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RESEARCH ARTICLE
A grounded theory exploration of the
enablers and barriers of public healthcare
access for people with comorbid serious
mental and chronic physical illnesses in
Jamaica
Patrice Whitehorne-SmithID
1
*, Kunal Lalwani
2
, Robyn Martin
3
, Gabrielle Mitchell
4
,
Ben Milbourn
5
, Wendel Abel
3
, Sharyn BurnsID
1
1School of Population Health, Curtin University, Bentley, Western Australia, Australia, 2School of Global,
Urban, and Social Studies, RMIT University, Melbourne, Australia, 3Department of Community Health and
Psychiatry, University of the West Indies, Kingston, Jamaica, 4School of Public Health, University of York,
Leeds, United Kingdom, 5School of Allied Health, Curtin University, Bentley, Western Australia, Australia
*p.whitehorne-smith@curtin.edu.au
Abstract
Chronic physical illnesses (CPI) are highly prevalent among people with serious mental ill-
nesses (PWSMI) yet people in this population experience significant challenges accessing
healthcare. This study utilised a constructivist grounded theory approach to collect and ana-
lyse data related to the enablers and barriers to public healthcare access for PWSMI & CPI.
Data were collected through semi-structured interviews conducted with fifty-seven partici-
pants comprising PWSMI &CPI and their caregivers, health policymakers, primary care phy-
sicians, psychiatrists, and mental health nurses. Enablers and barriers to healthcare access
were represented using a socio-ecological model consisting of five levels: wider society,
health system, clinician, family and community, and individual. Jamaica’s free public health-
care system was the most pronounced enabler of healthcare access, while poverty, stigma,
and discrimination were the most pronounced barriers. Factors such as social support, time,
clinician beliefs, attitudes and training, and individual characteristics were identified as con-
sisting of dimensions that were both enablers and barriers to healthcare access. These find-
ings indicated that factors that influenced healthcare access for PWSMI & CPI were aligned
with the social determinants of health. Improved healthcare access for PWSMI & CPI neces-
sitates strategies that incorporate a multi-sectoral approach to address social and environ-
mental factors influencing healthcare access across all levels of the socio-ecological model.
Introduction
A growing body of evidence indicates that people with serious mental illness (PWSMI) such as
schizophrenia and other psychotic disorders, bipolar disorder, and moderate to severe depres-
sive disorders are at increased risk of developing chronic physical illnesses (CPI) [1–3]. The
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OPEN ACCESS
Citation: Whitehorne-Smith P, Lalwani K, Martin R,
Mitchell G, Milbourn B, Abel W, et al. (2024) A
grounded theory exploration of the enablers and
barriers of public healthcare access for people with
comorbid serious mental and chronic physical
illnesses in Jamaica. PLoS ONE 19(8): e0309678.
https://doi.org/10.1371/journal.pone.0309678
Editor: Samane Shirahmadi, Hamadan University
of Medical Sciences School of Dentistry, ISLAMIC
REPUBLIC OF IRAN
Received: November 13, 2023
Accepted: August 15, 2024
Published: August 30, 2024
Copyright: ©2024 Whitehorne-Smith et al. This is
an open access article distributed under the terms
of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The data associated
with this work is from an ongoing doctoral thesis.
So the data is embargoed until the approval of the
completed official thesis and all journal articles
associated with the project have been published.
After which data appropriate for public sharing will
be deposited to “Espace” the Curtin University’s
institutional repository. Also, the data contained
here reflects participant information that can be
easily identified for among a small population of
CPI most prevalent among PWSMI include cardiovascular diseases, diabetes mellitus, and
cancers [4–7]. Similarly, individuals with CPI experience increased suicidal thoughts, anxiety,
and depressive symptoms in comparison to the general population [4,8]. The co-occurrence
of serious mental illness (SMI) and CPI has been linked to their shared aetiology often result-
ing from the effects of psychotropic medications as well as the impact of social determinants of
health [5,9–13].
Social determinants of health refer to the circumstances in which people are born, grow,
work, live, and age; and the economic, social, environmental, and political forces and systems
that define and shape their experiences of daily life [14,15]. Healthcare access has been identi-
fied as an important social determinant of health, with reduced access to healthcare resulting
in poorer health outcomes, especially among PWSMI [16–18]. Moreover, healthcare access is
also affected by other social determinants such as poverty, housing instability, and limited
access to transportation, which play a significant role in the health inequalities experienced by
PWSMI [8,19].
In this study, healthcare access represents a multidimensional construct that involves both
features of the health service as well as individual characteristics that affect people’s ability to
engage and interact with health services [20,21]. Levesque et al. [20] identified five interrelated
dimensions of health service accessibility, (1) approachability (services are identifiable), (2)
acceptability (cultural appropriateness of utilising services), (3) availability and accommoda-
tion (services are reachable and able to facilitate the delivery of care), (4) affordability (whether
costs are subsidised), and (5) appropriateness of care (adequacy and quality of the health ser-
vice). The five dimensions of health service accessibility interact with five parallel individual
abilities that help to determine whether a person’s health needs are met, this consists of the
individual ability; (1) to perceive (able to recognise health needs), (2) seek (capacity to choose
to seek care based on culture and values), (3) reach (access to a means of transportation), (4)
pay (able to afford health service), and, (5) obtain care (able to participate and engage in health
decision-making) for their health need [20].
Numerous social factors have been identified as enabling or restricting healthcare access for
PWSMI [22]. For example, healthcare access for PWSMI is improved in countries that have
clear mental health policies, legislation, strategic plans, and programs [22,23]. Integrated men-
tal healthcare models, especially those that are community-based, have also demonstrated
increased healthcare access for PWSMI & CPI [19,24,25]. When clinicians (doctors and
nurses) demonstrate sound knowledge, positive attitudes, and practices towards PWSMI &
CPI and when these individuals have familial and social support, they report better healthcare
access [26–28]. Individual characteristics such as being female, possessing good health literacy,
previously accessing mental health services, and having good experience with healthcare pro-
viders also enable healthcare access among this population [29–32].
On the other hand, stigma and discrimination are recognised as the greatest barrier to
healthcare access for PWSMI globally [33,34]. Stigma is a social process that attributes nega-
tive characteristics towards a specific group based on prejudice and is often manifested as dis-
crimination [35,36]. Mental health stigma has been reported to contribute to the lack of
political will and priorisation of financial investment in mental health services and to legisla-
tive frameworks that foster discrimination and social exclusion of people with mental illnesses
[37,38]. Limited social support, social isolation, exclusion and marginalisation of PWSMI are
all associated with mental health stigma [39,40]. These experiences contribute to the self-
stigma experienced by many people living with mental illness resulting in shame, masking,
and/or poor help-seeking among this population [39,40]. Issues of stigma and discrimination
related to mental health are especially prominent in low-and-middle-income countries with
limited financial and human resources invested in mental health, resulting in wide treatment
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health workers in Jamaica. For example, one group
has a total population of five people in the country.
As this is qualitative data we deem it unethical for
this database to be shared publicly. Direct quotes
have been shared where possible in the
manuscript. All reasonable requests for access to
the study data after the embargoed period can be
made to the Curtin University Human Research
Ethics Committee (email address: ROC-
ethics@curtin.edu.au).
Funding: The author(s) received no specific
funding for this work.
Competing interests: The authors have declared
that no competing interests exist.
gaps and insufficient healthcare access for PWSMI [38]. In addition, other social determinants
of health such as poverty and poor health literacy common among PWSMI create barriers to
help-seeking and subsequent healthcare access [41–43].
Jamaica represents an upper-middle-income-country that has taken intentional steps
through the implementation of community-based mental health care that is incorporated into
primary care to improve healthcare access for PWSMI despite limited financial and human
resources [44,45]. Jamaica also allocates a little over 5% of the health budget to mental health
care, which is higher than the median reported expenditure of high and low-income countries
on mental health services [46]. Other measures implemented in Jamaica include the provision
of specialised mental health services in all hospitals and most community health centres; free
public healthcare for doctor consultations (including specialists); the inclusion of subsidised
essential pharmacological medication; and redesigning the medical school curriculum to
improve mental health competence [45–47].
