Relationship between people with severe mental illness and primary care

This study explores the relationship between people with severe mental illness and primary care, focusing on barriers to care and potential solutions. It utilizes qualitative interviews with mental health nurses, primary care providers, and patients with severe mental illness. The study identifies factors such as poor access to care, untrained specialists, communication difficulties, patient limitations, and quality of care. The findings suggest the need for improved access to medical care and integration of mental health and primary care. Further research is recommended to explore the perspective of providers in primary care.

Relationship between people with severe mental
illness and primary care: A mixed method study to
examine ways to improve the contact and
information

Acknowledgement
It gives me immense pleasure to finally present my dissertation “Relationship
between people with severe mental illness and primary care: A mixed method
study to examine ways to improve the contact and information”. This research
topic has helped me to gain ample knowledge in this field of study. I wish to
extend my most sincere gratitude to all those who helped to make this dissertation
a reality. I am especially grateful to my supervisor who helped me extensively in
this study. I would like to also extend my gratitude to all my friends and classmates
whose assistance proved to be milestone in accomplishing my final goal. I
acknowledge their constant support in the fulfillment of this dissertation. Needless
to say, I alone am responsible for any shortcomings in this project.

Abstract
Even there is relationship of primary care with severe mental illness patients exist,
still person with severe mental illness are more likely to be undertreated and seek
care in emergency ward. The goal of this study is to obtain the in-depth details of
barriers to primary care for people with SMI and to provide the solutions to these
barriers. In this qualitative interview’s method are used to interview the mental
health nurses or primary care as well as patient with SMI. Several factors reported
in this research like poor access to care, untrained specialists, communication
difficulties, patient limitations, and quality of care. In results, Nursing professional
needs to improve the continue access the medical care of this patients and as well
as continue to integrate the mental health and primary care. The process of
engagement such as mattering, being perceived as capable, working together.
Further research should explore the relationship in primary care with SMI people
from the prospective of the providers. As per this, there are quantitative method are
used in this. Thus, this helps to provide the significance of the statistic. The
numerical data are evaluated in order to create the evidence based data. This data
used to provide the epidemiological preset data.

Table of Contents
Chapter 1: Introduction...............................................................................................................................7
1.1 Chapter Introduction.........................................................................................................................7
1.2 Aims and Objectives..........................................................................................................................7
1.3 Background and rationale of the study..............................................................................................8
1.4 Severe mental illness.........................................................................................................................9
1.5 Review of literature.........................................................................................................................14
Chapter 2: Research Methodology............................................................................................................16
2.1 Chapter Introduction.......................................................................................................................16
2.2 Philosophical aspects.......................................................................................................................16
2.3 Research Approach..........................................................................................................................18
2.4 Type of research..............................................................................................................................19
2.5 Research process.............................................................................................................................19
2.6 Research design...............................................................................................................................20
2.7 Research strategy............................................................................................................................21
2.8 Research Choice...............................................................................................................................21
2.9 Data collection.................................................................................................................................21
2.10 Sample techniques and size...........................................................................................................22
2.11 Inclusion and exclusion criteria......................................................................................................23
2.12 Bias and limitation of the study.....................................................................................................24
2.13 Ethical consideration.....................................................................................................................24
2.14 Chapter summary..........................................................................................................................25
Chapter 3: Data presentation, analysis & findings.....................................................................................25
3.1 Sample.............................................................................................................................................25
3.2 Procedure........................................................................................................................................29
3.4 Semi structured interview questions...............................................................................................30
3.5 Data analysis plan............................................................................................................................31
3.6 Findings............................................................................................................................................31
Chapter 4: Discussion................................................................................................................................36
Chapter 6: Conclusion & recommendations..............................................................................................40

6.1 Conclusion.......................................................................................................................................40
6.2 Recommendations...........................................................................................................................40
References.................................................................................................................................................41

Figure 1 Proportion of patients in 5 countries...........................................................................................11
Figure 2 research methodologies used......................................................................................................16
Figure 3 Types of research philosophy......................................................................................................17
Figure 4 Research design process flow......................................................................................................20
Figure 5 Inclusion and exclusion Criteria...................................................................................................23
Figure 6 Gender of participants.................................................................................................................26
Figure 7 Age of Participants.......................................................................................................................26
Figure 8 Ethnicity of Participants...............................................................................................................27
Figure 9 Participants marital status...........................................................................................................28
Figure 10 Participants educational background.........................................................................................29
Figure 11 finding Categories......................................................................................................................32

Chapter 1: Introduction
1.1 Chapter Introduction
Literature review is a systematic process in which the recent scholarly papers are
reviewed so that the study or research can be done in effective manner. In this
chapter, researcher discussed about the mental disorders in primary care. Also,
symptoms and diagnosis of mental health has been mentioned. Also, researcher
reviews some literature and discussed in this chapter. Lastly, significance, rationale
of the study, gap in literature has been mentioned (Mantovani 2020).
1.2 Aims and Objectives
According to the (Hardy & Gray, 2010)It is the duty of healthcare professional in
health care center or primary care to monitor the physical/mental health of the
people in UK. However, there is no specific professional training given to these
health care professionals to do this practice efficiently. But, according to the
(Reilly, et al., 2012), there are primary research has been conducted to evaluate the
structural processes of Severe mental illness health care. This research statement
will play an important role to shape the primary objective of this research, in which
there is evaluation of relationship between primary healthcare center and people
with SMI and also lack of significant research will be evaluated.
Aims
1. To develop a clear understanding of the barriers to the primary care
experienced by the people with SMI such as depressions, bi-polar disorder,
eating disorders, schizophrenia via the utilization of empirical data which is
associated with the mental health.

2. To further evaluate and expand via empirical evidence, specifically focusing
on established research concerning the gender barrier to the health care
among the people with SMI which is under studied and underrepresented
within the UK
Objectives
1. To examine the practices, perform by the primary health care workers to
ensure the physical health of the patient with SMI and perform a thorough
evaluation of the effectiveness of these practices.
2. To determine the relationship of primary care and patients with severe
mental illness.
3. To examine and critically evaluate the efforts taken by the health care
professionals on people with SMI to improve the health and further to
establish the knowledge of what measure should take to improve the mental
health among SMI population with in the UK.
1.3 Background and rationale of the study
As previously discussed, our primary objective of this research is to identify the
factors affecting the relationship between primary care and people with SMI and to
establish evidence which will aid in the improvement in the health surveillance in
UK. According to the (Patricia & Graor, 2012) premature death and other physical
health difficulties comes with SMI, which needs efficient primary care. It states
that Primary care is important to the vulnerable people because if this delivered
successfully, it emphasizes the care integration, clinical accountability, and a
sustained partnership with care. Also, it means that a strong relationship between
primary care and people with SMI may be key to assist individuals to meet their
health needs and limit low risk. There is semi structured interview were conducted
on 32 patients with SMI regarding their experience with health care services, the
results offered by the (Patricia & Graor, 2012). It results that people with SMI feels
the ‘mattering’ with health care professionals which means the sense of respect,
interest in their care, which concludes the successful relationship between patient
with service provider.
Further to this research, (Seymour & Morris, 2007), highlights the concern of
people with SMI for being ignored or not being believed when they tell the
physical health symptoms. However, (Seymour & Morris, 2007) states that there
are inconsistencies in primary healthcare treatment. A number of factors are

identified by executing a survey and distributed to the healthcare professionals.
Firstly, it founds that there is lack of trained specialists as they face the problem to
identify the mental and physical symptoms of the patients. This is also addressed
by (Bartels, 2004)(Happell, et al., 2010)(Hardy & Gray, 2010)(Sheila , 2012) the
who discussed the annual health checkup of people with SMI within primary care,
but due to lack of trained specialists or understanding of SMI, the physical
difficulties are faced by the people with SMI, the research specialist training to
ensure the significant improvement and treatment of people with SMI.
Further to this research, (Kaufman, et al., 2012) conducted a thorough investigation
with a primary objectives is to establish a better understanding of barriers between
the primary care and people with SMI via collection of data from the 10 patients
currently receiving SMI treatment. The data highlights the several factors in
regards to barrier with care. The first was access to care which means there is lack
of psychiatric personnel, lack of appointment and high waiting time. Secondly, it
was patient barrier which means social-economic status of the patient. Third,
(Kaufman, et al., 2012) concludes that there is fear of rejection or disrespect from
the providers to the patient with SMI as highlighted earlier by (Patricia & Graor,
2012). Further, (Kaufman, et al., 2012)(Penn & Martin, 1998)highlight the factor
of low self-esteem of patient which can affect the relationship between the primary
care and patient and also contribute in social exclusion. Fourth is incoherent care
system where the coordination of care is poor which makes patient unsuitable.
Fifth factors highlight the cultural barrier, communication gap, language problem.
Last factors suggest by the (Kaufman, et al., 2012) and (Patricia & Graor, 2012) is
quality of care and services and highlight the important of specialist care and
availability of service and enable the easy access to the primary care and ensure the
early treatment of the physical health symptoms.
1.4 Severe mental illness
Severe mental illness is often defined by its length of duration and disability its
produces. This mental illness includes various kinds of disease which produce the
psychotic symptoms such as schizophrenia and schizophrenia disorder, and other
form of other disease for example, depression, anxiety, stress and bipolar disorder.

