Association of travel time with mental health service use in primary health care according to contact type — a register-based study in Kainuu, Finland

Adequate health service availability is one of the key determinants of health [1]. Long geographical distances or travel times may act as a potential barrier for the use of health services, leading to lowered service use and manifesting in poorer health outcomes and health differences between populations and areas [2, 3]. Distance is a major determinant of the geographical accessibility of health services, describing the geographical aspect of the fit between the health care system and its users [4]. Geographical accessibility may be the primary concern in many rural and remote areas, although other issues can also affect access to health care, namely affordability (client’s ability to pay for services), availability (needed resources to meet the client’s needs), accommodation (how services are organised, including opening hours) and acceptability (how comfortable the client and provider are with each other) of services [5‐7].

A reasonable travelling time can be considered an enabling characteristic for health service use according to the Behavioral Model of Health Service Use [8], as it is a condition that makes the health service resources available to the individual. Other determinants of health service utilisation include predisposing characteristics such as age, gender or socioeconomic status that make people more likely to use certain services and illness-level characteristics that suggest that people may have some health-based reasons for health service use [8].

Geographic distance to health care has been identified as a significant barrier to the use of regular check-up visits and chronic care visits, especially in rural areas, whereas acute care visits appear to be less sensitive to distance [9]. Having health care provided within one’s daily activity area may be particularly important [10]. Also, fewer contacts with telephone-based out-of-hours services with increasing distance and rurality have been reported [11, 12], and fewer face-to-face consultations have been reported after the initial call [11].

While distance may affect the utilisation of all kinds of health care, there has been long-standing interest among researchers in the relationship between distance and mental health care [13], the interest can be traced back to the mid-1800s, when inverse associations between distance to the hospital and rates of admissions were first identified [14, 15]. Longer distance from service providers may aggravate the disparities in mental health service utilisation between patients of high and low socioeconomic positions [16], and it reduces the use of outpatient mental health after care following substance abuse treatment [17]. Among patients using secondary outpatient mental health services, distance seems to be negatively associated with the utilisation of community mental health centres and outpatient clinics [18]. In a recent study conducted in Switzerland, public transport travel time was also found to be negatively associated with the use of secondary outpatient services but not with inpatient ward use [19].

Regularity and continuity of care are important aspects of outpatient treatment for mental health service users [20, 21]. Especially for medical conditions that require regular contact with health care personnel, travel time may create a barrier to service use [22, 23]. Age, gender, high education, being unmarried, poor housing conditions and previous use of health services have been identified as possible predisposing factors [24‐27], and having health insurance, though inconclusively, as one of the enabling factors [24, 25] for mental health service use. The number of mental health-related diagnoses constitutes the main need factor for the use of mental health services [24], others being the low level of functioning, comorbidity and perceived overall and mental health [25, 27]. In England, area-level social factors, including unemployment and deprivation, have been associated with more contacts and a higher proportion of ethnic minorities in the population, with fewer contacts in mental health services [28].

Telehealth has been viewed as an effective means of increasing mental health care access and continuity of care for people experiencing geographic, clinical or social barriers to accessing in-person care [29, 30]. In particular, telehealth services have been suggested as a promising method for delivering mental health treatment and engaging underserved populations, especially in rural settings and remote areas [31]. In a study focused on veterans with access barriers, the use of video-enabled tablets was associated with improved mental health care continuity and a lower proportion of missed or cancelled appointments when compared with a control group consisting of individuals who received mental health care from clinicians not providing telehealth care [32]. In the past two years, the COVID-19 pandemic has led to a more widespread transition from in-person to telehealth services. Although the transition has, in many cases, been an improvised response to restrictions and social-distancing precautions, there is evidence that not only are telehealth services a substitute for in-person services, but they may, in fact, contribute to an increase in the number of attended appointments and fewer cancelled appointments by minimising several logistical problems to attendance [33].