Notwithstanding these improvements, the treatment and healthcare access gap for PWSMI
continues to be wide in Jamaica [46]. Research conducted in Jamaica suggests this can be
attributed to limitations in financial and human resources; effects of stigma and discrimina-
tion; clinicians’ attitudes towards mental health; as well as factors such as poverty; and low
health and mental health literacy [45,46,48–52]. However, there is an absence of research that
directly explores the enablers and barriers to healthcare access for PWSMI & CPI. This is a sig-
nificant research gap considering the outcomes associated with these co-morbidities. Further-
more, there is a paucity of mental health research in Jamaica that includes the perspectives of
PWSMI about their healthcare experience. The World Health Organisation [19,53] has called
for the incorporation of the voices of people with lived experience of mental illness, and vari-
ous relevant stakeholder in national mental health research. Research of this nature facilitates
comprehensive exploration of mental health issues that is situated in the local context, and
allows for the tailoring of intervention based on the specific needs and context of that country
[19]. Consequently, the current study sought to identify and describe the enablers and barriers
to healthcare access for PWSMI & CPI from the perspective of several stakeholder groups.
Materials & methods
Study design
A qualitative constructivist grounded theory approach guided this study [54,55]. To the best
of the authors knowledge this study was the first to explore the enablers and barriers to health-
care access for PWSMI & CPI in Jamaica, as such a qualitative approach enabled a deep and
rich exploration of the topic [56]. Charmaz [54,55] constructivist grounded theory approach
allowed for a careful, detailed and systematic process of exploration of psychological and social
processes within the context of the healthcare access. Additionally, the socio-ecological model
(SEM) was used as a conceptual framework to explore the Jamaican public health sector as a
system consisting of multilevel factors that affect healthcare access for PWSMI &CPI [57]. The
conceptual framework of the SEM guided the identification of relevant stakeholder groups and
provided context to the data analysis process and framing of the study findings. The involve-
ment of multiple stakeholder groups in the study added a level of complexity to the data analy-
sis process that could be addressed using this methodology and led to the development of a
conceptual model grounded in the study findings [58].
Setting
Jamaica is an English-speaking Caribbean island nation currently classified as an upper-mid-
dle-income country with a population of 2.82 million [59]. The most recent available estimates
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identify schizophrenia and bipolar disorder as the most prevalent serious mental illness in the
population, affecting 1.4% and 1.3% of the population respectively [60]. Most PWSMI attend
public community health centres to access health services [45]. There are 315 community
health centres located island-wide offering a range of health services through curative and spe-
cialty clinics including mental health clinics [61]. Psychiatrists and/or mental health nurses
manage mental health clinics in primary care with the support of psychiatric aides who form
the core of the mental health team; a few teams include a psychologist and/or social worker
[45]. Mental health teams engage in the screening and management of mental illnesses with a
focus on SMI, crisis management, home visits, and health promotion activities [62]. Secondary
and tertiary public healthcare is offered through 23 hospitals across the island [61]. Within the
Jamaican public health system, service users are referred to as patients; therefore the language
of this paper acknowledges this local context.
Participants
This study comprised six participant groups. The first two groups consisted of the health ser-
vice users of interest, namely; (1) PWSMI & CPI and (2) caregivers of PWSMI & CPI. The
inclusion criteria for the PWSMI& CPI were, a pre-existing SMI diagnosis made by a psychia-
trist, no reported psychiatric crisis in the past seven days, and, reported at least one CPI. For
caregivers of PWSMI & CPI, the inclusion criteria was that they had a family member whom
they provide care for with co-morbid SMI and CPI. The remaining four groups consisted of
health professionals who had varying levels of involvement in health service delivery to
PWSMI & CPI. These groups included, (3) health policymakers (HPMs), (4) primary care phy-
sicians (PCPs), (5) psychiatrists (Psychs) and (6) mental health nurses (MHNs). Inclusion cri-
teria for health professional participant groups one to four were: having a current role in the
public health system for a minimum of one year, or for Psychs, at least a final year resident in
Psychiatry. Participants from all groups were aged 18 years or older. Based on the diverse of
the participant groups, this paper uses different terms to categorise participants. The term
health professionals apply to participants from groups three to six represent all participants
working in the health system. The term clinicians is used to denote participant groups four to
six while mental health clinicians refers to participants from groups five and six.
Recruitment & data collection
Ethical approval for the study was provided through the Ministry of Health and Wellness
Jamaica’s Medico-legal Ethics Committee (2019/49), Curtin University Human Research Eth-
ics Committee (HRE 2020–0022), and the University of the West Indies, Faculty of Medical
Sciences Ethics Committee (#ECP 101, 19/20). Purposive and snowball sampling techniques
were used to recruit participants [56]. Health policymakers were purposively selected based on
their involvement with PWSMI & CPI and were recruited via direct email invitation. Psychia-
trists and PCPs were recruited through their expression of interest to a flyer circulated via rele-
vant medical associations as well as through snowball sampling. Recruitment of PWSMI &
CPI and their cargeivers was achieved through an expression of interest to a flyer circulated in
a mental health support group as well as via study sensitisation sessions conducted at eighteen
mental health clinics island-wide.
Before taking part in the study all participants who met the inclusion criteria for each group
received participant information sheets outlining details of the study and provided written
informed consent to be interviewed and audio recorded. For members of the PWSMI & CPI,
the research team who were trained Jamaican psychologists asked pre-screening questions to
capacity to provide consent by enquirying about their experience of a psychiatric crisis in the
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past seven days and their current mental health state. This method of informed consent was
approved by all three ethical committees. Non-identifying demographic information was col-
lected via a pre-interview checklist. Semi-structured interviews were conducted with the aid of
interview guides and allowed for the exploration of enablers and barriers and discussion
around unanticipated topics presented by participants [63]. Each interview guide consisted of
questions relevant to the participant group and included questions that explored aspects of
diagnoses, screening and management, enablers and barriers to healthcare access for PWSMI
& CPI as well as perceptions around the health system response to PWSMI & CPI. For exam-
ple, PWSMI & CPI were asked “what are some circumstances that have allowed you to be able
to access the care you needs for chronic physical illness?”. This question directly considered
enablers to healthcare access for CPI. They were also asked “what are some circumstances that
have made it difficult for you to access the care you needs for chronic physical illness?” as a
measure of barriers to healthcare access. All interview guides included a variation of these
question. Interviews were conducted by the lead author and lasted between 30–60 minutes.
Members of the PWSMI & CPI and caregivers groups received a mobile recharge voucher val-
ued at $500 (USD $3.50) as a token of appreciation for participating in the study. Data was col-
lected from March to November 2020. During this time, the COVID-19 pandemic was
ongoing, interviews were conduced via telephone or video conferencing in keeping with physi-
cal distancing guidelines [64].
Data analysis
Audio recordings from interviews were transcribed verbatim and where possible returned to
participants with email access for their review. A constructivist grounded theory approach was
used to guide the data analysis with emphasis on identifying and understanding emerging
enablers and barriers to healthcare access for PWSMI & CPI [55]. Data was coded using
NVivo version 14 software [65]. The full transcript for each participant was reviewed multiple
times using line-by-line coding to identify initial codes [66]. Codes were then refined into
focused codes based on case-by-case comparisons and negative case analysis within and across
the six participant groups with the aid of field notes and memos that guided the analytic pro-
cess [58,66]. The process indicated a pattern of common focused codes and then categories
across participant groups, which reflected a SEM of enablers and barriers across five levels.
Theoretical codes were then generated to integrate and synthesise the categories into themes
representing a localised grounded theory of enablers and barriers to healthcare access for
PWSMI & CPI [54,55].
To ensure the rigour of the study and data analysis process several measures were taken.
Detailed records of the study protocol, data collection and analysis were maintained through
the use of field notes and memos which safeguarded the dependability of study [58]. All tran-
scripts were transcribed and where possible shared with participants for their review and feed-
back. There was also prolonged engagement with the data, with data triangulated within and
across participant groups [56]. All codes and categories were assigned by PWS and indepen-
dently reviewed by SB and BM. The research team engaged in bracketing and frequent reflex-
ive discussions about emergent findings to ensure that interpretations were rooted in the data
and to enhance credibility and confirmability [66]. Participants were purposively sampled and
the number of participants sampled and the amount of data gathered were deemed sufficient
to meet the research objectives as codes became repetitive in later interviews ensuring the
transferability of the results [67,68]. As an added measure to secure the overall rigour of the
study findings, a six-member stakeholder reference group, consisting of health and mental
health researchers and clinicians as well as a PWSMI and a caregiver provided oversight of the
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study [69]. The stakeholder reference group engaged in meetings and discussions throughout
the data collection process, provided face validity for the study instruments and made recom-
mendations related to the study data collection process, presentation of study findings, and the
study dissemination plan.