Illness that produces various symptoms like perception, delusions, hallucinations
and unusual behavior are sometimes called disorders. As these symptoms reveal
the loss of contact with the reality so this order also called as psychotic disorder.
These symptoms or severe mental illness can be treatable, with proper treatment
and management of this severe mental illness and patients who are suffering from
this disease are recovery timely.
Schizophrenia is the most common disorder. In this person feel problems in
attention and there is slower processing of information memory, planning and
organizing. There will be problems with depression, anxiety, anger and mood
shifts. Schizoaffective disorder is quite similar to the schizophrenia but it is usually
for a long term. People with schizophrenia and schizoaffective disorders can have
symptoms of anxiety, depression, or both types of symptoms. However, patients
with the schizoaffective have severe depression or severe mania symptoms which
means symptoms of schizoaffective occur more often for a longer period of time
(Severe Mental Illness | Behavioral Health Evolution, 2018).
Schizophrenia is caused by various reasons such as imbalance in brain chemicals
called as neuron transmitters. There are some biological elements of the
schizophrenia which are combinations of some factors which are genetics and early
environmental influences such as parental nutrition and complications related to
obstetric. Schizophrenia affects both the sex, male and female equally however,
onset in men is earlier. For example, the symptoms of schizophrenia occur in men
in late teens and twenties whereas in the female it is in the late twenties and early
thirties.
The depressive symptoms are loss of interest, irritability, thoughts of death or
suicide, feeling restless or sluggish, difficulty in concentrating, feeling hopeless
and sad, feeling trouble in sleeping and oversleeping etc where as manic symptoms
are irritable mood, decreased need for sleep, distractedness, spending more money
then have, fast movement & speech, decreased need for sleep.
There are various treatments for schizophrenia which are effective, such as
medications, therapy and rehabilitation. Addition to this, there is some programs
which are run by family named as psycho education programs which help in
teaching the patients about the disorder and explain how to manage it and how to
relieve the stress and conflict. The most effective medications for the
schizophrenia are antipsychotics drugs. While this medicine do not cure the
schizophrenia but it helps in the relieve of schizophrenia symptoms such as

hallucinations, delusions and thinking problems. Also, addition to this these
medications help in the prevention of relapses of these symptoms. Additionally,
doctors prescribe the anti depressants and mood stabilizing medications to prevent
these symptoms. Because the disorder usually persists over the long term and
reduce the long term symptoms. The symptoms of schizophrenia especially the
symptoms of psychotic often fluctuate over the time. When these symptoms
become severe and affect the functioning of the human body, primary care may
require protecting the patient from harming because in the severe condition, patient
starts harming themselves. Therefore it is important to manage the medications of
schizophrenia disorder and make sure that the patients are taken regularly.
Therapy and rehabilitation is also help in the treatment of symptoms of
schizophrenia. The goal of these treatment is to make sure that the patient with
SMI are developing the skills for better communication, self care, independently
work and living and to manage the illness with strategies such as taking
medications regularly.
Bipolar disorder is another disorder in severe mental illness. It cause the extreme
mood swings ranging from the mild or extreme happiness, irritability or decreased
need of sleep. Bipolar disorder is not simply having the mood swings instead
bipolar disorder involves the dramatic shifts not only in mood but in the person
behavior, energy level and outlook. The cycle of depression include the depression
and mania which is called as mixed state. The manic symptoms of bipolar disorder
are racing thoughts, inflated self esteem, and grandiosity, become more talkative
(Severe Mental Illness | Behavioral Health Evolution, 2018).
Bipolar disorder requires a proper treatment plan for the reoccurring mood cycles
that focus on the immediate, acute problem of depression and mania as well as
long term preventative care. The treatment of bipolar disorder is the combination
of the medication and the therapy & rehabilitation which is also known as the best
strategy for recovery. Addition to this, there is family programs like in
schizophrenia which is designed to treat the bipolar patients. In this program,
patients with bipolar disorder learn how to manage the symptoms and how to
reduce the stress and conflict.
There are two stages in the treatment of bipolar disorder i: e the acute stage and the
maintenance stage.
Acute stage: The primary goal of this stage is to reduce or eliminate the stress
symptoms or depression symptoms of bipolar disorder. This can be done by the

medication, therapy, rehabilitation, hospitalization and psychotherapy,
electroconvulsive therapy. There are number of medications are used in the
treatment of bipolar disorder and the most effective mediations for bipolar disorder
are lithium, anticonvulsant medications, antipsychotic medications and anti
depressants. There are some moods stabilizers are used in the bipolar disorder such
as lithium, valproic acid and divalproate are the most common medications.
Maintenance stage: the primary goals of this stage are to maintain the stable mood
to prevent future episodes of depression and mania and for the faster recovery in
areas such as social relationships, school, working areas, and self-care. This can be
treating by the medications, therapy, rehabilitation, education and support. There
are different options in therapy such as cognitive-behavioral therapy, interpersonal
therapy, and program run by family like psycho education etc. patients with the
bipolar disorder can also get the benefit from individual care management and
rehabilitation programs such as supported employment. If bipolar disorder patient
takes a medications on regular basis if there is no symptoms then it can help in
prevention of future episodes. Additionally, knowing more about the bipolar
disorder and know the reason of triggering the relapses in the symptoms can help
in better treatment of this disorder.
Severe mental illness includes schizophrenia, bipolar disorder, and other mental
related illness. Severe mental illness is linked with poor health, high primary care
costs, and burden of disease (Murray, et al., 2013). According to the Harris, (2000)
life expectancy of people with severe mental illness is lower by 20 years than the
normal people. SMI is also associated with high cost of treatment in primary care
or hospitalization. Therefore, people of severe mental illness in United Kingdom
getting treatment from the primary care and having a long-term contact with the
primary care then the general population. Even in the mental care system of
developed countries, primary care is playing a key role in the treatment of people
with severe mental illness. The quality of primary care for people with severe
mental illness becomes the problem on international level (WHO, 2013).
In the United Kingdom, there is scheme as national pay under pay-for-
performance, the quality and outcomes framework (QOF). QOF is a financially

reward for the families for achieving the target for patients with the long-term
conditions. The severe mental illness quality indicators in the quality and outcomes
framework covers the both the mental related illness care and general physical
care. The QOF will measure the physical disease than mental illness because it is
easy to measure (Gutacker, et al., 2015).
In high income countries there are estimated 35%-50% of people with severe
mental illness whereas 76% to 85% in low- or middle-income countries receiving
no treatment (WHO, 2013). Low income countries are hit more as compared with
others because of the two major reasons i: e is low education and social economic
status (Kessler, et al., 2009). Patient with severe mental illness (SMIs) for example,
bipolar, depression etc.suffer from medical illness. It is said that the life
expectancy of people with SMIs is reduced by 25 years which means it is loss of
33% of their lifespan as compared to people who don’t have severe mental illness
(Colton & Manderscheid, 2006;Mark & Theodore, 2010). According to some
researcher, low level of seeking primary care and metabolic syndrome are the
factors that are attributed this increase rate of mortality (Michael, et al.,
1999;Decoux, 2005). Serious mentally illness people are suffering from the
obesity, diabetes, cardiovascular disease and other kind of physical problems
which are characteristics of symptoms of metabolic syndrome (Morrato, et al.,
2009). Newcomer (2007) suggest that people with severe mental illness are at high
risk of metabolic syndrome because of high dose of medications, lifestyle changes
such as poor diet, smoking, low physical activity.
In the program of international consortium of psychiatric epidemiology (ICPE),
Bijl, et al., (2003) highlighted the few diffferences in a comparison of five
countries for the examination of propotion of people with severe mental illness
from the last one year who received the treatment.

