This is an excellent approach for a systematic review on health equity and mental health care access! PROGRESS-Plus provides a robust framework for identifying and analyzing disparities.

Let's break down each PROGRESS-Plus factor, explaining its relevance to access to mental health care, and what to look for when conducting your review.

Understanding PROGRESS-Plus in the Context of Mental Health Care Access

PROGRESS-Plus is an acronym and a framework used in health equity research to identify and analyze determinants of health inequalities. It stands for:

• Place of residence


• Race/ethnicity


• Occupation


• Gender/sex


• Religion


• Education


• Socioeconomic status


• Social capital

For each factor, we'll consider:

• Why it matters for mental health care access: The specific mechanisms through which this factor can create or exacerbate disparities.


• What to look for in studies: How to identify and categorize this factor during data extraction and synthesis.

PROGRESS-Plus Factors and Mental Health Care Access

1. P - Place of Residence

• Why it matters for mental health care access:


• Geographic Proximity: Rural areas often have fewer mental health providers, longer travel distances, and limited public transportation. Urban areas might have more providers but still face "mental health deserts" in specific neighborhoods.


• Community Resources: Availability of community mental health centers, crisis services, and support groups varies significantly by location.


• Digital Divide: Access to reliable internet and devices (crucial for telehealth) differs between urban/rural and high/low-income areas.


• Local Stigma & Norms: Community-level attitudes towards mental illness can impact help-seeking behaviors.


• Policy & Funding: State, provincial, or local policies can influence funding for mental health services, insurance mandates, and provider licensing.


• What to look for in studies:


• Categorization: Urban, rural, suburban; specific postal codes/ZIP codes, census tracts; regional/national data.


• Measures: Provider density maps, travel time to nearest facility, public transport availability, internet access rates, community mental health infrastructure.


• Disparities: Studies comparing access metrics (e.g., service utilization, wait times, treatment initiation) between different geographic areas.

2. R - Race/Ethnicity

• Why it matters for mental health care access:


• Cultural Competence: Lack of culturally sensitive providers who understand diverse cultural expressions of distress, family dynamics, and traditional healing practices.


• Language Barriers: Limited availability of bilingual providers or interpreters, making communication difficult.


• Stigma: Mental health stigma can be particularly strong within certain racial/ethnic communities, discouraging help-seeking.


• Historical Mistrust: Past discrimination and mistreatment in healthcare systems can lead to distrust among racialized groups.


• Discrimination: Experiences of racism and discrimination can contribute to mental health issues while simultaneously acting as barriers to seeking care.


• Insurance & Socioeconomic Factors: Racial/ethnic minorities often face systemic disadvantages in employment, income, and insurance coverage, indirectly affecting access.


• What to look for in studies:


• Categorization: Self-identified race/ethnicity (e.g., White, Black/African American, Hispanic/Latino, Asian, Indigenous/Native American, Mixed Race), specific sub-ethnicities (e.g., Hmong, Somali, Puerto Rican).


• Measures: Self-reported race/ethnicity of participants, language spoken at home, immigrant status (often correlated), measures of discrimination.


• Disparities: Differences in rates of diagnosis, treatment initiation, treatment completion, provider-patient concordance, experiences of discrimination in care.

3. O - Occupation

• Why it matters for mental health care access:


• Insurance Coverage: Many people receive health insurance through their employer. Uninsured or underinsured individuals (often in low-wage or precarious employment) face significant financial barriers.


• Income & Time Off: Low-wage jobs may not offer paid time off for appointments, and the financial burden of missing work can be prohibitive.


• Job Stress: Certain occupations (e.g., first responders, healthcare workers, frontline service staff) have higher rates of mental health issues but may face unique barriers to seeking help (e.g., stigma, fear of job loss).


• Unemployment/Underemployment: Lack of stable employment is a major stressor and can lead to loss of insurance and financial resources.


• What to look for in studies:


• Categorization: Employment status (employed, unemployed, retired, student, homemaker), specific job titles or industries (e.g., manual labor, professional, service industry).


• Measures: Type of employment, income level (often linked), health insurance status (employer-sponsored vs. public/private), hours worked.


• Disparities: Differences in access based on type of employment, employer-provided mental health benefits, and time flexibility for appointments.

4. G - Gender/Sex

• Why it matters for mental health care access:


• Gender-Specific Needs: Some mental health conditions are more prevalent in one gender (e.g., depression and anxiety in women, substance use disorders in men). Postpartum depression is unique to birthing parents.


• Societal Roles & Stigma: Traditional gender roles can influence help-seeking (e.g., men encouraged to suppress emotions, women labeled as "hysterical").