Results
Thirteen males and 44 females (N = 57) participated in the study (Table 1). The most common
age groups were 51–60 years (n = 18, 31.5%), followed by 31–40 years (n = 14, 24.6%). Among
health professionals, most participants had worked in their current role for 6–10 years (n = 11,
37.9%) or 1–5 years (n = 9, 31%). Amongst participants in the PWSMI & CPI and caregiver
groups, primary and secondary level education was most commonly reported (n = 18, 64.2%).
The most common SMI diagnoses reported in these groups were schizophrenia (n = 16, 57%),
followed by ‘unknown’ representing those who did not know their own or their relative’s diagno-
sis (n = 6, 21.4%). The most frequently reported CPI was hypertension (n = 10, 35.7%), followed
by the combination of hypertension and diabetes (n = 7, 25%) and other CPIs (n = 7, 25%).
The enablers and barriers to public healthcare access for PWSMI & CPI identified an inter-
play of themes spanning across five categories representing five levels of a SEM (Fig 1). These
levels included: (1) Wider society—representative of cultural views and attitudes, (2) health
system—representative of the health system structure and operation, (3) clinicians—represen-
tative of clinicians’ beliefs attitudes, training, and practices, (4) family and community—repre-
sentative of social support available to PWSMI, (5) individual—representative of individual
characteristics that influence healthcare access. Themes and sub-themes are presented accord-
ing to the levels they operate at in the SEM. All themes were presented as both enablers, and
barriers except, two: cultural attitudes, and stigma and discrimination, which are solely barri-
ers. Table 2 illustrates how various enablers and barriers affect the dimensions of healthcare
accessibility at each level of the SEM.
Across all levels of the SEM
Stigma and discrimination were identified as major barriers to healthcare access that existed at
all levels of the SEM. Participants descriptions of stigma indicated interpersonal, structural
and intrapersonal stigma which resulted in discrimination. The manifestation of stigma and
discrimination negatively affected healthcare access on both the health service dimensions and
individual abilities dimension (Table 2). On the health services dimensions cultural norms
that promoted stigma and discrimination towards PWSMI & CPI reduced the acceptability of
utilising health services and the appropriateness of care provided by clinicians. Additionally,
for PWSMI & CPI stigma and discrimination negatively affected their ability to perceive, seek,
reach and engage with healthcare services due to a fear being labelled by the community or
their own family members (Table 3).
Interpersonal stigma. Participants indicated that societal beliefs and attitudes limited the
social support given to PWSMI & CPI and often resulted in their exclusion by family and com-
munity members or in PWSMI & CPI withdrawing and becoming socially isolated. Stigma
and discrimination were attributed to a general lack of awareness and understanding of mental
illness, fear, and a societal belief that PWSMI are ‘aggressive’ and ‘unpredictable’. Several clini-
cians indicated that these cultural views about mental illness mediated diagnoses of MI because
it was seen as an indication that they were “mad,” which was viewed negatively within the
community, and created social isolation.
In some communities, people who were labelled as ‘mad’ were ostracised and treated
poorly. For some family members the stigma affixed to their relative extended to them and so
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they withheld their social support as a means of distancing (Table 3). Interpersonal stigma and
discrimination towards PWSMI impeded the individuals’ ability to seek, reach, and engage
with healthcare. Participants believed that interpersonal stigma led to a delayed presentation
to mental health services by PWSMI resulting in symptom exasperation and worsened health
outcomes. This form of stigma was also seen as related to structural and intrapersonal stigma
and discrimination.
Structural stigma. Structural stigma and discrimination towards PWSMI & CPI was
identified as a feature of the public health system which manifested in: (1) policy and resource
Table 1. Participant characteristics (N = 57).
Characteristic Health policymakers
(n = 4)
Primary care
physician (n = 9)
Psychiatrists
(n = 11)
Mental health
nurses (n = 5)
PWSMI & CPI
(n = 23)
Caregivers
(n = 5)
Total
(N = 57)
%
Gender
male 2 3 2 1 5 13 22.8%
female 2 7 9 4 18 5 45 78.9%
Age group
25–30 years 3 1 4 7.0%
31–40 years 4 9 1 14 24.6%
41–50 years 1 2 1 3 6 13 22.8%
51–60 years 2 1 2 12 1 18 31.6%
Over 60 years 1 3 4 8 14.0%
Education level
Primary 6 1 7 12.3%
Secondary 9 2 11 19.3%
Vocational 5 5 8.8%
Tertiary 4 9 11 5 3 2 34 59.6%
Number of years working in role*
1–5 years 2 6 1 9 15.8%
6–10 years 1 1 9 11 19.3%
10–20 years 1 2 1 4 7.0%
over 20 years 1 1 3 5 8.8%
SMI Diagnosis** (personal
diagnosis or that of relative)
Schizophrenia 14 2 16 28.1%
Schizoaffective disorder 1 1 1.8%
Bipolar disorder 1 1 1.8%
Major Depression 1 1 2 3.5%
Schizophrenia & Bipolar disorder 1 1 1.8%
Drug induced psychosis 1 1 1.8%
Unknown 5 1 6 10.5%
CPI Diagnosis** (personal
diagnosis or that of relative)
Hypertension only 9 1 10 17.5%
Diabetes only 3 1 4 7.0%
Hypertension & Diabetes 7 7 12.3%
Other CPIs 4 3 7 12.3%
*characteristics applicable only workers in the public health system
** characteristics applicable only to PWSMI & CPI and caregivers
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allocation, (2) challenges accessing physical health services, and (3) stigma and discrimination
among healthcare clinicians and staff.
Policy and resource allocation. Participants believed that structural stigma negatively
affected government prioritisation and investment in mental healthcare, including influencing
policy frameworks: “I think stigma is the factor that affects access to care. . . stigma affects the
beginning in terms of how we’re approaching the patient. . . including even policymakers.” (Psych
#5). Structural stigma affected PWSMI & CPI, their family members as well as psychiatrists as
it influenced the allocation of resources, the placement of psychiatric services in facilities, and
even interactions with clinicians from other specialties (Table 3).
Challenges accessing physical health services. Hospital settings were noted to be the health-
care context with the highest level of structural stigma. Participants explained that PWSMI &
CPI often encountered challenges gaining entry to facilitates, receiving screening and treat-
ment to address their physical health needs, being made to wait longer than other patients for
services, and being passed off to mental health services: “once the patient is mentally ill,nothing
else counts.So even if they go there and say they have whichever other issues,the mental illness
takes prominence and nobody else remembers what the other issues are that they have.”(MHN
#3).
Stigma and discrimination by clinicians and other staff. In attempting to access healthcare
PWSMI & CPI may experience public ridicule, humiliation, and disrespect which sometimes
resulted in them leaving without receiving services and/or not returning for treatment. While
Fig 1. Socio-ecological model of enablers and barriers to public healthcare access for PWSMI & CPI. (Note: Text in white are the primary
enablers and barriers).
https://doi.org/10.1371/journal.pone.0309678.g001
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Table 2. Socio-ecological model of enablers and barriers to healthcare access for PWSMI & CPI.