Canada Chile USA Netherland Germany
65.70%
80.30%
46.00%
74.60%
36.50%
Majority of patients
Majority of patientsFigure 1 Proportion of patients in 5 countries
Source: (Bijl, et al., 2003)
There was an ascertained in the treatment rates which are low in Canada by 7%
whereas it is high in Chile by 17.3%, with the US rate being 10%. Participants
were also asked about the sector of treatment for example, general medical
practitioner, special psychiatric or other counseling etc. As shown in the above
figure 1, the majority of the patients were seen in the general medical practitioner
which were Chile (80.3%), Canada (65.7%), USA (46%) whereas in Netherlands
(74.60%) and Germany (36.50%).
Symptoms and diagnosis of mental illness
Most of the cases, it is difficult to diagnosis the illness which required an
immediate intervention. Sometimes, GP even face the problem regarding the
relationship between the particular disorders and the specific indication of specific
treatments due to number of co morbidities found in mental illness (Wittchen,
1996).
There is high number of cases of mental illness which raises the questions that this
disease is required a professional treatment in primary care. For better
understanding of treatment issues of mental illness, it is important that patients
must first complaint about the symptoms. To illustrate, when a patient complains

about the sleep disorder, they get the treatment according to the doctor knowledge
like the diagnosis of sleep disorder which is insomnia and the prescription of
hypnotics. Alternatively, sometimes doctor may find the sleep disorder due to the
depression and prescribe the antidepressant to the patient or refer to the patient to
the psychotherapy. Sleeping disorder can be symptoms of depression or insomnia
but it can be symptoms of stress and unhappiness also. Therefore, it is not clear the
reason of sleep disorder so the diagnosis is very important for the treatment and
this is same case in mental illness due to improper diagnosis in patient care, this
disease become severe and cause other medical illness.
Physical diseases linked to severe mental illness
Obesity in SMI
Obesity and severe mental illness are overlap to clinically significantly some extent
(McElroy, 2009). According to the various studies, it shows that the people who
are having severe mental illness are more likely to have overweight (BMI=25 to
29.9) even it started in early phase of mental illness or with/without medication.
However, the risk of obesity in people with severe mental illness varies by
diagnosis. People with schizophrenia are most likelihood to get the obese (Coodin,
2001).
In the general population, the people with severe mental illness are having obesity
due to various lifestyle factors such as poor diet, lack of exercise or it can be due to
depression or other related illness. There is adverse effect which contribute in the
weight gain such as sedation and their medication effect on the appetite and food
intake (Wildes, et al., 2006).
Metabolic syndrome in SMI patients
There is high prevalence of metabolic syndrome in the treated patient of
schizophrenia. On the contrary, people with schizophrenia exhibit more metabolic
syndrome then the general population across the world (Meyer & Stahl, 2009).
Metabolic syndrome rate in patients with bipolar disorder and schizophrenia have
been reported to 22-30% and 42% respectively (Basu, et al., 2004).

Diabetes mellitus in SMI patients
In the world, three to four percent of population has diabetes mellitus which
increase the risk of other disease like renal failure, CVD diseases and also reduce
the life expectancy by 10 years or even more. There is high prevalence of diabetes
mellitus in developing countries. By the end of 2030, there will be 80% of people
with diabetes mellitus who live in developing countries (Blas & Kurup, 2010).
The prevalence of diabetes mellitus in people with schizophrenia and people with
bipolar disorder is higher than other people (Bushe & Holt, 2004). Along with this,
the risk of diabetes mellitus in people with the depression is higher than people
without depression (Brown, et al., 2005). The reason of high risk of diabetes
mellitus in the severe mental illness people is due to multi factors and it includes
genetically or lifestyle changes such as poor diet, lack of exercise as well as
disease and specific treatment effect. Also, prevalence of diabetes mellitus in SMI
people is much higher than general population according to the different age
groups such as 15-25= 2%, 25-35= 3.2% etc.(Hert, et al., 2006)
CVD in SMI patients
The term CVD (cardiovascular diseases) refers to any disease which affects the
cardiovascular system. Cerebrovascular disease and coronary heart disease are the
two main components in the CVD and make the largest contribution (Mackin,
2008). According to the WHO (2009), around the globe, 29% or 17.1 million
deaths are due to CVD. People who are living in developing countries have less
access to the effective primary care center which helps in their needs. The factors
which contributed in CVD are obesity, smoking, mental illness, hypertension,
diabetes mellitus etc. Also, there are other factors which increase the risk of CVD
such as unhealthy diet, lack of exercise and also low socioeconomic status
(Lindholm & Mendis, 2007).
The evidence suggests that there is high risk of cardiovascular disease in the people
with bipolar disorder, depression, mental illness, schizophrenia etc than the general
population. The most of the deaths of SMI patients is also due to CVD. The
prevalence of CVD is higher in people with the schizophrenia and bipolar disorder
is increasing specially in younger individuals. The main activity which is link
between the mental illness and CVD is lack of physical activity (Saiz, et al., 2009).

1.5 Review of literature
The nature and severity of the physical health problems for people with severe
mental illness have been recorded in the literature. Jones, et al., (2004) have
founded in the sample of 147 people with SMI that the 75% of people have atleast
one severe comorbidity whereas 50% of the people have a two or more disorders
with the chronic pulmonary disease is the most important disease found. It is also
founded that age, obesity, and other related factors are strong predictors of severe
comborbidity. On the contrary, Gold, et al., (2008) reported that 75% of the People
with severe mental illness smoke and also do not exercise reguraly, eat unhealthy
food, and live the below poverty line. Smoking, lack of exercise, low economic
status, obesity are the various factors which contribute in the high chance of risk of
CVD and increase morbidility. On average, Persons with severe mental illness
have low life expectancy or die 25years before the normal people due to the
inadequate prevention from the various factors such as obesity, lack of physical
activity, smoking(Parks, et al., 2006). According to the Parks, et al., (2006),
common cause of mortality for the population has arranged in hierarchical order
such as cardiovascular disease, diabetes and its complications, respiratory illness
and infectious disease. Although general population is gaining life expectancy
whereas life expectancy of people with severe mental illness has decline. Second
generation antipsychotic drug has been used frequently to treat the cognitive and
other perceptual symptoms associated with the serious mental illness, and increase
the metabolic syndrome in many patients. Symptoms of metabolic syndrome are
weight gain, insulin resistance, hyperglacmia, obesity etc(Leucht, et al., 2009). The
risk factors of metabolic syndrome has been linked with the development of the
cardiovascular and respiratory disease(Parks, et al., 2006).
Most people with severe mental illness have access to the primary care through
various United Kingdom NHS schemes. An ambulatory care-sensitive (ACS)
medical conditions is a condition in which early detection and early prevention can
treat in the primary care such as diabetes and depression. People who hospitalized
during ACS conditions reflect the poor primary care efficiency.Li, et al.,
(2008)Study claims that the out of 13514 patients admitted in the hospital for
ambulatory care sensitive conditions, people with the severe mental illness are 2.3
times more than the general population and had stays in longer time in hospital at
greater cost. In the study of 5365 patients, Druss, et al., (2000)found that people

with severe mental illness are less likely to undergo cardiac or revascularization
procedures.
Barriers to the primary care are the reason behind the decrease use of primary care
by the people with severe mental illness. In a study of 673 patients who is suffering
from the severe mental illness are wants to seek primary care but they didn’t do
so(Hahm & Segal, 2005). The more severe the mental illness, the greator the
reluctance to seek the primary care. People reported that they have fear of rejection
when they exposed that they are suffering from the mental illness to the primary
care system. A lack of insurance, confidence, severe depression, severe infectious
illness also contribute in the participants reluctance to seek the primary health care.
Also, according to the some general practicioner people with severe mental illness
do not the value the treatment. Miller, et al., (2003) found no evidence which
claims that the people with severe mental illness doubt the value of medical care or
reluctanct to partcipate in the health care treatment.
People with severe mental illness is frequently using the emergency departements
(ED) to obtain the routine health care. SMI patiens reported that the subsatnce
abuse is a critical factor in their medical crisis(Decoux, 2005). The most reason
behind the choosing the emergency department then the primary care center
because of the urgency of the need, also belief that the complaints regarding the
mental disorder will not taken serious by the primary care. Also, family support is
playing an important role and due to lack of family support for addressing their
mental illness symptoms also contributing in their seeking care in the emergency
department. Gold and killbourne (2008) reported that patients admit to
exaggerating their symptoms because they fear they could not effectively
communicate their distress to caregivers. A final concern that is contributing in the
seeking of emergency department by the people with SMI was the belief that their
mental health providers were totally unaware of their medical problems. Decoux
(2005) concluded that help seeking can be resolved by creating of atmosphere of
acceptance and positive primary care experiences. By doing this it will help the
people with severe mental illness to redirect them to the medical care and use more
appropriate community based services for their medical needs and giving the
medical care continoulsly will reduce their cost of healthcare.
In summary, people with severe mental illness have an increased risk of morbidity
and mortality from chronic illness. Giving them the proper medical care from the
primary care allow them to manage the illnees. Despite of access of various NHS
schemes, people with severe mental illness must use the primary care services.