• Violence & Trauma: Women are disproportionately affected by gender-based violence, which significantly impacts mental health and shapes their interactions with healthcare systems.


• Gender-Affirming Care: Transgender and gender-diverse individuals face significant barriers due to discrimination, lack of affirming providers, and systemic ignorance.


• Provider Bias: Implicit biases can lead to different diagnoses or treatment recommendations based on gender.


• What to look for in studies:


• Categorization: Self-identified gender (man, woman, non-binary, genderqueer, etc.), sex assigned at birth (male, female).


• Measures: Gender identity, sex assigned at birth, history of gender-based violence, experiences seeking gender-affirming care.


• Disparities: Differences in rates of diagnosis, referral patterns, types of treatment offered, experiences of discrimination or affirmation in care.

5. R - Religion

• Why it matters for mental health care access:


• Stigma: Some religious communities may hold strong negative views towards mental illness or professional mental health treatment, encouraging reliance on spiritual leaders over clinicians.


• Alternative Support: Religious institutions can provide strong social support networks, which might be a protective factor or an alternative to formal care.


• Conflict with Beliefs: Treatment options (e.g., medication) may conflict with deeply held religious beliefs for some individuals.


• Culturally Sensitive Care: Need for providers who understand and respect diverse religious perspectives and can integrate spiritual practices into care where appropriate.


• What to look for in studies:


• Categorization: Self-reported religious affiliation (e.g., Christian, Muslim, Jewish, Hindu, Buddhist, Atheist, Agnostic), level of religiosity/spiritual practice.


• Measures: Religious affiliation, frequency of religious service attendance, importance of religion in daily life.


• Disparities: Differences in help-seeking behaviors, preferences for traditional vs. spiritual healers, and perceived acceptability of mental health interventions.

6. E - Education

• Why it matters for mental health care access:


• Health Literacy: Lower educational attainment is often associated with lower health literacy, making it harder to understand mental health symptoms, navigate complex healthcare systems, and comprehend treatment options.


• Awareness of Services: Individuals with less education may be less aware of available mental health services or how to access them.


• Socioeconomic Link: Education is strongly correlated with income and occupation, which directly influence insurance status and ability to pay.


• Empowerment: Higher education can empower individuals to advocate for their health needs and demand appropriate care.


• What to look for in studies:


• Categorization: Highest level of education completed (e.g., less than high school, high school diploma/GED, some college, bachelor's degree, postgraduate degree).


• Measures: Years of schooling, specific educational attainment levels.


• Disparities: Differences in knowledge about mental health, help-seeking intentions, service utilization, and engagement with treatment based on educational background.

7. S - Socioeconomic Status (SES)

• Why it matters for mental health care access:


• Financial Barriers: Direct costs of therapy, medication, and co-pays are major barriers for low-income individuals.


• Insurance Coverage: Lower SES often correlates with lack of or inadequate health insurance, limiting access to affordable care.


• Transportation & Childcare: Cost and availability of transport to appointments, and childcare during appointments, are often greater burdens for low-income families.


• Stress & Competing Needs: Individuals facing poverty often prioritize basic needs (food, housing) over mental health care.


• Environmental Factors: Living in poverty-stricken neighborhoods often means less access to quality mental health services.


• What to look for in studies:


• Categorization: Income level (individual, household), poverty status, wealth, housing tenure (homeowner, renter), access to financial resources.


• Measures: Income brackets, poverty line relative income, free/reduced lunch eligibility, wealth indicators, insurance status, housing stability.


• Disparities: Differences in ability to pay for services, insurance coverage, and utilization of services.

8. S - Social Capital

• Why it matters for mental health care access:


• Social Support Networks: Strong social ties (family, friends, community groups) can provide emotional support, information about services, and practical help (e.g., transport, childcare) for accessing care.


• Community Cohesion: Trust and collective action within a community can lead to the development and support of local mental health initiatives.


• Trust in Institutions: Lack of social capital (e.g., distrust in authorities or healthcare systems) can deter individuals from seeking professional help.


• Social Isolation: Low social capital or severe social isolation is a risk factor for mental health conditions and a significant barrier to seeking help.


• What to look for in studies:


• Categorization: Measures of social support (e.g., number of close friends/family, perceived support), community participation, volunteering, trust in neighbors/local institutions.


• Measures: Standardized social support scales (e.g., Lubben Social Network Scale), civic engagement indicators, perceived community cohesion.


• Disparities: Differences in awareness of services, help-seeking encouragement from peers, and practical support for accessing care.