Level of socio-
ecological
system
Categories Enablers Barriers Dimension of Access Affected
Across all levels Stigma and
discrimination
Interpersonal stigma Health service dimensions: Acceptability,
Appropriateness Individual abilities: ability to
seek, reach, pay and engage
Structural stigma Health service dimensions: Acceptability,
Appropriateness Individual abilities: ability to
engage
Intrapersonal stigma Individual abilities: ability to perceive, seek,
reach and engage
Wider society Negative cultural
beliefs and attitudes
Cultural beliefs and attitudes about
substance use, causes of illness,
obesity and PWSMI
Health service dimensions: Acceptability,
Appropriateness Individual abilities: Ability to
perceive, seek, reach and engage
Health system Free public
healthcare
policy and legislation for free
healthcare and mental health
Gaps in policies and guidelines
related to the screening and
management for PWSMI & CPI
Health service dimensions: Approachability,
availability and accommodation, affordability,
appropriateness
Free physical and mental health
consultations
Staffing constraints Health service dimension: Appropriateness
Individual abilities: Ability to seek, reach, pay
and engage
Co-location of primary healthcare in
community settings
Health service dimensions: Approachability,
acceptability, availability and accommodation,
affordability, appropriateness Individual
abilities: Ability to seek, reach, pay and engage
Level of socio-
ecological
system
Categories Enablers Barriers Dimension of Access Affected
Health system
(continued)
Community outreach by the mental
health team
Emphasis on the bio-medical
approach
Health service dimensions: Availability and
accommodation, appropriateness Individual
abilities: Ability to perceive, seek, reach, and
engage
Presence of multidisciplinary teams in
some settings
Health service dimensions: acceptability,
availability and accommodation,
appropriateness Individual abilities: Ability to
perceive, seek, reach, and engage
Availability of medication Health service dimensions: Affordability,
appropriateness of care Individual abilities:
Ability to pay and engage
Health system
& Clinician
levels
The impact of time
on healthcare access
Clinicians with additional training or
experience with mental illness/CPI
spend more time
Limited time as a barrier to
healthcare access in terms of wait
time for patients to be seen and
time spent with clinician.
Health service dimensions: Availability &
accommodation and appropriateness
Individual abilities: Ability to seek, and engage
Clinician Clinician beliefs
attitudes, training
and practices
Positive beliefs and attitudes towards
PWSMI & CPI improved practice
Lack of additional training and
experience in MI or CPI negatively
affected practice
Health service dimensions: Acceptability and
appropriateness of care Individual abilities:
Ability to perceive, seek, and engage
Positive beliefs and attitudes towards
PWSMI/CPI improved collaboration
between clinical teams
Clinician negative beliefs, attitudes
towards SMI or CPI management
negatively affected practice
Health service dimensions: Acceptability and
appropriateness of care Individual abilities:
Ability to perceive, seek, and engage
Positive beliefs and attitudes towards
PWSMI & CPI improved patient-
centred care and collaboration
between clinical teams
Health service dimensions: Acceptability and
appropriateness of care Individual abilities:
Ability to perceive, seek, and engage
Level of socio-
ecological
system
Categories Enablers Barriers Dimension of Access Affected
Family &
community
Social support Presence of social support as an
enabler to healthcare access
Absence of social support as a
barrier to healthcare access
Individual abilities: Ability to perceive, seek,
reach, pay and engage
(Continued)
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issues of stigma and discrimination were more commonly reported by health professionals, a
few PWSMI & CPI and family members reported instances of stigma and discrimination by
clinicians, health administrative staff, and security personnel (Table 3). In these instances,
PWSMI & CPI and their family members attributed the mistreatment to their SMI diagnosis.
These participants reported experiences where clinicians disbelieved physical health symp-
toms, and were denied access to health services.
Intrapersonal stigma. Intrapersonal stigma diminished the individual’s ability to per-
ceive, seek, reach, and engage with healthcare. Clinicians indicated that intrapersonal stigma
in PWSMI & CPI manifested as ‘denial of their diagnosis’, unwillingness to accept treatment,
Table 2. (Continued)
Individual Financial Capacity Adequate financial capacity Poverty Individual abilities: Ability to reach, ability to
pay
Individual beliefs,
attitudes
Positive beliefs, attitudes, and
experiences with health services
Gender and Education
characteristics that bar healthcare
access
Individual abilities: Ability to percieve, ability
to seek, ability to engage
Socio-demographic
features
Gender and Education characteristics
that enable healthcare access
Negative beliefs, attitudes, and
experiences with health services
Individual abilities: Ability to perceive, seek
and engage
Health literacy and
self-management
skills
Self-management skills enable
healthcare access
Individual abilities: Ability to perceive, seek
and engage
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Table 3. Illustrative quotes of themes and sub-themes represented across the socio-ecological model.
Level of socio-
ecological model
Themes Sub-themes Number of
Participants
Illustrative Quote
Across all levels Stigma and
Discrimination
34 So, there’s a lot of negative connotations attached to mental illness, psychiatry,
psychology because of how persons might be viewed in the community. . ., That’s
one big thing, Jamaicans are afraid of mental illness and the diagnosis of mental
illness. . . they’re very afraid to let anybody else. . . whether in their household, or
close relatives know about the mental illness because of what it can cause in their
work life, or personal life. (PCP #10)
Interpersonal
stigma
30 The relatives don’t like the stigma of their family member being mentally ill, so
they might not come with them to the clinic or help them take their medication.
Some prefer to know that they are on the streets than at home. (MHN #1)
Structural
Stigma
28
Policy and resource allocation:[Psychiatry] is the sort of Black Sheep or forgotten
stepsister. . . it makes it difficult for our clients to access services. . . you will
interact with clinicians in different settings and they will make statements that are
obviously indicative of holding a certain level of stigma against you. . . this
[attitude] filters down to all of the various levels of staff. So even when you’re
talking about how persons are treated and greeted when they enter an institution
by security guards, administrative staff, all of those things can end up impacting
people’s well-being and wellness. (Psych #4)
;Challenges accessing physical health services: in text
Structural
Stigma
Stigma and Discrimination by clinicians and other staff: I think the stigmatizing
that they put on the mentally ill is bad. Especially the nurses who know that mental
illness can happen to anyone at any time. . . They need to talk to the patient in a
better way and make us feel more comfortable. They should stop being impatient
with us and embarrassing us. They should not want to hurt a person who is
mentally ill.” (PWSMI # 19)
Self-stigma 11 [PWSMI] might not even wait for treatment because they are also in denial. . .they
look at it as, I’m mad, as they would call it . . . acceptance is a big issue. . .so that
leads to no follow-up, which leads to persons not taking medications. (PCP #10)
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and/or reluctance to disclose the diagnosis (Table 3). Some PWSMI & CPI explained that they
did not share their mental health diagnosis with family members, friends, and even PCPs as
they did not want to be viewed differently. These PWSMI & CPI saw mental and physical
health as separate issues: “I don’t want them (PCPs) to be biased and say okay,I guess it’s
because you’re not well [mentally],why are you asking about your prostate. . . so I treat them sep-
arately” (PWSMI #2).
Wider society
At the level of the wider society, some cultural beliefs and attitudes were identified as barriers
to healthcare access. The cultural acceptance of the use of alcohol, tobacco, and marijuana as
typical aspects of social behaviour even among health professionals was seen as mitigating
against the routine screening and management for substance misuse among PWSMI & CPI.
This served to reduce PWSMI & CPI’s access to acceptable and appropriate care that addressed
substance misuse. Likewise, a few health professionals indicated that healthcare access was
affected by cultural beliefs about the origin of SMI and CPI such as “obeah” (witchcraft).
Obeah is believed by some to be the origin of physical and mental illnesses:
“Sometimes they [patients] incorporate it into their psychosis that persons might be “obeah-
ing” [witchcraft] them to make them sick both mentally and physically so they refuse help
from doctors”(Psych #1)
These cultural beliefs and attitudes limited individuals’ ability to perceive, seek, and engage
with health services as substance misuse was either not recognised or accepted as a health con-
cern, or in the case of obeah not considered to be treatable by health professionals.
Health system
The free public health system operating at the health system level of the SEM was recognised
by the vast majority of participants as the primary enabler of healthcare access for PWSMI &
CPI.
The free healthcare system was built on policy and legislation inclusive of physical and
mental health care provision, which promoted access across primary, secondary, and tertiary
care. Even so, participants were able to identify features of the free public health system that
represented enablers as well as barriers to healthcare access for PWSMI & CPI.
Enablers in the free public health system. Participants identified four aspects of the free
public health system that enabled healthcare access these included: (1) co-location of primary
healthcare in community settings; (2) community outreach by the mental health team; (3)
availability of free medication, and (4) presence of multidisciplinary teams.
Co-location of primary and mental healthcare in community. The co-location of primary
care and mental health services within communities island-wide, facilitated the healthcare
access on the dimensions of availability and accommodation of health services to PWSMI &
CPI. This was especially true for those who lived in rural/remote areas who would otherwise
travel great distances to receive health services. It also aided easy referral of patients across clin-
ics and facilitated clinician access to shared patient records (Table 4).