Undertanding of the relationship of the people with the SMI to their primary care
will help in the providing the better care to the vulnerable population.
Chapter 2: Research Methodology
2.1 Chapter Introduction
Research methodology is an essence of the research. It is proper procedure of
collecting the data from the choose sources, analyze the data. It also allows the
checking the validity of the data. It includes sampling of designs, type of research,
research design, research philosophy, type of approach, method of data collection.
Conducting a successful research is a critical task and research methodologies can
guide a researcher. In this chapter, researcher has discussed about the various
research methodology used to conduct the research successful. Also, researcher has
mentioned inclusion and exclusion criteria in this study.
Figure 2 research methodologies used
2.2 Philosophical aspects
To conduct the successful research, the first and foremost step is choosing the
research philosophy which suits to the research at optimum level. There are four
Positivism philosophy
Deductive approach
Decriptive design

types of research philosophies for example: realism, pragmatism, positivism and
interpretive. In this research, author has adopted the positivism philosophy.
Figure 3 Types of research philosophy
Type of research philosophy
Positivism: Positivism philosophy is used when there is range of data which is
needed to be analyzed and also there is large sample which is highly structured and
quantitative. It is kind of techniques which states that the sole way to learn about
the truth and explore something is science (Gill & Johnson, 2010).. It generally
depends upon the quantifiable observations which lead to statistical analysis. It is
hard to explain the positivism research philosophy in certain manner due to vast
difference between the presumptions used by the researcher. As per this, they are
used to analyze the factor which is associated with the qualitative research which is
linked with paradigm which is used to access the essential norms in this.
Pragmatism: It is concepts that are used which are only relevant where they
support action. This philosophy is used when the research is starting with the
problem and this philosophy aims to contributing the practical solutions to the
research. Addition to this, this philosophy states that there is no single view of
point which give us clear cut picture of the study instead there is different ways of
Pragmatism Positivism
Realism Interpretive

interpreting the study. In this method, the most important element is questionnaire
(Kelemen & Rumens, 2008).
Realism: Realism philosophy is based on the scientific approach which depends
upon on the development of the knowledge and it is divided into two categories
(Reed, 2005).
Direct Realism: This is type of realism which means that what you see is what you
get and it is also called as Naïve realism.
Critical realism: it suggests that sensations and images of real world can be
deceptive which is used to portray the world.
Interpretive: Interpretive philosophy is kind of philosophy which is used to
integrate the human interest into study. The purpose of using of this type of
philosophy is to create the new and better understanding of social worlds and
interpretations of context. It is like a critical realism which develops a critique of
positivism but from subjective perspective (Crotty, 1998).
2.3 Research Approach
It is process and method which contain the various steps in which the data can be
generalized from general to specific or vice versa. Research approach is divided
into three parts which are listed below:
 Inductive approach
 Deductive approach
 Adductive approach
In above of the approach, any approach can be used for this research which helps
in the determination of the relationship between the primary care with the people
with severe mental illness. In this study, researcher has used the inductive
approach.

2.4 Type of research
There is different type of research as per the need and requirements of the author in
the study. However, it is also dependent upon the nature of variables and prevailing
situations at the time of conducting studies. It is method of collecting, compiling,
analyzing interpreting and implication of data to pertain any sort of problem.
There are three types of research which are discussed as below:
Qualitative or Quantitative: Qualitative research is based on the quality of data
which is non-numerical. For instance, mankind, personality, character are the
examples of the variables which are used to measure the qualitative research.
Whereas the quantitative research is depending upon the amount of data and
quantity. For example, weighing and measuring are the variables of the
quantitative research (Dang, 2017).
Descriptive or analytical: It is type of research which deals with the everything
that can be counted or studied and it involves the various type of studies and
contain surveys which is used to identify the various facts. Descriptive research
needs the detailed description of the small facts whereas in the analytical research
just need to use the available information and make the analytical statement for the
same.
Explorative or conclusive: Conclusive research is conducted to drive the final
statements of the analyzed data whereas the explorative research aims to explore
something new and innovative. It does not want to reach any definite conclusion or
provide any conclusive statements.
In this study, researcher has used qualitative and quantitative research method to
analyze the data. Also, researcher used analytical and explorative method to derive
something new in this research.
2.5 Research process
Research process is the procedure which contains various steps which should be
followed to conduct the successful research. Research process involves identifying,

locating and analyzing the information that is needed to support the research
questions and then developing and expressing your ideas (florida, 2020).
Figure 4 Research design process flow
As shown in the above figure, researcher going to the researcher the problem.
When the research philosophy is selected, research structure is designed and data is
collected through the primary collection data method. After collecting the ample
amount of data, there is analyzing of the data and prepare the final presentation of
the data so that purpose of the data can be completed. The same above method is
used to conduct the research on relationship of primary care with their patients of
severe mental illness.
2.6 Research design
It is the blueprint of the collection, measurement, analyzing of the data. It is a
framework for planning of research and answering the research questions.
Research design can be considered as the structure of research which holds the all
the elements of the research project together. According to the scholar, Research
Define the
problem
Design the
research
Design the
Data
collection
forms
Specify the
sample
Collect the
data
Analyze the
data
Write the
research
reports
Present its
finding
Final
submission

design is the arrangement of conditions for the collection and analysis of the data
in a manner that aims to combine relevance to the research purpose with procedure
(Akhtar, 2016).
2.7 Research strategy
It is process of action which contains the number of steps and provides the
direction to the researcher to conduct the research in a systemic manner. Research
strategy enables the research to focus on the research and enhance the quality and
reduce the time & cost. The most important benefit of research strategy is that it
sets benchmarks so that researcher can be desired are achieved or not. For
exploratory research different strategies like action, case study, grounded theory
and experimental strategies can be used. In this study, researcher has used the
interview strategy. In this study, researcher has conducted the interviews with the
primary care staff and patients who are seeking the primary care for their mental
illness. In this study, both qualitative and quantitative type of data has been
collected.
2.8 Research Choice
It is technique which is used to combine the qualitative and quantitative data.
There are three types of research choices which are multiple method, mono method
and mixed method. In this study, researcher has used the mixed method as this
mixed method research strategy is not related to a single phenomenon. By this
research choice, researcher is able to get the information from the high authority of
the hospital and also get the information from the other staff about their
relationship with the SMI patients. Furthermore, there will be structured interview
with the other primary care staffs to get some qualitative facts to measure the
relationship of primary care with their SMI patients.
2.9 Data collection

In this study, researcher has used the primary data collection method. Interview
and questionnaire are two methods which are used in this study. Researcher has
arranged a semi structure interview with the patients of severe mental illness and
key primary care staff. It is semi structured interview which cover all aspects of the
study. Researcher used questionnaire method to collect the data from the staff
members. As it is difficult to interact with individuals’ staff so the questionnaire is
best suitable method for this. In this study, open and close ended questions were
asked from the primary care staff members based on their relationship with the
SMI patients.
Population of the study
Population of the study is the total number of the units from where the data can be
collected potentially. In this study, population is various patients who are suffering
from the severe mental illness, primary care workers. This population was selected
& filtered through the inclusion & exclusion criteria. The target group is
consultants, nursing staff etc.
2.10 Sample techniques and size
Sampling technique
In this study, researcher has selected the sampling techniques to collect the data
from the large number of populations on the basis of time, cost, size etc. In this
researcher, author has used the probability technique to collect the random data
from the population. If researcher wants to include any participants in the study,
then the participants should be included in the random selection.
Sample size
There should be alignment in the behavior of whole population with the sample
which has been selected from them. If researcher has selected wrong sample then it
will difficult to generalize the conclusion in the common. Primary care has been
selected across the United Kingdom including the consultants who is representing
the primary care centers. Convenience and theoretical sampling were used to
recruit the 32 participants with severe mental illness.