Mental health home visits and treatment have been found to be associated with both positive clinical outcomes and substantially lower costs of care compared with conventional outpatient care, especially among elderly people with depression [34, 35]. There is also evidence that mental health home visits that combine community-based and hospital-based home services can improve the stabilisation of clients’ illnesses and enhance their daily living and communication abilities [36, 37]. Despite the apparent benefits of home care services for the recipients of care, employees of home care services may have to spend a significant amount of time visiting clients. Studies have indicated that the amount of travel time may be underestimated, and the associated scarcity of time left for the actual delivery of service is a major restricting factor in providing home care services [38, 39]. Therefore, it is reasonable to assume that the geographic location of service providers, the distance between providers and recipients of mental health care services, and the available personnel exert a stronger influence on the provision of home care services than on other contact types. However, while much attention has been paid to the operational planning of service delivery [40], including route optimisation and personnel scheduling, the effect of distance on the provision of mental health home care remains a less studied area.

The purpose of our study is to investigate mental health service use in the Kainuu region in Finland from 2015 to 2019 in the adult population residing in the region, with a special focus on how mental health services are used in different parts of the region and whether travel time to primary health services acts as a potential barrier for use in different means of contacting mental health services (in-person visits, remote contacts, home visits). In this study, we focus on mental health services provided through primary health care due to the emphasis of the Finnish health care system on considering outpatient care as the primary form of treatment of patients with mental disorders [41]. Under this principle, mental health services should be organised primarily as outpatient services and clients should be supported in seeking care on their own initiative and in independent living. Mental health services provided at health centres increase the possibilities of seeking help for mental health problems, and primary care outpatient care and rehabilitation in health also costs less than hospital care.

Our study is motivated by the distinct regional differences in morbidity in Finland, including mental health and variations between rural and urban areas [42, 43]. In terms of many health indicators, northern and eastern Finland, as well as rural areas, show adverse health compared with more urbanised areas in the south and west of the country. The possible reasons for this are the lower socioeconomic status, adverse health behaviour, lack of social contacts and inadequate availability of health services in areas with higher morbidity [42]. However, the role of geographic distance and travel time to health services remains inconclusive. In a previous study focusing on the use of public primary health services by young adults in Northern Finland, distance was not found to be a major barrier to primary health care service use [44]. However, the study was based on self-reports and did not differentiate the reason for the visit, thus falling short of providing conclusive evidence on the matter.

We expect that distance may have a greater effect on in-person primary care visits (patients’ limited ability to travel) and home visits (providers’ difficulties supplying services to clients residing in remote areas) than on remote contacts. Despite a long history of studies regarding the relationship between travel distance and mental health service use, to our knowledge, the role of travel distance has not been studied explicitly with regard to the different contact types of mental health service use. This study provides information about inequalities in health service utilisation, which is essential for policy, planning and resource allocation in mental health services.

The locations of health centres in the Kainuu region, postal code areas with their average travel time to health centres and health centre areas are shown in Fig. 1. In 28 out of 70 postal code areas, the population resides, on average, within 15 min of travel time to the health centre. The longest average travel times are found in postal code areas located in the northern and eastern parts of the region.

The study population consisted of 7643 patients, of whom 7119 had made in-person visits to a health centre, 4855 had used remote contacts and 1503 had received home visits related to mental health during 2015–2019. The mean age of patients using home services was higher (57.8 years) than that of patients making in-person visits (47.9 years) or using remote contacts (47.5 years). Also, the percentage of patients having mental health diseases was higher among patients receiving home visits (80.2) than among patients making in-person visits (71.9) or using remote contacts (76.4).

During 2015–2019, the number of patients was highest in Kajaani (3621) and smallest in the Ristijärvi (117) health centre area (Table 1). The mean number of in-person visits per patient ranged between 11.5–45.5 (median 4–7), the mean number of remote contacts between 2.3– 5.1 (median 1 in all areas), and the mean number of home visits between 0.8–6.1 (median 0 in all areas) in different health centre areas. Most patients in different health centre areas had made mental health in-person visits to a health care personnel’s office (88.4%–94.3%) and used remote contacts (52.7%–71.2%). Home visits were less common and had been received by 12.8%–32.9% of patients in different health centre areas. The mean age of the patients ranged between 43.5 years in Kajaani and 54.8 years in Puolanka, whereas the percentage of patients having mental health diseases ranged between 55.3% in Puolanka and 72.0% in Kajaani. Patients’ average travel time to a health centre, as calculated for postal code areas, varied between 5.9–12.1 min.