Community outreach by the mental health team. Members of the mental health team engage
in community outreach activities, respond to crisis calls, and conduct home visits for patients
who have not attended their clinic appointments. The mental health teams’ home visits was
seen as a vital measure to that enhanced healthcare access on the dimensions of availability
and accommodation of health services. Home visits allowed individuals who missed their
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Table 4. Illustrative quotes from the SEM level of the health system.
Level of socio-
ecological model
Themes Sub-themes Number of
Participants
Illustrative Quote
Health System Enabler is the free
public health
system
52
Co-location of primary &
mental healthcare in
community
45 Trying to treat people as close as possible to the home. . . especially out
in the rural parts. . . the network we have, the way that’s clinics are
structured are very effective, added to that, is that we also have a
community [mental health] outreach team (MHN #1).
Community outreach by the
mental health team
25 The fact that they send person, nurses, aides, and psychiatrists, doctors
into the environment sometimes on these visits to seek out persons
who have been seen in the hospital and in the clinics to follow up on
them [works well]. (PCP #7).
Availability of medication 18 In-text
Presence of multidisciplinary
teams
12 The fact that we can have all these other members of the team
accessible if I have an issue, I can reach out to them. . . I have my social
work and [if] there’s a social issue with the patient, I can lean on that
professional. I have the psychiatrist there. . . so that works well. (PCP
#8).
Barriers in the free
public health
system
31
Limited time as a barrier to
healthcare access
29 Clinician:Most of the time they’re not adhered to [international
guidelines] and that’s the honest truth. Because in the clinic setting in
the public system, we are limited, in that we don’t have the nursing
staff at times to assist with taking the measurements that we may need.
Again, the clinic numbers may be large. Patients are outside getting
frustrated, so you want to try to move them through as quickly as you
can. (Psych #9)
Patient:It’s just the length of time that I have to wait to see the doctor
[that is difficult]. That’s the worst part because. . . it causes a lot of
pain. By the time I see the doctor, I’m in so much pain. I can’t even
think straight.” (PWSMI # 1)
Staffing constraints 26 Well, staffing is an issue. . . in order to develop good rapport with
patients and a good treatment compliance sometimes the patient
needs to see the same doctor over again for a good period of time. So,
there is an issue with frequent turnover of doctors, and they aren’t
staying there long enough and we don’t necessarily have enough staff
to do the work as well. . . as it relates to mental health, we have a
paucity of some skills in the system. (HPM # 1)
Emphasis on the bio-medical
approach
18 We give the person medication but they may not have somewhere to
live, the patient may not have food to eat and all of those are not
addressed necessarily because there’s nobody who is really looking at
those issues so the patient goes home diabetic have the right
medication but can’t eat the right food, can’t afford the right food to
eat so with that diet which is an important part of his management is
taken care of similarly with a psychiatric patient. So those support staff
mainly psychologists and social workers are really lacking and if you
have one of those in the system it helps the overall care of the patient
instead of just taking care of them in terms of their medication but
also thinking of their psychosocial needs which contributes towards
their improvement. (HPM #4)
Gaps in policies and guidelines 18 sometimes they [patients] can’t even advise you what happened either
[at the PCP appointment], they can just say I went to the doctor and
they gave me that medication and some may have brought a
prescription with them that you need to make out what it is they were
possibly diagnosed with given the medications prescribed. (Psych #1)
(Continued)
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appointments or who were in crises to access mental health and sometimes, physical health
consultation and receive medication in their homes (Table 4).
Availability of medication. Medications were often made available free of cost through gov-
ernment-operated pharmacies (DrugServ) frequently co-located at community health centres.
This aided PWSMI &CPI and their family members who could not afford medication to gain
access to treatment:: Well,I mean the Drug Serv,I go through them to get medication,so that
helps,because I can’t afford the tablets other than getting it from the Drug Serv.” (PWSMI #21).
When medications were unavailable through DrugServ, PWSMI & CPI who had govern-
ment insurance cards could obtain subsidised medication at a private pharmacies. This facili-
tated the affordability of healthcare and treatment for PWSMI & CPI.
Presence of multidisciplinary teams. Optimal healthcare access occurred in settings where
multidisciplinary teams were present, which increased the appropriateness of care provided to
patients. These teams included medical staff, dieticians as well as psychologists and/or social
workers, or when PCP worked along with the mental health team. However, this was more of
an exception than normal practice (Table 4).
Barriers to the free public health system. Participants also discussed some barriers to
healthcare access for PWSMI & CPI. These included: (1) limited time as a barrier to healthcare
access, (2) staffing constraints, (3) gaps in policies and guidelines related to screening and
management for PWSMI & CPI and (4) emphasis on the bio-medical approach.
Limited time as a barrier to healthcare access. Participants indicated that throughout the
public health service, time was an issue for both clinicians and patients due to limited staffing
and large patient volumes. Time was related to both the wait time to see patients and time
spent in consultation with patients. Health professionals recognised that having limited time
with patients resulted in inadequate screening, detection, and management of both SMI and
CPIs based on international guidelines. This decreased patients’ access to appropriate care to
address their health needs (Table 4).
From the perspective of the PWSMI & CPI and their family members, the wait time to see
clinicians was challenging. This was especially true for patients who experienced pain from sit-
ting or standing for long periods as well as the elderly (Table 4). These participant groups
described a system that was often involved waiting all-day, with patients arriving early and
leaving six to eight hours later. Waiting was not only a problem because of frustration but also
because of hunger. Several participants indicated that PWSMI and their family members often
did not have money to purchase food while they waited. Some PWSMI & CPI and their family
members accepted the system and did not ‘complain’, but a few said that waiting was a deter-
rent and resulted in them not attending appointments or delaying access to health services.
Staffing constraints. Health professionals indicated that limited staff and high staff turnover,
especially in primary care was a central barrier to healthcare access for PWSMI & CPI.
Table 4. (Continued)
Level of socio-
ecological model
Themes Sub-themes Number of
Participants
Illustrative Quote
Sometimes we find that patients might even have to change
medication even though they’re doing well on it because it’s just not
available. That in itself, deters the patient, they lack the confidence in
this new medication because they were responding so well to one and
now they’re not on it anymore. And those are some of the things that
can negatively impact the Health Care system as well as the overall
patient compliance and positive attitude towards us. (Psych #6)
Note: dominant enablers and barriers are written in bold italics
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Participants explained that PWSMI & CPI often did not have a regular doctor as PCPs rotated
between health centres. Across participant groups, the cycling of clinicians was noted as affect-
ing the dimension of access related to the appropriateness of care as it presented challenges for
rapport building, co-management, and continuity of care (Table 4).
Staffing issues existed across the public health service, particularly with limited specialised
staff. Some mental health teams did not have an assigned psychiatrist, especially in rural or
remote areas and many did not have a PCP that worked with their team.
Gaps in policies and guidelines related to the screening and management for PWSMI & CPI.
Although the presence of policies and guidelines related to mental health care enables some
access, gaps in these policies and guidelines created barriers to healthcare access, especially
related to the appropriateness of care received by PWSMI & CPI. The lack of clear co-manage-
ment guidelines for SMI & CPI resulted in role ambiguity among PCPs and Psychs regarding
the level and type of responsibility for the physical health of these patients. This created incon-
sistent practices in the screening and management of PWSMI & CPI.
Additionally, a lack of structured engagement and communication protocols between PCPs
and mental health teams resulted in clinicians primarily relying on patients to transfer infor-
mation. Several health professionals indicated that sometimes this method was ineffective, as
patients may be unsure of their diagnosis or the name of prescribed medication, resulting in
clinicians making assumptions or uninformed decisions when prescribing medications
(Table 4).
This was a substantial concern when patients utilised health services other than their com-
munity health centres such as hospitals or clinics in other areas. In these circumstances, clini-
cians were unable to access patient records due to the lack of a centralised electronic database
of patient records within the public health system.
Emphasis on the bio-medical approach. Participants reflected on the bio-medical approach
that focused on the role of doctors and nurses with limited attention to the contribution of
allied health professions in improving the healthcare access and outcomes for PWSMI & CPI
(Table 4). Additionally, clinicians indicated that over-reliance on medication as the only treat-
ment for PWSMI & CPI coupled with inconsistent medication supply sometimes resulted in
sub-optimal treatment. Shortages of medications led to new prescriptions which created chal-
lenges for the clinician-patient relationship and patient attitudes towards treatment and com-
pliance (Table 4). These factors reduced the appropriateness of care provided to PWSMI &
CPI who also felt there were few alternatives to treatment provided to them outside of
medications.