To collect primary data from customer researcher have designed a questionnaire to
be filled by the participants. By this research researcher came to know about the
gap between the expectation of patient and staff behavior towards the SMI patients.
2.11 Inclusion and exclusion criteria
In this study, researcher has collected the ample of amount of data from the
primary source. However not all data has been included in the study as there are
some criteria for selecting the data as discussed below.
Figure 5 Inclusion and exclusion Criteria
Establishing an inclusion and exclusion criteria for respondents is a standard,
required practice when conducting high-quality research. Inclusion criteria are
defined as the key features of targeting those participants for the study who fit to
the research objectives and answer the research questions. On the contrary,
exclusion criteria are defined as not to consider those individuals who don’t fit to
the research objectives and can’t provide the relevant information on the research
topic.
Inclusion
Criteria Exclusion
Criteria

In this study, researcher had chosen the consultants who have the direct
interactions with the patients. Questionnaire which is properly filled and interview
questions which are properly answered are included in this research. Whereas,
people who don’t have any link with SMI patients are excluded from this research.
Also, participants who didn’t give their consent are excluded from the study.
Additionally, question answers and short answer of questionnaire were excluded
from this study.
2.12 Bias and limitation of the study
There are some limitations while conducting this study. This research contains
sensitive information of the patient. So, we need highly secure place to secure it so
that nobody will access it. While interviewing the patient with SMI there are some
limits for asking the questions because of SMI. The survey or questioner sample
will be too short. There is limited access to the professional workers due to covid-
19. There is some bias in the research such as habituation which means participants
sometimes give the same word answer to the questions to save the energy or being
responsive. To overcome this, each answer should be analyzed separately.
2.13 Ethical consideration
Heath related research always need to be highly regulated, formalized and consider
of ethical issues. The right and safety of our participants is our top priority.
Researcher is aware of the issue of protecting privacy of the participants so the all
key ethical principles such as respect, sincerity and justice are considered in this
study. Ethical approval will be obtained from the management of participated
primary care and other public health related organizations before the data
collection. Participation in this survey was voluntary.
To protect the confidentiality of the participants, researcher didn’t ask any personal
information in the survey that will disclose their identity. The paper surveys were
stored in secure place and only will be accessed by the researcher until the data is
transferred into electronic file. After enter the data into the software the paper
surveys were destroyed. This research has followed the Data protection Act of UK
(1998) in this aspect. Also, addition to this the conclusions and relevant
information related to the SMI patients have not been manipulated and they are
mentioned as it in the collected data.

2.14 Chapter summary
This chapter has discussed about the research methodology which is used to
determine the relationship of primary care with SMI patients. In this study,
positivism philosophy has used to perform the broad analysis of the primary data
that was collected by conducting interview and designing a questionnaire.
Researcher has used the deductive approach to collect the quantitative and
qualitative data. Addition to this, researcher has used inclusion and exclusion
criteria to select the suitable source. Lastly, ethical consideration and limitation of
the research has been mentioned.
Chapter 3: Data presentation, analysis& findings
3.1 Sample
Convenience and theoretical sampling were used to select the 32 participants who
are suffering from the severe mental illness for this study. Participants were
theoretically selected on the basis of gender, age, & ethnicity. Participants who are
more then 18 years of age or older are included in this study and they are ability to
speak the English. In this study there was 17 males and 15 males whose age is
lying between the 24 to 68 years.
Participant’s background
For better understanding of the relationship of patients with the primary care and
barriers to the primary care, the researcher has gotten the background information
of the patients. The participants are from the different backgrounds, culture,
gender, ethnicity and age.

Gender:
Male
53%
Female
47%
Gender
Figure 6 Gender of participants
In this study, researcher has selected random participants and mix-up of the both
the gender. In this research, there were 17 males and 15 females.
Age:

1 8 - 4 0 4 0 o r a b o v e
10
7
8
7
Age of Parti cipants
Male Female
Figure 7 Age of Participants
There are 32 participants in this study. In which out of seventeen males, ten
participants have age between the 18 to 40 whereas other seven males have age 40
or more. On the contrary, out of fifteen females, eight females have the age
between the 18 to 40 whereas other seven females have age 40 or above.
Ethnicity:

16%
31%
16%
38%
Ethnicity
Asian
African
British
Other
Figure 8 Ethnicity of Participants
Researcher has filtered the participants according to their ethnicity. From the above
data it’s clear that out of thirty-two, ten participants are from African ethnicity, five
from Asian and British each and rest twelve is from another category.
Marital status

Married Never married Seperated Divorced
3
18
2
9
Figure 9 Participants marital status
In this research, researcher has also segregated the participants according to their
marital status. From the above figure, it concluded that participants who are never
married are high in number. There are 18 participants which are never married
whereas nine participants are divorced. Similarly, three participants are married
and two are separated.
Educational background

44%
31%
16%
9%
Educational background
Professional degree
Bachleor degree
School
diploma
Figure 10 Participants educational background
In this study, participants were from different educational background. Maximum
of participants are from professional background and they are perusing or done
master degree. Out of thirty-two participants, fourteen are from professional
background and ten are from bachelor degree. Whereas five participants are school
going and three are from diploma background.
3.2 Procedure
Participants were selected randomly who is suffering from severe mental illness.
Researcher presented the study to the staff member of the primary care. There are
some set of questions that were asked by the researcher to the participants and staff
members. Also, staff member provided the information to the participants about
the study. Staff member also provide the researcher information to the patients and
also get the patient information to have the direct contact with the patients over
telephone. Before the site location, prearranged meeting, and private meeting
appointment, researcher has verified that inclusion criteria of participants were met
and also study has described to the participants, providing the sufficient
information on the rights of human subject. Questions were asked and answered,
both the consent form and audio tapping form has been signed by all the

participants. Participants who declined to sign the consent form have been
excluded from the study.
Once they sign the consent form, participants remained seated comfortably and
microphone has been pinned in their dress. The entire interview has been
conducted to collect the demographic location. This semi-structured interview has
been conducted for 40-45 minutes and also questionnaire about their background
information has been collected. Also, break of 15 minutes have given to the
participants. Also, a £10 given to each participant as a gesture of the gratitude at
the end of the interview.
3.4 Semi structured interview questions
The researcher has collected first background information. Questions were adapted
or eliminated based on whether the participant covered the area of interest in
sufficient details for the purpose of the study.
1. Explain your good experience with the primary care?
2. Explain your bad experience with the primary care?
3. What do you want from the primary care (doctor, nurse who treats your
mental problem)?
4. What motivates or encourage you to see the doctor or primary care?
5. What helps you to see the doctor or primary care center continuously?
6. What helps you do what the primary care and doctor recommends?
7. What does primary care or doctor need to know or understand about you?
8. What keeps you seeing your doctor or primary care center?
9. What is the most important thing you want to tell your primary care center
or doctor?
10.What suggestions do you have for others in order for them to get the care
from the doctor or primary care center?
11.How you feel while treating the patient with severe mental illness?
12.Do you have any comments or suggestions?
13.Are there any other questions you wish I would have asked?

3.5 Data analysis plan
There is specific method was used to analyze the data. To ensure the
confidentiality of the participants, participant’s names were linked with the tape
with the unique identification number. There were linked by the code sheet and
this code sheet were stored separate from the names of participants in locker. Only
researcher has access to this information. Taped interviews were transcribed
following the interviews. After the first interview and collection of the sample and
other related data, the data analysis has begun. Theoretical sampling was driven by
the data analysis on the basis of grounded theory. Data saturation was achieved
after 32 participants had been interviewed and answered the questionnaire.
Interview recording were transcribed verbatim by a trained transcriptionist and
entered into the NVIVO version 9.0. To ensure that there is no error in the
transcription; researcher listened to each taped interview and simultaneously read
the transcript. Constant comparison was essential during the content analysis when
the respondents talked what engaged them in relationship with the primary care
centers or doctors and what did not engage them. Also, to verify the grounded
theory which was used by the researcher in this study, researcher examines the
literature for fits with the categories and theory.
3.6 Findings
Described the grounded theory which were used to identify concepts and
categories and explained the relationship of patient with severe mental illness to
their primary care. Researcher has divided the findings into three categories:
1) Mattering
2) Being perceived
3) Working together
4) Barriers

Figure 11 finding Categories
Mattering
Mattering is the positive and ongoing encounters in the primary care treatment
where participants share their experience of mattering to their primary care centers.
In their answers, they discussed how they feel in the primary care center, how they
are doing, what they want or need, and what they thought which shows that it
really matters to the primary care centers. It also includes that the participants
feeling like that primary care center or staff member is giving them care and
respect which means when the participant need them, participant call, when
participant want to see, primary care arrange a meeting or appointment.
Participants feel they are counted within the general population. Mattering also
contain the participants feeling that the primary care center had better interest in
their treatment, looking for the patients and helping in keeping up. One of
participant’s statements is shown below
‘Doctor treats me like normal patient. He treats me like a friend. He doesn’t
disrespect me. He never says like that we are going to test you and test any
specific disease. He allows me to speak and ask me how I feel. Also, he gave
me enough time to understand my problem and my feeling. He clears my all
doubt’
Mattering
Working
together
Barriers
Being
perceived as
capable and
credible