Plus (+) Factors

These are additional characteristics that often lead to marginalization and significant disparities in mental health care access.

1. Age

• Why it matters for mental health care access:


• Youth/Adolescents: Parental consent laws, school-based access, transition from pediatric to adult services, unique developmental stages. Stigma can be particularly potent among peers.


• Older Adults: Mobility issues, cognitive decline, multiple comorbidities, caregiver burden, ageism in diagnosis, limited geriatric mental health specialists.


• Digital Literacy: Differences in comfort and access to technology for telehealth across age groups.


• What to look for in studies:


• Categorization: Specific age ranges (e.g., 0-18, 19-35, 36-64, 65+), continuous age variable.


• Measures: Age, specific life stage.


• Disparities: Age-specific barriers to entry, utilization rates for different age groups, appropriateness of services for different ages.

2. Disability

• Why it matters for mental health care access:


• Physical Accessibility: Lack of ramps, elevators, accessible restrooms in clinics.


• Communication Barriers: Lack of sign language interpreters, accessible materials, or providers trained to work with individuals with cognitive or sensory disabilities.


• Dual Stigma: Experiencing both disability stigma and mental health stigma can compound barriers.


• Provider Knowledge: Lack of provider training in managing co-occurring mental health and physical/developmental disabilities.


• Transportation: Significant barriers for individuals with physical disabilities.


• What to look for in studies:


• Categorization: Self-reported disability status, type of disability (e.g., physical, sensory, developmental, intellectual, chronic illness), use of mobility aids.


• Measures: Specific disability diagnoses, functional limitations.


• Disparities: Differences in physical access to facilities, communication effectiveness, and provider competence for individuals with disabilities.

3. Sexual Orientation

• Why it matters for mental health care access:


• Minority Stress: Experiences of discrimination, prejudice, and internalized homophobia/biphobia/transphobia contribute to higher rates of mental health conditions.


• Stigma & Discrimination: Fear of being judged or receiving inferior care can deter help-seeking.


• Lack of Affirming Providers: Difficulty finding providers who are knowledgeable about LGBTQ+ issues and can provide affirming care.


• Disclosure Concerns: Fear of negative repercussions if sexual orientation is disclosed to providers.


• What to look for in studies:


• Categorization: Self-reported sexual orientation (e.g., heterosexual, homosexual/gay/lesbian, bisexual, queer, pansexual, asexual).


• Measures: Specific self-identified sexual orientation, experiences of discrimination based on sexual orientation.


• Disparities: Differences in help-seeking, experiences of discrimination in care, and access to affirming services.

4. Other Characteristics Leading to Marginalization

• Immigration/Refugee Status: Language barriers, cultural differences, trauma from migration, legal status concerns, fear of deportation, lack of familiarity with healthcare systems, limited insurance.


• Incarceration History: Stigma, difficulty finding housing/employment (which impacts stability for care), lack of continuity of care post-release, mistrust of systems.


• Housing Status (Homelessness): Immediate survival needs override mental health care, lack of fixed address for appointments/follow-up, lack of documentation, high rates of co-occurring substance use.


• Veteran Status: Specific mental health challenges (PTSD, moral injury), but also unique service systems (e.g., VA) that may have their own access issues (e.g., wait times, geographic distribution).


• Chronic Illness/Comorbidity: Mental health needs may be overlooked in favor of physical health, fragmented care, medication interactions, additional stigma.

Practical Steps for Your Systematic Review

• Develop Clear Search Strategies: Incorporate keywords related to these PROGRESS-Plus factors alongside your core terms (mental health care, access, disparities, equity). For example: "mental health access rural," "racial disparities mental health," "LGBTQ mental health barriers."


• During Screening (Title/Abstract & Full-Text): Pay attention to studies that specifically mention or analyze any of these factors as determinants of access or outcome.


• Data Extraction: Create a structured data extraction form that includes dedicated fields for each PROGRESS-Plus factor.


• For each study, note which factors were measured/reported.


• Record how they were defined or categorized (e.g., "low SES defined as income below $30,000").


• Extract specific findings related to disparities in access attributed to these factors.


• Data Synthesis:


• Categorize by Factor: Group findings by each PROGRESS-Plus factor to identify common themes and specific disparities.


• Intersectional Analysis: Where possible, look for studies that analyze the intersection of multiple factors (e.g., rural Indigenous women, low-income LGBTQ+ youth). This is crucial, as people rarely experience marginalization based on just one characteristic.


• Methodological Quality: Assess how robustly studies measured and analyzed these factors.


• Missing Data: Note which factors are consistently under-reported in the literature, as this highlights research gaps.