Clinician
At the clinician level, the training and experience of clinicians influenced their beliefs and atti-
tudes about the management of PWSMI & CPI. This in turn shaped their practices and
affected whether their response to patients presented as enablers or barriers to the accessibility
of acceptable and appropriate healthcare.
Clinician related factors that enable healthcare access. Participants discussed three cli-
nician related factors that were enablers of PWSMI & CPI healthcare access, namely: 1) posi-
tive beliefs and attitudes towards PWSMI & CPI improved practice, 2) clinicians with
additional training or experience with mental illness or CPI who spend more time in consulta-
tion, and 3) positive beliefs and attitudes towards PWSMI & CPI improved collaboration
between clinical teams.
Positive beliefs and attitudes towards PWSMI & CPI improved collaboration between clinical
teams. Clinicians with positive beliefs and attitudes towards PWSMI & CPI were more likely
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to report good relationships and higher levels of collaboration between PCPs and the mental
health team. This improved healthcare access for patients on the dimensions of approachabil-
ity and appropriateness of the health service. Some health professionals expressed that when
communication channels were open and dialogue was ongoing between PCPs and the mental
health team, patients received better access and quality of care because there was a sense of rec-
iprocity between teams and a better platform for patient advocacy: “I think when you have a
good rapport with your colleagues. . .they send their patients and you be an ally for them [their
patients],then they would be more willing to see your patients and care for them also.” (Psych
#7).
Clinicians with additional training or experience with mental illness/CPI who spend more
time in consultation. Time was previously noted as a major barrier however, the barrier of time
was reduced among PCPs with additional training in mental health or previous experience
working directly with the mental health team (Fig 2). In their practice, these PCPs reported
screening and initiating treatment for mental illness, spending more time with PWSMI and
following up on both the mental and physical health of patients. When giving referrals to the
mental health service, these PCPs spent time explaining the reason for referral and encourag-
ing patients to attend clinic appointments: “I feel that every interview I should be able to add
value to patients and can add a lot of value from counselling a lot of social barriers does exist so I
tend to ask about what’s happening.” (PCP #8). Similarly, Psychs who had previous experience
working in physical health care before pursuing Psychiatry reported spending more time
enquiring about and investigating the physical health concerns of their patients with PWSMI.
Positive beliefs and attitudes towards PWSMI & CPI improved practice. Primary care physi-
cians who expressed positive beliefs and attitudes towards the treatment of PWSMI indicated a
greater understanding of mental illness, the bidirectional nature of mental illness and CPIs,
and expressed greater investment in rapport with patients. Likewise, all mental health nurses
(MHN) believed that monitoring physical health in PWSMI was a part of their role. Psychia-
trists who reported being comfortable with managing physical illnesses stated that the physical
health of patients was a part of their role and responsibility. They expressed that taking a holis-
tic approach offered greater benefits to patients but required more time, effort, and vigilance
(Table 5).
Fig 2. Time as an enabler and barrier to healthcare access across the levels of the health system and clinician.
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Clinician related factors that act as barriers to healthcare access. Two clinician related
factors were discussed as barriers to healthcare access for PWSMI & CPI: (1) Clinician negative
beliefs, and attitudes towards SMI or CPI management negatively affected practice, and (2)
lack of additional training and experience working in mental illness or CPI negatively affected
practice.
Clinician’s negative beliefs and attitudes towards SMI or CPI management negatively affected
practice. Health professionals indicated that negative beliefs and attitudes towards SMI were
pervasive in the public health sector (Table 5). Among PCPs, those who believed PWSMI were
‘unpredictable’ expressed ‘discomfort’ treating them unless they were ‘stable’. These PCPs
tended to immediately refer patients with suspected mental illnesses, often without conducting
detailed screening and medical investigations. Likewise, Psychs who believed that physical
health care was outside their scope stated that they would not routinely screen or monitor
physical health problems or CPIs and would refer patients who presented with those concerns
to PCPs or other specialists.
Clinicians in this category also indicated poorer communication and collaboration between
PCPs and mental health teams with each team treating PWSMI & CPI separately. This
approach negatively affected PWSMI & CPI access to appropriate healthcare that would facili-
tate early detection and treatment of developing mental or physical illnesses.
Table 5. Illustrative quotes from the SEM level clinician.
Level of socio-
ecological
model
Themes Sub-themes Number of
Participants
Illustrative Quote
Clinicians Clinician related factors
that enable healthcare
access
28
Positive beliefs and attitudes towards
patients improved practice
24 It does require more effort and vigilance. It’s positive
because if you are effective in treating the whole person
then that client has more of a trust in your ability to treat
their mental illness as well. The family will have more trust
in your ability to be clearly on the client side for their well-
being. So they will see the care and consideration put forth,
that maybe, is perhaps a breath of fresh air, when they
compare it to other experiences they’ve had where they just
feel rushed along and passed on. (Psychs #2)
Clinicians with additional training/
experience spend more time
14 In-text
Positive beliefs and attitudes towards
patients improved collaboration
10 In-text
Clinicians Clinician related factors
that act as barriers to
healthcare access
25
Clinician’s negative beliefs and
attitudes towards SMI or CPI
management negatively affected
practice
22 I think there’s a lot of discomfort or let me call it
discomfort amongst all our primary care physicians around
mental health in general and it’s not something that
persons. . ...They’re not comfortable with it and as such
they either don’t screen for it or they don’t recognize that
this is why the patient is/maybe not compliant. (HPM #1)
Lack of additional training and
experience in MI or CPI negatively
affected practice
13 . . .patient would knock on your door. You’re not a
psychiatrist and based on their interactions you would pick
up that there’s something mentally wrong with them but as
far as you’re concerned your hands off because you don’t
have any mental health training and you don’t really make
an appropriate referral and as a result it does a disservice to
both you and the patients. (PCP # 9)
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Lack of additional training and experience in MI or CPI negatively affected practice. Accessi-
bility to appropriate healthcare was negatively affected by PCPs who indicated their reluctance
to undergo screening and initiate management of mental illness due to a lack of knowledge,
confidence, and understanding about mental illness (Table 5). Likewise, Psychs who were
reluctant to undergo screening and initiate management of CPIs associated this with a lack of
current knowledge on the procedures and treatments for CPIs: “I don’t feel kind of very com-
fortable in starting the process.I will,but I don’t feel like I’m up to date in the different criteria”
(Psych #7).
Family & community
At the level of family and community, access to healthcare was affected by the amount of social
support available to PWSMI & CPI. Social support existed in the form of family, friends,
church members, neighbours, and community members. The presence or absence of social
support was related to the individual abilities aspect of healthcare access.
The presence of social support as an enabler of healthcare access. The presence of social
support enabled healthcare access for PWSMI & CPI. Social support was explained in the form
of financial, physical, emotional, and/or spiritual support. Financial support included money
for transportation for appointments and to purchase medication and food. Physical support
consisted of accompanying PWSMI to the clinic, advocating for care, and aiding with treat-
ment compliance. Emotional support involved check-ins, listening to concerns, providing
encouragement, and demonstrating concern for their well-being. Spiritual support related to
facilitating PWSMI & CPI’s church attendance and praying for their wellness (Table 6).
Among PWSMI & CPI, those who had social support whether family, friends, or commu-
nity support also stated that managing their comorbidities was ‘easy’ and they experienced bet-
ter healthcare access. Social support helped to address aspects of all five individual abilities that
contribute to healthcare access as it allowed PWSMI & CPI to be able to perceive, seek, reach,
pay, and engage with health services.
The absence of social support as a barrier to healthcare access. When social support
was absent, this presented a dominant barrier to healthcare access for PWSMI & CPI. Those
who reported limited or no social support also reported poorer health and expressed that it
was ‘difficult’ to manage their conditions. The lack of social support reduced PWSMI & CPI’s
ability to perceive, seek, reach, pay, and engage with healthcare. This was true among the
elderly and those who lived alone, lived far away from family, or did not have family or other
social support (Table 6).
Table 6. Illustrative quotes from the SEM level of family & community.
Themes Sub-
themes
Number of
Participants
Illustrative Quote
The presence of social support as an
enabler of healthcare access
32 I have a friend of mine who is like a prayer partner that we pray every Sunday over the
phone and they pray for my needs and I pray for their needs so there is moral support there.