Participants have positive attitude towards the primary care center and saying that
primary care are so caring and show genuine concern for them. Also, primary care
accepts the participants without judging them treat them with the respect and listen
their query properly. Another participant said that staff member or doctor listen her
properly and write down the each and every information. Another participant gave
the below statement
‘Doctor use nice tone while consulting me, give smiles, make an eye contact
and address me by my name. In primary care center, no body wants to be
treated like a case or case number. Everyone wants to feel like special like
they have really interest in them’
Participants also said that mattering means significant others which helps them to
stay involved with the treatment in the primary care centers. One participant said
that the grandmother pushed for the treatment as she cares what happened to me
whereas one participant said that I have joint family and I come here for my kids
and grandkids. Mattering is important when a patient with severe mental illness
becomes careless about themselves and in this case, encouragement comes from
the others. Encouragement comes from the friends, staff member, family or
psychiatrist. One old women participant said below words.
‘I just know that I am getting old so I need regular checkup and when I was
younger may be, I didn’t have a checkup regularly but I am getting an aged
now where things get complicated and even become wrong’
Being perceived
When a participant is talking about the positive attitude of the primary care
towards the patients of severe mental illness and ongoing relationship between the
primary care then it described as being perceived as capable and credible. One
participant said
‘I am the lowest potential given employee in my company at one time in my
life but after getting treatment my life came back on the track and that’s
how primary care center treats me and it helps me. They treat me like a
human being’
Another participant said doctor treats like a friend, he listens to me what I am
saying and believe on what I said. He treats me for my symptoms and did some

tests and if required refer me for further testing. As participants discussed about the
getting the importance of being believed, understood and taken as seriously by the
primary care, they described that it requires an effort on the participant part to be
perceived in this way. One participant talked about the importance of the emotional
attachment with themselves and said ‘I know it’s important to have my brain with
me and I have to do this for myself’. Participants said that primary care providers
are knowledge seeker and willing to learn more as they tell more. Also,
participants said the primary care providers saw them capable especially when
doctors or staff members of the primary care centers spoke frankly and opened
with the participants about the procedures and treatment options.
The most important aspects of this part were being perceived as capable and
credible by the primary care providers which show that the participants are capable
and credible. Participants said they could trust the primary care center which were
competent and they know what they are doing like maintaining the cleanliness of
the center, maintaining the patients record, clinical outcomes or efficiency of the
providers, control of infectious, and hygienic criteria. One participant said that
whether the doctor or staff member washed their hands before consulting the
patients. Follow up with the patients about their problems, symptoms and treatment
shows that primary care is paying attention to the individual details. Once the
participants make sure that the primary care center is capable and credible then
being perceived as credible and capable becomes meaningful.
Working together
When a participants discussing about the positive attitudes of the primary care
providers, all participants described a working together theory. This comes in end
when the patient believe that they mattered to the primary care center and that they
are perceived as being credible & capable by the primary care centers who they
had determined as capable and credible. Working together means the having a trust
on each other and there is honesty in the work of providers and patients. It also
means that participants feel educated, primary care providers realize them they are
important and can do something that they did not thing the are able to, get the
proper feedback from the healthcare providers and getting a desired result. There
are some below participant’s statements which are the examples of the working
together dimensions of the engagement.

Primary care was so professional, they teach me how to calculate the
calories and it was so impressing and I was impressed by myself.
Primary care providers make a time and meet me whenever I required.
Doctor listens to me and takes times out to understand my problem. If
something wrong with my test report then they explain me what is going on
and what is reason behind this and also tell me how to treat instead of brush
off or make me feel like that I am crazy. Doctor validates me in a way.
Doctor was as helpful as they explained everything me theoretically and
practically. For example, to listen the heart beat doctor told me to run on the
treadmill to see how my heart would react and how fast it is going. That was
helpful and positive and I thought it relieve my stress.
Sometimes doctor wants me to do something which is not acceptable but
after doctor came to know from where I am coming, they understand.
Some participants discussed about the working together on the basis of medication
dosing.
When I said to the doctor about the dose of medicines is too strong. Can you
loosen it some up? And the doctor agrees with these shows that I have
control on my own body.
I have a problem with the acid reflux medication and when I said this to the
doctor then he understood my problem. But doctor told me to take this
medication and explain me the benefits of the medicine. It stood out in my
mind because doctor understood that I don’t want to take this medicine and
doctor didn’t force me to take the medicine instead she shows me the
beneficial of the medicine and then I understood.
Some Participants said they are taking active roles while they are working together
with the primary care providers
If doctor recommended something to me which I don’t like then I speaks up
openly to my doctor and then she explains me everything and tell us what is
necessary. Doctor told me that it is important either you like it or not. We
have one to one open discussion on the various topic which feels me like that
I am playing an active role in the discussion or consultancy.
If something is too technical for me then I speak up with the doctor and
asked her to break into the parts so that it is easily under stable to me. As I
feel I am not sound like idiot as everyone don’t know everything so I speak
up frankly and doctor clear all my doubts without feel any irritation.

Barriers
When everyone is talking about the positive attitude of the primary care center then
there are some who said there are some barriers which stop them to go to primary
care center at initial stage until unless it’s not become important or emergency.
There are several factors which are contributing in the barriers to the primary care
for the SMI patients such as untrained specialists, quality of care, access to primary
care center, hospitalization charges etc. There are some below comments which are
said by some patients.
I feel uncomfortable when doctor discuss some personal thing with me.
Telling my personal things to opposite sex doctor is bit uncomfortable for me
and whenever I book an appointment with the primary care, they gave me
male doctors. This thing stops me to go see the primary care at early stage.
When I go to see the doctor, she treats me like an object. For her I am a
testing material and tried various types of medications for my symptoms.
Sometimes I feel shy when I go to the doctor as my friend’s call me mentally
disabled. So, this stops me to go primary care center.
In my locality or area, there is limited access to the care and if there is any
care then the quality of care is very poor as they don’t have proper
equipment’s. I need to go another place for lab test and to collect the reports
I need to go another place. So, there is proper access to the care.
Whenever I have visited to the doctor, they don’t understand my problem
instead they recommend the medication which is not related to my illness.
Which shows that they are untrained doctors?
Chapter 4: Discussion
When a patient with severe mental illness feels that they are mattered to the
primary care then the process of engagement or relationship began in between the
primary care and patients with severe mental illness. Mattering and perception of
capable and credible by the primary care providers leads to the SMI patients for

working together with the primary care centers. As it gives the results of an
outcome that the person feel is worthwhile. Experience of working together affects
SMI patient’s perception of mattering to primary care. However, there are some
barriers which stop the SMI patients to see the doctor and get the treatment at early
stage.
Mattering
Rosenberg & McCullough, (1979) described the mattering in the report and said ‘it
is feeling that depend on other, other are interested in us, are concerend with us and
experience us. Feeling of the mattering to the others is the important as it helps in
the human development and psychological well being throughout the span.
Perceptions of mattering includes the four dimensions which are discussed
below(Rosenberg & McCullough, 1979).
1. Attention: the feeling in which a person feel being noticed or interested by
others.
2. Important: the feeling that someone thinks he or she is important to the other
and another is interested in your thoughts, feelings.
3. Dependence: the feeling that you have sense of social purpose.
4. Ego extension: the feeling that others are interested in what you are doing.
Perceived mattering to someone based on the quantity and quality of attending
behaviors of the someone. Attending behavior is that someone is significant to
another and there will be eye to eye contact and being selectively attended to
another. Attending behavior also contribute in the influencing of the patient for the
treatment and regular checkup. Because it gives the feeling of being concerned by
another and show best interest at heart. Mattering to another and significance are
positively related to each other.
Interpersonal mattering can be positively or negatively. It positively associated
with the self-esteem and wellbeing in patients with severe mental illness of various
age groups such as adolescents, old age, school going (Marshall, 2001). It also
positively associated with the employees who are on various position and they are
satisfied with their job. On the contrary, interpersonal mattering is negatively
associated with the depression, anxiety, stress of students in university or school.
Gender difference is also contributed in perceiving mattering as study shows that
the female perceived higher level of perceptions than the male(Dixon & Kurpius,