The mean number of different types of primary health care mental health contacts in postal code areas in Kainuu shows a larger variation in in-person visits than in home visits and remote contacts (Fig. 2).

According to the Kruskal–Wallis test, there were statistically significant differences in mental health in-person visits (H (df 8, N 7643) = 63,28; p < 0.001), remote contacts (H (df 8, N 7643) = 78,08; p < 0.001) and home visits (H (df 8, N 7643) = 306,19; p < 0.001) across health centre areas. Mean ranks and the number of significant differences between areas are shown in Table 2. The city of Kajaani differs from the other five areas in terms of in-person visits, as the average rank of in-person visits was highest in Kajaani. In remote contacts and home visits, the differences were more diverse between health centre areas: Suomussalmi, Sotkamo and Ristijärvi had the lowest and Kuhmo the highest average ranks in remote contacts, while Kajaani, Paltamo, Puolanka, Ristijärvi and Sotkamo had the lowest average ranks in home visits. More detailed pairwise comparisons between areas are available as supplementary material.

The characteristics of patients and types of mental health contacts were investigated in different travel time distances. Over 90% of patients lived in postal code areas which were on average within a 15-min drive time from the municipality’s health centre, and less than 2% lived in postal code areas which were over 30 min away from the municipality’s health centre (Table 3). There were more women than men living near the health centres, while the median age of patients was higher in distant areas. The percentage of patients having mental health-related diseases showed a U-shaped pattern, being lowest in postal code areas that were 15 to 30 min away from a health centre. The percentage of patients making in-person visits was virtually uniform across different travel distance categories, whereas the percentage of patients using remote contacts slightly decreased and patients receiving home visits slightly increased with increasing travel time. The mean number of in-person visits and home visits per patient decreased with increasing travel time, while the mean number of remote contacts per patient was quite uniform across the travel time categories.

The incidence rate ratios (IRRs) indicate a decrease in the mental health service use with increasing travel time distance for health centre in-person visits and home visits (Table 4). There were approximately 14% fewer in-person visits to a health centre in the travel time distance category of 15–30 min and 37% fewer in-person visits to a health centre in the travel time distance category of over 30 min, compared with the 15 min travel time distance to a health centre. After adjusting for gender, age, having mental health diseases and the nearest health centre, the association became insignificant for the distance category of 15–30 min, but remained virtually unchanged (36% fewer visits) for the over 30 min distance category. As for home visits, there were 61% fewer visits in the travel time distance of 15–30 min and 68% fewer visits in the travel time distance of over 30 min compared with the 15 min travel time distance. After adjusting for gender, age, mental health diseases and the nearest health centre, associations indicated even greater differences: there were 67% and 83% fewer visits in the 15–30 min distance category and in the over 30 min distance category, respectively, compared with the 15 min distance category. In remote contacts, the IRRs indicated 29% less use in the 15–30 min travel time distance when compared with the 15 min travel time distance. After adjusting for gender, age, having mental health diseases and the nearest health centre the IRR notably increased but no statistically significant association remained with travel time distance and remote contacts.

To the best of our knowledge, this study is the first to examine the association of travel time with primary health care mental health service use by contact type. The study revealed significant differences in primary health care mental health service use across health centre areas and in relation to travel time in the Kainuu region of Finland. The associations varied according to how the patients contacted the services. The use of mental health services in doctors’ or health care personnel's office and home visits decreased with longer travel time, whereas remote contacts were used more uniformly across distances. Also, while all mental health contact types were most frequently used near the health centres, the percentage of patients having received home services was higher and the percentage of patients having used remote contacts was lower in distant areas. This may be an indication of difficulties in providing services to patients living in remote areas and that not all patients in distant areas may be candidates for remote services.

In particular, the distribution of in-person visits in Kajaani, the biggest population centre in Kainuu, diverged from other health centre areas, according to the statistical analysis. Kajaani differs from the surrounding municipalities in many aspects: the number of the patients is the highest, the patients are the youngest on average, the percentage of patients having mental health diseases is the highest, and the average travel time to a health centre is the shortest. These factors likely both predispose and enable patients to use in-person mental services more in Kajaani than in the surrounding areas. Also, better overall social and health service availability, including the secondary care provided in the central hospital in Kajaani, may encourage people with health problems to settle in Kajaani.

