.01), particularly NKdim (CD56lo) cells (p<0.01), but fewer CD4+ T cells (p<0.01) than healthy controls. NTHi challenge significantly increased the proportion of activated (CD107a+) NK cells in otitis-prone and non-otitis-prone children (p<0.01), suggesting that NK cells from otitis-prone children are functional and respond to NTHi. CD8+ T cells and NK cells from both cases and controls produced IFNγ in response to polyclonal stimulus (Staphylococcal enterotoxin B; SEB), with more IFNγ+ CD8+ T cells present in cases than controls (p<0.05) but similar proportions of IFNγ+ NK cells. Otitis-prone children had more circulating IFNγ-producing NK cells (p<0.05) and more IFNγ-producing CD4+ (p<0.01) or CD8+ T-cells (p<0.05) than healthy controls. In response to SEB, more CD107a-expressing CD8+ T cells were present in cases than controls (p<0.01). Despite differences in PBMC composition, PBMC from otitis-prone children mounted innate and T cell-mediated responses to NTHi challenge that were comparable to healthy children. These data provide evidence that otitis-prone children do not have impaired functional cell mediated immunity

Australian Aboriginal children with otitis media have reduced antibody titers to specific nontypeable Haemophilus influenzae vaccine antigens

Indigenous populations experience high rates of otitis media (OM), with increased chronicity and severity, compared to those experienced by their nonindigenous counterparts. Data on immune responses to otopathogenic bacteria in these high-risk populations are lacking. Nontypeable Haemophilus influenzae (NTHi) is the predominant otopathogen in Australia. No vaccines are currently licensed to target NTHi; however, protein D (PD) from NTHi is included as a carrier protein in the 10-valent pneumococcal polysaccharide conjugate vaccine (PHiD10-CV), and other promising protein vaccine candidates exist, including outer membrane protein 4 (P4) and protein 6 (P6). We measured the levels of serum and salivary IgA and IgG against PD, P4, and P6 in Aboriginal and non-Aboriginal children with chronic OM who were undergoing surgery and compared the levels with those in healthy non-Aboriginal children (controls). We found that Aboriginal cases had lower serum IgG titers to all NTHi proteins assessed, particularly PD. In contrast, serum IgA and salivary IgA and IgG titers to each of these 3 proteins were equivalent to or higher than those in both non-Aboriginal cases and healthy controls. While serum antibody levels increased with age in healthy controls, no changes in titers were observed with age in non-Aboriginal cases, and a trend toward decreasing titers with age was observed in Aboriginal cases. This suggests that decreased serum IgG responses to NTHi outer membrane proteins may contribute to the development of chronic and severe OM in Australian Aboriginal children and other indigenous populations. These data are important for understanding the potential benefits of PHiD10-CV implementation and the development of NTHi protein-based vaccines for indigenous populations

Barriers to accessing primary health care: Comparing Australian experiences internationally

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain

“It's hard for me to tell my story” The experiences of Aboriginal and Torres Strait Islander male clients at a residential drug and alcohol rehabilitation centre using primary health care

Abstract Issue addressed Aboriginal males who use drug and alcohol may experience unique barriers accessing primary health care. This study explores the perceptions of Aboriginal males in treatment for drug and alcohol use around their experiences accessing primary health care, and barriers to access. Methods Twenty male Aboriginal clients at a fee‐paying residential drug and alcohol rehabilitation centre completed semi‐structured interviews about their primary healthcare experiences before their stay. Interpretative Phenomenological Analysis was used to inductively develop themes. Results About half the males had regular General Practitioners at a mainstream primary health care service or Aboriginal Medical Service. Positive experiences included having medical needs met or understanding the health information provided; and negative experiences included inefficient health service or system processes or experiencing cultural bias or racism. Barriers included limited access to appointments or to the same GP regularly, long wait times, lack of access to transport, worry or fear about their health or the visit, or their complex lives taking priority. Conclusion This research showed that the participants sought out health care and identified barriers to accessing care and potential improvements So what? Access to a regular General Practitioner, continuity of care, and culturally‐appropriate and comprehensive communication techniques are important to facilitate access to primary health care by Aboriginal males. Efforts to enhance access may focus on inherent strengths within Aboriginal communities including focusing on relationships between clinicians and families, providing a welcoming environment and encouraging clients to bring a trusted family member to appointments

Panel 6 : Vaccines

Objective. To review the literature on progress regarding (1) effectiveness of vaccines for prevention of otitis media (OM) and (2) development of vaccine antigens for OM bacterial and viral pathogens. Data Sources. PubMed database of the National Library of Science. Review Methods. We performed literature searches in PubMed for OM pathogens and candidate vaccine antigens, and we restricted the searches to articles in English that were published between July 2011 and June 2015. Panel members reviewed literature in their area of expertise. Conclusions. Pneumococcal conjugate vaccines (PCVs) are somewhat effective for the prevention of pneumococcal OM, recurrent OM, OM visits, and tympanostomy tube insertions. Widespread use of PCVs has been associated with shifts in pneumococcal serotypes and bacterial pathogens associated with OM, diminishing PCV effectiveness against AOM. The 10-valent pneumococcal vaccine containing Haemophilus influenzae protein D (PHiD-CV) is effective for pneumococcal OM, but results from studies describing the potential impact on OM due to H influenzae have been inconsistent. Progress in vaccine development for H influenzae, Moraxella catarrhalis, and OM-associated respiratory viruses has been limited. Additional research is needed to extend vaccine protection to additional pneumococcal serotypes and other otopathogens. There are likely to be licensure challenges for protein-based vaccines, and data on correlates of protection for OM vaccine antigens are urgently needed. Implications for Practice. OM continues to be a significant health care burden globally. Prevention is preferable to treatment, and vaccine development remains an important goal. As a polymicrobial disease, OM poses significant but not insurmountable challenges for vaccine development.Peer reviewe

Factors associated with multiple barriers to access to primary care: an international analysis

Abstract Background Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems. Methods In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions. Results Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care. Conclusion A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed