Access to care among older adults with mental health problems : measurement, inequity, and the impact of a task-shifting approach

Abstract

Access to mental health care in old age is a global challenge; most people living with dementia or late-life depression are untreated. With population ageing and increasing awareness, a surge in demand is expected in future years. Evidence is needed on effective strategies to ensure adequate and equitable access to appropriate care and services. Task-shifting is a potential strategy, but existing evaluation is limited by methodological challenges, including a lack of conceptually valid measures of access. This thesis comprises three studies to investigate: (1) how access can be quantified based on existing conceptualizations; (2) provider and user factors contributing to inequities in access, using dementia intervention as context; and (3) the association between task-shifting and access, using a task-shifted service for late-life depression as a case study. Study 1 is a literature review on the concept of access and its operationalization to identify discrepancies and recommend best practice. After systematically screening 1,304 records, sixteen reports providing theoretically guided measures were reviewed and synthesized. Current literature conceptualizes access as the fit between care system characteristics and people’s needs, identifying six dimensions: availability, spatial accessibility, accommodation, affordability, acceptability, and timeliness. Only seven studies explored multidimensional fit, using a correlation between subjective and objective indicators, comparison among providers, and multilevel models of provider characteristics. Applying weights to the six dimensions and using both subjective and objective indicators are recommended in future standardized measures of access. Study 2 is a cross-sectional study of prescription patterns of non-pharmacological interventions in people with mild cognitive impairment or dementia receiving care in 28 memory clinics in mainland China (n=889). Multilevel logistic regression was used to identify factors associated with prescription inequity. Overall, only 36.3% of participants received prescriptions. Among those considered as having a need but who received no prescription, ‘declined by user/carer’ was the main reason for not prescribing. Greater caregiving gain, lower burden, worse dyad relationship, and family history of dementia are user factors associated with prescription, while within this model, 73% of the variance was attributed to hospital characteristics. Study 3 is a survey applying a weighted multidimensional measurement based on Study 1 to test differences in perceived access among older people who are current or potential users of task-shifted or traditional services for depression (n=167). Analytic hierarchy process analysis showed that timeliness was the highest-weighted dimension. Multiple regression showed that task-shifting correlated with better access. Mediation testing showed that task-shifting mediated the association between inequitable factors (living alone, more severe symptoms) and access dimensions (availability, accommodation). Factors contributing to inequity in accessing mental health care in old age can occur at different levels and be both user- and provider-related. A theory-based multi-dimensional measure of access will allow advances in strategies to improve access. Task-shifting can potentially improve access by mediating certain inequitable factors in access.