Financial support, there are some friends that have been very helpful over the years and they
continue to help me. . . (PWSMI #2).
The absence of social support as a
barrier to healthcare access
27 The elderly are coming to the Health Centre alone so that is something that does affect care
because if a diabetic who is on insulin [is] not taking their correct insulin because they can’t
see properly they don’t have anybody to give it to them- that’s an issue. That affects care for
that patient, so a lack of a support system and also resources, if you don’t have resources that
always challenges the care that you can get the patients. (PCP #8)
Note: dominant enablers and barriers are written in bold italics.
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Individual
At the individual level, several individual characteristics act as enablers or barriers to PWSMI
& CPI’s ability to perceive, seek, reach, pay, and engage with healthcare.
Individual characteristics that enable healthcare access. The individual characteristics
that facilitated healthcare access for PWSMI & CPI included: (1) being female and/or having
completed higher education levels, (2) positive beliefs, attitudes, and experiences with health
services, (3) adequate financial capacity and (4) possessing adequate self-management skills.
Being female and/or having higher education. Across participant groups, it was noted that
females and people with higher levels of educational attainment experienced better healthcare
access. Participants attributed this to having health literacy and the willingness to seek help
(Table 7).
Positive beliefs,attitudes,and experiences with health services.PWSMI & CPI and caregivers
who had positive sentiments about the public health system tended to report greater healthcare
access. The relationship between PWSMI & CPI and clinicians was also important to healthcare
access, with good relationships facilitating trust and greater treatment adherence. This worked
especially well in settings where clinicians were familiar with patients and their circumstances
and took steps to accommodate them (Table 7). These PWSMI & CPI expressed gratitude for
free healthcare services and most reported easy engagement with healthcare services.
Adequate financial capacity. Among PWSMI & CPI, those who had financial resources
whether through employment or social support were able to reach and pay for costs of trans-
portation to attend their appointments, purchase food and medication as needed, and provide
for their basic needs (Table 7).
Possessing adequate self-management skills. A few participants in the PWSM & CPI indi-
cated that they self-managed and independently followed through on treatment directives. “I
am very much able to monitor myself,I can do it myself.” (PWSMI #11). Self-management skills
enhanced their ability to perceive, seek, and engage with healthcare, thus improving their
healthcare access. The ability to self-manage was complemented by a belief in the benefits of
medication for treating their comorbidities. For others, self-management was aided by their
‘faith’ in God. Other PWSMI & CPI indicated that social support enabled their self-manage-
ment activities.
Individual characteristics that act as barriers to healthcare access. Individual factors
that inhibit healthcare access included: (1) poverty; (2) Being male and/or having lower educa-
tional attainment, and (3) negative, beliefs, attitudes, and experiences with health services.
Poverty. Across all participant groups, poverty was recognised as the main barrier to health-
care access for PWSMI & CPI. Most PWSMI & CPI in the study indicated that they were
unemployed and lacked adequate financial resources to meet their needs. Health professionals
indicated public health services are primarily accessed by people from lower socio-economic
status because they cannot afford private healthcare which is usually considered as preferred to
public healthcare (Table 7).
Participants indicated that poverty affected healthcare access directly and indirectly.
Directly and as previously noted, PWSMI & CPI who lacked financial resources, were often
unable to pay the costs of transportation or food for the day at the clinic. In addition, because
physical and mental health clinics often took place on different days in the community health
centres, patients could not afford to attend both clinics and would select one, but not both. If
medication was not freely available, many PWSMI went without. This was true even for those
with government insurance cards who had to pay very little for the medication (Table 7).
The experience of poverty resulted in some PWSMI & CPI being homelessness, having
unstable residences, or having a home but living in poverty. They could not afford to adhere to
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medical advice related to nutrition and self-care because they could not afford healthy foods
and other necessities. Consequently, poverty indirectly affected healthcare access as it
obstructed PWSMI & CPI’s ability to reach, pay, and engage with healthcare services. While a
few PWSMI & CPI were able to access government welfare assistance programs to help with
their basic needs, others were unsure of how to access help. This situation was exacerbated by
the COVID-19 pandemic, which led to some PWSMI & CPI and/or their relatives who sup-
ported them losing their jobs, driving some patients into greater poverty.
Being male and /or having lower educational attainment. Across clinician groups, PWSMI
& CPI who were males and those had limited education, including not completing school,
Table 7. Illustrative quotes from the SEM level of the individual.
Level of socio-
ecological model
Themes Sub-themes Number of
Participants
Illustrative Quote
Individual Individual characteristics that
enable healthcare access
23
Being female and/or having
completed higher education
levels
17 Well [regarding] the educational level, those that are more
educated most times I think those persons with tertiary
education, tend to be more aware of it [CPI]. I think those
who have a higher education level, tend to be more vocal as it
relates to their underlying illness. So maybe I don’t know if it’s
because they are talking more about it, why it was picked up
more. . . as opposed to seeing someone who is not as
educated, somewhat illiterate, but just know that they have a
mental illness and just coming in for that. (Psych # 6)
Positive beliefs, attitudes, and
experiences with health services
12 “Whenever I have the [clinic appointment] date and I have to
be at work. . . I would explain it and they would look after me
and the nurse there, she would call and get my medication for
me and bring them for me because I work a little way from
her [where she lives]. (PWSMI #14)
Adequate financial capacity 10 I don’t really have to depend on somebody and because I
work, I am not so stressed to manage the diabetes. So, it really
doesn’t affect me very much because as long as I am on my
medication, I am okay. (PWSMI # 23)
Possessing adequate self-
management skills
8 In-text
Individual characteristics that
act as barriers to healthcare
access
51
Poverty 48 Clinician:If you’re working in a public system, you know, the
type of persons you’re going to encounter are from less
fortunate type of social economic background and possibly
doesn’t have the same type of financial resources to allocate to
private care. (Psych #5).
Patient:It’s difficult, because sometimes I have to buy the
medications and. . . [my] husband not working. . . and I just
doing a part time job, with the [government insurance card]
NHF card I only have to pay $200 [$1.30 USD] for it but
sometimes I don’t have the money. (PWSMI #4)
Being male and /or lower
education
11 In-text
Negative, beliefs and attitudes
towards and experiences with
health services
9 The issues are if you have a mental illness and a physical
illness depending on how acute the physical illness is, you’re
going to suffer. If you have a mental illness, you are not an
easy patient, you’re going to give trouble and people don’t
want trouble. People get very impatient with you, as a
mentally ill person who has a physical illness. (Caregiver #1).
Note: dominant enablers and barriers are written in bold italics.
https://doi.org/10.1371/journal.pone.0309678.t007
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were seen to have lower health literacy and awareness, and be less likely to perceive healthcare
needs, seek help, and engage with health services before symptoms were uncontrolled:“. . .men
in Jamaica have poor health seeking behaviour so majority of the clinics are dominated by
women” (PCP #4).
Negative,beliefs and attitudes towards and experiences with health services. A few of the
PWSMI & CPI and caregivers expressed being mistrustful of the health system. They felt that
clinicians were hurried or disinterested in them and or did not feel their prescribed psychiatric
medication was helpful. This negatively affected their ability to engage with health services.
Others reported negative experiences with clinicians and administrative staff in the health sys-
tem, marked by a lack of competency, empathy, and patience (Table 7).
Discussion
The findings of this study identify five levels of a socio-ecological model that included enablers
and/or barriers to public healthcare access for PWSMI & CPI in Jamaica. The primary enabler
of access reported across all participant groups was the free public healthcare system as it pro-
vided a policy framework for physical and mental healthcare, community-based co-located
mental and physical primary healthcare services, community outreach for PWSMI & CPI, and
no-cost medication. In this way, it helped to address some issues of healthcare approachability,
availability and accommodation, affordability and appropriateness of health services as it
allowed PWSMI & CPI to obtain consultancy and treatment for their health concerns close to
their homes [20,22].
Despite the benefits of a free healthcare system, poverty, followed by stigma and discrimina-
tion were identified as the most pronounced barriers to healthcare access for PWSMI & CPI.