2008). Although there is no study that shows that the perceived mattering in
between the SMI patients and Primary care. No studies explore mattering in the
primary care relationship with their patients. The finding of this study fills the gap
in knowledge by giving better understanding of mattering which play an important
role in the process of engagement of patients with their primary care.
Being perceived
Patient credibility
There is no any study which shows or investigated the patients experience of being
perceived as capable or credible.Werner & Malterud, (2003) described the
excellent work done by the women patients during the chronic muscle pain and
perceived as credible when consulting the doctor. The women described
intentionally presenting with appropriate appearance and balancing not to appear
too strong, or too weak, too healthy or too sick. Malat, et al., (2006) eexamined the
importance of positive self-presentation to get the best treatment from the primary
care centers. Also, author found that the disadvantageous groups like African are
more likely compared with their counterparts. The strategy of impress the primary
care can reduce the negative perception of the primary care. Managing self-
presentation requires additional cognitive and emotional work which adds to stress.
Patient with severe mental illness seeks physical health care additionally as the
diagnosis of severe mental illness is difficult. This is especially in the case when
the patient feels difficult to explain the medical problems. Furthermore,
KoekKoek, et al., (2011)found that once a primary care provider tags a patient as a
difficult patient, this label perceives the patient as they feel that they are less
respected and less effectively and excluded from services. This bias leads the
primary care to presume the lack of credibility even before giving the patient the
opportunity to present. By describing the perceiving as capable and credible best fit
in the process of engagement during the treatment of SMI patients at primary care
center and it increase the understanding about the work of persons with severe
mental illness during engaging with the primary care centers.
Primary care credibility

Few researchers have studies perceived provider credibility. According to them,
credibility is defined as a degree of trust, goodwill, character and honesty. The
exceptions have investigated the credibility as communication styles and patient
outcomes. Brann (2005) found that primary care credibility is associated
positively with the psychological style. Also, credibility found the primary care
perceived associated with the patient’s response to the primary care. For instance,
when a patient with severe mental illness perceive the high credibility then they are
more likely to comply with treatment recommendations, feel satisfied with primary
care and establish ongoing relationship with the primary care providers which lead
to better health outcomes. Therefore, studies show that the primary care providers
credibility are mean to be communication styles and this primary care credibility is
associated with better patient outcomes. When participants talked about the
interactions with the primary care, they described the communication approaches
similar to the social communication style. Participants also talked about each other,
the cleanliness of the office, infection control, the conditions of medical records of
the participants, the efficiency of the doctors and other staff members of the
primary care. Therefore, findings about how provider credibility fit in the
engagement process extend understanding about how credibility is determined and
how it contributes in the relationship between the primary care and patient of
severe mental illness. Lastly, no studies show the primary care or patient capability
was found. Capability is power or ability which in the case of the health care
providers is related to clinical competence. Therefore, measure of primary care
credibility may include the primary care capability.
Working together
Working together in a primary care means actively participation of patients of
severe mental illness and staff member. Bordin (1979) further discussed about the
three elements:
 Agreements on goals of treatment
 Agreements and collaboration on necessary task to meet the goals
 Positive emotional bond
The working relationship is identified as a key component in patient centered care.
Research about the relationship between the primary care and patients of severe

mental illness is limited. However, Brechin & Swain, (1988) explored the
historical context of professional relationship of primary care with their patients.
They proposed a working alliance to replace the dependent relationship of the
disabled population on the basis of human rights and dignity. Good working
alliances were also associated with the good relationship of primary care with the
SMI patients and show the better health outcomes. In order to boost the adherence
to medical treatment, patient satisfaction and self-efficacy, it is necessary to make
a working together environment in the primary care for the general population.
There are several factors which can weaken the working together environment.
The behavior of the primary care providers towards the patients especially with
severe mental illness. Personally, traits such as suspicion and introversion which
are conditions linked with the severe mental illness can inhibit the development of
the working together. No studies identified the examine the working together in the
primary care setting with people with severe mental illness.
These three concepts, mattering, being perceived as capable or credible and
working together provides the model of relationship in primary care with the
patients of severe mental illness. However, maximum of the participants is
suffering from the schizophrenia and bipolar disorder; findings may not be
generalized to those with other diagnosis of severe mental illness.
Chapter 6: Conclusion & recommendations
6.1 Conclusion
Severe mental illness is very common among the United Kingdom population and
rest of the world. After conducting this study, it is concluded that some of the
participants said that they have good relationship with the primary care center But
the patient who is suffering from the severe mental illness didn’t visit the primary
care due to several factors such as quality of care, untrained specialist, social
economic status etc. there are three concept which gives the better understanding
of relationship between the primary care center and patients of severe mental
illness such as mattering, being perceived as capable or credible and working
together. These three theories explained the relationship between the primary care
and patient of severe mental illness.

6.2 Recommendations
There are three prominent practice implications from this study. The first
implications are the importance of the relationship between the primary care
providers and patient with severe mental illness. To build and maintain this
relationship between the primary care providers and patients of severe mental
illness it requires efforts and time. Ten minutes primary care follow-up
appointment is not adequately for this type of patients. Having an availability of
the primary care providers for longer period of time is also a priority. An
acceptable, friendly environment, nice gesture and ambience by the front desk are
also important in creating the best suitable environment that supports the
relationship. The second practice implications are to maintain the mental health of
the SMI patients by giving an aggressive treatment of psychiatric disorder. To
maintain the healthy relationship between the primary care providers and severe
mental illness patients, cognitive abilities must be optimized. There are different
examples of promoting the optimal cognitive abilities in the patient of SMI may
include the primary care providers. (a) Discussed with the primary care providers
how cognitive abilities are important to the primary care provider- SMI patient
relationship and their work of promoting the patient health. (b) Identify how the
patients will plan to optimize the cognitive abilities. (c) Promising the patients that
the primary care providers will frankly discuss with you about the problems and
(d) getting the patients consent if any key people need to be contacted by the
primary care providers if providers have any concern about the patient’s health or
cognitive abilities. These discussions occur during the mattering and how the
patients feel and think matters to the primary care center. Finally, the model
developed applicable to all the populations.
The implications of education for primary care providers is important and
mandatory which emphasis the development of necessary skills for building the
interpersonal relationship with people of severe mental illness and other general
population.
References

Akhtar, I., 2016. Research design. In: 1st, ed.
Research in Social Science: Interdisciplinary Perspectives .
New delhi: Deptt. of Political Science, Faculty of Social Sciences, Jamia Millia Islamia, .
Bartels, S. J., 2004. Caring for the Whole Person: Integrated Health Care for Older Adults with Severe
Mental Illness and Medical Comorbidity.
American Geriatrics Society, 52(12), pp. 240-257.
Basu, R., Brar, J. S., John, V. & Parepelly, H., 2004. The prevalence of the metabolic syndrome in patients
with schizoaffective disorder--bipolar subtype.
Biopolar disorder, 6(4), pp. 314-8.
Bijl, R. V., Graaf, R. D., Hiripi, E. & Kessler, R. C., 2003. The prevalence of treated and untreated mental
disorders in five countries.
Health affairs, 22(3), pp. 122-33.
Blas, E. & Kurup, A. S., 2010.
Equity, social determinants and public health programmes, Geneva: World
health organization.
Bordin, E., 1979. The generalizability of the psychoanalytic concept of the working alliance.Psychotherapy: Theory, Research & Practice, 16(3), pp. 252-60.
Brechin, A. & Swain, J., 1988. Professional/client relationships: Creating a "working alliance" with people
with learning difficulties..
Disability, Handicap & Society, 3(3), pp. 213-26.
Brown, L. C., Majumdar, S. R., Stephen, N. C. & Johnson, j. A., 2005. History of depression increases risk
of type 2 diabetes in younger adults..
Diabetes care, 28(5), pp. 1063-7.
Bushe, C. & Holt, R., 2004. Prevalence of diabetes and impaired glucose tolerance in patients with
schizophrenia.
The Bristish journal of psychiatry, Volume 47, pp. 67-71.
Colton, C. W. & Manderscheid, R. W., 2006. Congruencies in Increased Mortality Rates, Years of
Potential Life Lost, and Causes of Death Among Public Mental Health Clients in Eight States.
Preventing
chronic disease, 3(2), p. A42.
Coodin, S., 2001. Body mass index in persons with schizophrenia..
Canadian journal of psychiatry, 46(6),
pp. 549-55.
Crotty, M., 1998.
The Foundations of Social Research. London: Sage Publications ltd..
Dang, T., 2017.
Type of research, Lucknow: Dept. of Journalism and Mass, Farsi University.
Decoux, M., 2005. Acute versus primary care: The health care decisionmaking for individuals with severe
mental illness.
Issues in mental health nursing, 26(9), pp. 935-51.
Dixon, S. K. & Kurpius, S. R., 2008. Depression and College Stress Among University Undergraduates: Do
Mattering and Self-Esteem Make a Difference?.
Journal of college student development, 49(5), pp. 412-
24.
Druss, B. G. et al., 2000. Mental disorders and use of cardiovascular procedures after myocardial
infarction.
JAMA, 283(4), pp. 506-511.
florida, U. o. s., 2020.
The research process. [Online]
Available at: https://guides.lib.usf.edu/c.php?g=291297&p=2104188#:~:text=The%20research