This finding reflects other international studies, which highlight the commonplace nature of
poverty among PWSMI [70,71]. Poverty and mental illness have been found to have a bidirec-
tional relationship [41]. People who grow up in poverty are more prone to develop mental ill-
ness due to poor environmental conditions [41,72]. On the other hand, people from middle
or upper-income brackets who develop mental illness are likely to descend into poverty due to
changes in the capacity to work as well as due to the effects stigma, discrimination, social isola-
tion and exclusion [41,72]. Although poverty was presented as an individual characteristic in
the SEM, it is understood that poverty is a complex and multidimensional social issue that is
also associated with stigma and discrimination [70]. For instance, our findings indicated that
most PWSMI &CPI had lower education levels and were unemployed and reported having no
sustainable means to take care of themselves. Thus, although healthcare services were free and
deemed affordable, they still were not consistently accessible to the poorest of the poor in this
patient population. Additionally, lower educational attainment is common among people who
experience poverty and has been linked to lower levels of health literacy and negative health
beliefs and attitudes towards healthcare resulting in delayed utilisation of health services [73].
However, the availability of social support was found to improve healthcare access for
PWSMI & CPI in this study. Positive participation of social support improves healthcare access
for PWSMI &CPI [26,74]. In the context of low material resources, people may tap into social
support as a means of accessing needed resources [26]. Yet, the benefits of social support
extended beyond financial resources in this study and were physical, emotional, and spiritual
and aided individuals’ ability to access healthcare in various ways.
In contrast, a connection was found between PWSMI & CPI having a lack of financial
means, perceiving their comorbidities as difficult to manage, feeling isolated and the absence
of social support in this study. Other literature has identified this pattern and has demon-
strated a connection between poverty, social exclusion, and isolation experienced by PWSMI
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to stigma and discrimination [70,75]. Our findings indicated that stigma and discrimination
were reported to exist across all levels of the socio-ecological system represented as interper-
sonal, structural, and intrapersonal stigma. Stigma and discrimination toward PWSMI have
been described as enforcing and re-enforcing marginalisation and social exclusion [33,70].
Thus serving to perpetuate health inequalities for PWSMI and result in delayed utilisation of
health services, diagnostic overshadowing, poorer screening and management of health con-
cerns which leads to underdiagnoses of CPIs and poorer health outcomes [76,77]. These find-
ings suggest the need for the development of strategies that can address issues of poverty that
interplay with stigma and discrimination to directly and indirectly hinder healthcare access for
this vulnerable population.
Some health system factors further contributed to reducing healthcare access for PWSMI
&CPI. For instance, the emphasis on the bio-medical approach was seen as a barrier to the
accessibility of appropriate healthcare. The bio-medical approach has been criticised for its
lack of recognition and attention to social and environmental factors in creating, maintaining
and worsening the health care access and negative health outcomes of PWSMI & CPI [70].
The application of a bio-medical approach to a complex socio-ecological system serves to
affirm a health system focus on individual symptom reduction and medical maintenance [70].
This is central finding of the study considering that poverty, stigma and discrimination and a
lack of social support were the primary barriers to healthcare access, which are all social deter-
minants of health recognised to perpetuate health inequalities among PWSMI & CPI [41].
Furthermore, the bio-medical approach relies predominantly on physicians and nurses to
provide health services. Participants indicated that limited staff and high patient volume
extended the wait time for patients to be seen and reduced the time clinicians spent in consul-
tation. This can present substantial limitations to health service delivery especially in the con-
text of limited resources [78]. It also has clear implications for screening, early detection and
treatment of patients’ health concerns which is especially important when managing patients
with comorbidities or complex disabilities [79]. However, clinicians who had more training or
experience with mental illness/CPI spent more time with patients and were considered to have
better attitudes and practices related to the care of PWSMI & CPI. When clinicians display
interest in holistic care, demonstrate competency around mental health and physical health
and engage in screening and management procedures, access and outcomes are improved for
PWSMI [27,28,42]. These findings highlight the importance of additional training and expe-
rience in reducing stigma and discrimination and improving the competencies and practices
of clinicians working with this patient population and enhancing healthcare access for PWSMI
& CPI [80–82].
Nevertheless, the shortfalls of the bio-medical approach were still pronounced as clinicians
who expressed confidence and competence in managing PWSMI & CPI were in the minority
and even then, they acknowledged their limitations in addressing the social and environmental
needs of patients. Additionally, the bio-medical approach has been viewed as fostering frag-
mentation of health through over specialisation, over reliance on medication as treatment, a
lack of holistic care, ongoing paternalistic relationships between doctors and patients that dis-
empower individuals and reduce their right and opportunity for self-direction and self-advo-
cacy around their healthcare preferences [83,84].
Contemporary approaches to mental healthcare such as the social model of health and
recovery-oriented approaches may improve healthcare access and outcomes for PWSMI &
CPI [53,85,86]. These approaches support the inclusion of multidisciplinary teams; some-
thing highlighted as improving healthcare access by some participants in this study. Indeed,
best practice guidelines for the treatment of PWSMI & CPI recommend the involvement of
multidisciplinary teams [19]. These contemporary approaches also reduce the burden of care
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for medical practitioners, help to address social aspects of healthcare, emphasising the empow-
erment of PWSMI & CPI towards self-management through psycho-education, and skill
building to experience better health and quality of life [86–88].
The findings of this study suggest the need for a reconceptualisation of healthcare access for
PWSMI & CPI in Jamaica to build on areas of strength and to develop strategies that address
the barriers that exist across the SEM. The challenges that affect healthcare access for PWSMI
& CPI are extend beyond the health sector and require the involvement of multi-sectoral stake-
holders to ensure strategies are impactful and sustainable [89]. Within health service delivery,
there is a need for a graduation from co-location of services towards further integration of
mental health care with the inclusion of more multidisciplinary teams (with social workers,
psychologists and occupational therapies), better co-ordination and collaboration of clinicians
and person-centred care to meet the healthcare access needs of PWSMI & CPI [90].
Strengths & limitations
A constructivist grounded theory approach was utilised in this study to allow for a comprehen-
sive exploration of enablers and barriers to public healthcare access for PWSMI & CPI. Purpo-
sive sampling was used to identify key participant groups that could provide meaningful
insight into the research area [91]. The findings of the study are situated in the context of the
time, place and culture of Jamaica and were representative of this setting [55]. However, only
the perspectives of selected health professionals were considered in the study, inclusion of
other health professionals such as nurses, and administrative staff would have enhanced these
findings. Additionally, interviews were conducted via telephone or video conferences and
therefore people without access to this technology were not able to take part in the study.
Conclusion
The enablers and barriers to healthcare access for PWSMI & CPI have been found to exist
across a five-level SEM. The provision of free public healthcare and primary healthcare
through community-based co-located mental and physical health services represented the
main enabler to healthcare access for this population. However, issues of poverty, stigma, and
discrimination were identified as formidable barriers to healthcare access and reduced the
effectual gains made by other enablers. Given the socio-cultural basis, the current bio-medical
approach to healthcare was deemed inadequate to help PWSMI &CPI overcome the barriers
they experience to healthcare access particularly in the realm of the social determinants of
health. There is a clear need for the identification of strategies that address the barriers to
healthcare access across the SEM, this would likely include a reconceptualisation of the current
healthcare approach as well as incorporate multi-sectoral approaches that span beyond the
health sector. There is also a need for further research that expands beyond healthcare access
for PWSMI & CPI to exploring quality of life and health outcomes for this vulnerable
population.
Supporting information
S1 Questionnaire.
(DOCX)
Acknowledgments
We wish to thank the members of the stakeholder reference group and all the study
participants.
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Author Contributions
Conceptualization: Patrice Whitehorne-Smith, Kunal Lalwani, Robyn Martin, Ben Milbourn,
Sharyn Burns.
Formal analysis: Patrice Whitehorne-Smith, Kunal Lalwani, Robyn Martin, Ben Milbourn,
Wendel Abel, Sharyn Burns.
Methodology: Patrice Whitehorne-Smith.
Project administration: Patrice Whitehorne-Smith.
Supervision: Robyn Martin, Ben Milbourn, Wendel Abel, Sharyn Burns.
Visualization: Patrice Whitehorne-Smith.
Writing – original draft: Patrice Whitehorne-Smith, Kunal Lalwani, Gabrielle Mitchell.
Writing – review & editing: Patrice Whitehorne-Smith, Robyn Martin, Gabrielle Mitchell,
Ben Milbourn, Wendel Abel, Sharyn Burns.
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