%20process%20involves%20identifying,or%20put%20together%20a%20presentation.
[Accessed 05 12 2020].
Gill, J. & Johnson, P., 2010.
Research methods for managers. 4th ed. London: Sage.
Gold, K. J., Kilbourne, A. M. & Valenstein, M., 2008. Primary care of patients with serious mental illness:
your chance to make a difference.
The journal of family practice, 57(8), pp. 215-25.
Gutacker, N., Mason, A. R., Kendrick, T. & Goddard, M., 2015. Does the quality and outcomes framework
reduce psychiatric admissions in people with serious mental illness? A regression analysis..
BMJ, 5(4).
Hahm, H. C. & Segal, S. P., 2005. Failure to Seek Health Care Among the Mentally Ill.
American journal of
orthopsychiatry, 75(1), pp. 54-62.
Happell, B. et al., 2010. A role for mental health nursing in the physical health care of consumers with
severe mental illness.
Journal of Psychiatric and Mental Health Nursing, 18(8), pp. 706-711.
Hardy, S. & Gray, R., 2010. Adapting the severe mental illness physical Health Improvement Profile for
use in primary care.
International journal of Mental health Nursing, 19(5), pp. 350-355.
Harris, M., 2000. General practice recruitment for schizophrenia prevention studies..
The Australian and
New Zealand Journal of psychiatry, Volume 34, pp. 137-9.
Hert, M. D., Winkel, R. V., Eyck, D. V. & Hanssens, L., 2006. Prevalence of diabetes, metabolic syndrome
and metabolic abnormalities in schizophrenia over the course of the illness: a cross-sectional study..Journal of clinical practice and epidemiology mental health, 27(2), p. 14.
Jones, D. R. et al., 2004. Prevalence, severity, and co-occurrence of chronic physical health problems of
persons with serious mental illness.
Psychiatric service, 55(11), pp. 1250-70.
Kaufman, E. A., McDonell, M. G., Cristofalo, M. A. & Ries, R. K., 2012. Kaufman, E.A. (2012). Exploring
Barriers to Primary Care For Patients with Severe Mental Illness: Frontline Patient and Provider
Accounts. Issues in Mental Health Nursing. 33: 172-180..
Issues in Mental health nursing, 33(3), pp. 172-
180.
Kelemen, M. L. & Rumens, N., 2008.
An Introduction to Critical Management Research. London: Sage
Publications ltd.
Kessler, R. C., Gaxilo, S. A., Alonso, J. & Wang, P. S., 2009. The global burden of mental disorders: an
update from the WHO World Mental Health (WMH) surveys.
Epidemilogy of psychiatric society, 18(1),
pp. 23-33.
KoekKoek, B., Hutschemaekers, G., Meijel, V. B. & Schene, A., 2011. How do patients come to be seen as
'difficult'?: a mixed-methods study in community mental health care.
Social science and medicine, 72(4),
pp. 504-12.
Leucht, S. et al., 2009. Second-generation versus first-generation antipsychotic drugs for schizophrenia:
a meta-analysis.
Lancet, 373(9657), pp. 31-41.
Lindholm, L. H. & Mendis, S., 2007. Prevention of cardiovascular disease in developing countries..Journal of Lancet, 370(9589), pp. 720-2.

Li, Y., Glance, L. G., Cai, X. & Mukamel, D. B., 2008. Mental illness and hospitalization for ambulatory
care sensitive medical conditions.
Journal of medical care, 46(12), pp. 1249-56.
Mackin, P., 2008. Cardiac side effects of psychiatric drugs.
Journal of Human psychopharmacology, 23(1),
pp. 3-14.
Malat, J. R., Ryn, M. V. & Purcell, D., 2006. Race, socioeconomic status, and the perceived importance of
positive self-presentation in health care.
Social Science and Medicine, 62(10), pp. 2479-2488.
Mark, V. & Theodore, S., 2010. The impact of serious mental illness on health and healthcare.
American
Psychological Association, 51(6), pp. 458-465.
Marshall, S. K., 2001. Do I Matter? Construct validation of adolescents' perceived mattering to parents
and friends.
Journal of Adolscence, 24(4), pp. 474-90.
McElroy, S. L., 2009. Obesity in patients with severe mental illness: overview and management.
The
journal of clinical psychiatry, 70(3), pp. 12-21.
Meyer, J. M. & Stahl, S. M., 2009. The metabolic syndrome and schizophrenia.
Acta psychiatrica
Scandinavica, 119(1), pp. 4-14.
Michael, B. R., Jose, S., Micahel, Z. & Charles , C., 1999. Health care utilization by persons with severe
and persistent mental illness.
American Psychological Association, 50(4), pp. 559-61.
Miller, C. L., Druss, B. G., Dombrowski, E. A. & Rosenheck, R. A., 2003. Barriers to primary medical care
among patients at a community mental health center.
Psychiatric services, 54(8), pp. 1158-60.
Morrato, E. H., Newcomer, J. W., Kamat, S. & Baser , O., 2009. Metabolic screening after the American
Diabetes Association's consensus statement on antipsychotic drugs and diabetes.
Diabetes care, 32(6),
pp. 1037-42.
Murray, C. J., Richards, M. A., Newton, J. & Fenton, K., 2013. UK health performance: findings of the
Global Burden of Disease Study 2010..
Lancet, 381(9871), pp. 997-2010.
Newcomer, J. W., 2007. Metabolic considerations in the use of antipsychotic.
The journal of clinical
psychiatry, 68(1), pp. 20-7.
Parks, J., Svendsen, D., Singer, P. & Foti, M. E., 2006.
Morbidity and Mortality in People with Serious
Mental Illness. [Online]
Available at: https://www.nasmhpd.org/content/morbidity-and-mortality-people-serious-mental-illness
[Accessed 25 12 2020].
Patricia, G. & Graor, C. H., 2012. Engagement in primary care treatment by persons with severe and
persistent mental illness..
Archives of Psychiatric Nursing, 26(4), pp. 272-284.
Penn, D. L. & Martin, J., 1998. The Stigma of Severe Mental Illness: Some Potential Solutions for a
Recalcitrant Problem.
Psychiatric Quateraly , 69(3), pp. 235-247.
Reed, M., 2005. Reflections on the ‘Realist Turn’ in Organization and Management Studies.
Journal of
management studies, 42(8), pp. 1621-1644.

Reilly, S. et al., 2012. The Role of Primary Care in Service Provision for People with Severe Mental Illness
in the United Kingdom.
PLos One, 7(5), pp. 1-10.
Rosenberg, M. & McCullough, C. C., 1979.
Mattering: Inferred Significance and Mental Health Among
Adolescents, Rockville: National Institute of Mental Health.
Saiz, P. A., Bascaran, M. T., Bobes, J. & Torres, P., 2009. Cardiovascular risk in patients with bipolar
disorder..
Journal of Affective Disorder, 115(3), pp. 302-8.
Seymour, L. & Morris, B., 2007. Seymour, L., Morris, B. (2007). How can primary care improve the care it
offers people with mental health problems? Improving access to primary care. . ..
Mental Health Today,
pp. 33-35.
Sheila , H., 2012. Training practice nurses to improve the physical health of patients with severe mental
illness: effects on beliefs and attitudes.
International journal of mental health nursing, 21(3), pp. 259-
265.
Werner, A. & Malterud, K., 2003. It is hard work behaving as a credible patient: encounters between
women with chronic pain and their doctors.
Social science and medicine, 57(8), pp. 1409-19.
WHO, 2009.
Cardiovascular disease, Geneva: World health organization.
WHO, 2013.
Mental health action plan 2013 - 2020, Geneva: World healh organization.
WHO, 2013.
The World health report , Geneva: World health organization.
Wildes, j. E., Marcus, M. D. & Fagiolini, A., 2006. Obesity in patients with bipolar disorder: a
biopsychosocial-behavioral model.
The journal of clinical psychiatry, 67(6), pp. 904-15.
Wittchen, H. U., 1996. What is comorbidity--fact or artefact?.
The british journal of Psychiatry
supplement, Volume 30, pp. 7-8.
Mantovani, A., Scorletti, E., Mosca, A., Alisi, A., Byrne, C.D. and Targher, G., 2020. Complications,
morbidity and mortality of nonalcoholic fatty liver disease. Metabolism, 111, p.154170.