Our study concurs with other studies by suggesting that increased travel time may be associated with fewer mental health-related visits [19, 22]. Compared with patients residing near health centres in urbanised areas and population centres, patients living in sparsely populated outskirts must travel farther and may encounter other problems, such as scarcity or a complete lack of public transport [9]. What is an acceptable distance or travel time to health services from the perspective of an individual has been shown to be dependent both on contextual factors, such as the rurality or urbanity of the area, and the ability of individuals to travel [54, 55]. People living in rural areas have been found to tolerate longer travel distances better than people living in urban areas [55], and they may also be better equipped to overcome the long distances. However, a perceived lack of local services may impose feelings of insecurity on individuals needing the services even though they would have the readiness to travel to access services [54]. It is important that services are provided to patients according to their needs, as per the principles of universal health coverage and access [56].

In the case of home visits, the variation between health centre areas was more pronounced compared to other contact types. Kajaani, Paltamo, Puolanka, Ristijärvi and Sotkamo had lower average ranks in home visits than other areas. At the same time, the average age of patients was the youngest in two of these areas, Kajaani and Sotkamo. The percentage of patients having mental health diseases was the lowest in Puolanka, and the average travel times were the shortest in Kajaani and Ristijärvi, all being factors that may partly be attributable to the differences. Elderly people living alone are generally deemed prominent users of home services [57], and in this study, the patients using mental health-related home services were, on average, older than patients making either mental health in-person visits or using mental health remote contacts. Some factors on the service provider side may also account for some of the variation in service use in health centre areas in Kainuu. The availability of skilled home care personnel, long travel times and scattered residential locations of patients are things that can make service delivery difficult to manage [38, 39]. Thus, service providers may have different possibilities for offering home care to patients. Our discussions with the managers of home care in Kainuu have indicated that, rather unsurprisingly, the best home service coverage is achieved in areas in proximity to service providers. Although no definite distance thresholds for service provision exist, practice has shown that services can be provided most efficiently within about 10 kms from the facilities of the service providers, beyond which the delivery of services becomes considerably more difficult. The findings of this study also seem to strengthen this notion with regard to mental health services, as mental health-related home services were used less in the remote than in the near postal code areas. Moreover, our finding that the percentage of patients using home services is higher, but the average number of home visits is smaller in distant than in near areas, may indicate that people living far away from service providers may consist of patients who can manage their condition well, but also of people who may occasionally need home services.

The frequency of remote contacts also varied between health centre areas. Suomussalmi, Sotkamo and Ristijärvi had the lowest average rank in remote contacts and thus differed from many other areas. However, the characteristics of these areas are not fully consistent with what one might expect to decrease the use of remote contacts [58]: for example, the distance to a health centre was the longest in Suomussalmi, and the average age of patients was relatively young in Sotkamo. Kuhmo, on the other hand, had the highest average rank in remote contacts with the average age of patients and percentage of patients having mental health diseases relatively high. Still, not all studies have found an association between predisposing factors, such as gender or age, and the use of telehealth services [59]. Users of telehealth may differ distinctly from those using primary health care face-to-face services in health centres, as they may be younger, more highly educated and have a higher income [58].

The travel costs related to travel time from remote areas are often overlooked in health service use, even though they may be marked [60]. In some cases, remote contact may be a reasonable means of gaining access to health care for people living far away from service provider facilities. In our study, the percentage of those who had used remote contacts slightly decreased with distance, while the mean frequency was almost uniform. When gender, age, mental diseases and nearest health centre were considered, there were not any statistically significant associations with distance and the use of remote contacts, though the IRRS increased. In some other studies, however, telephone access to out-of-hours services has been found to decline with distance [11, 12], which does not fully agree with our study. However, in those studies, the geographical and health care setting was different from our study, and the studies specifically focused on general-practitioner services. In recent years, there have been efforts to strengthen telehealth services in the Kainuu region, which is manifested as an increase in the share of remote contacts from the year 2013 onwards [51]. Telehealth and remote contacts might be a feasible way to overcome some of the barrier effects posed by the long travel time in remote areas, although remote contacts may be appropriate for a limited type of patients and conditions only. The strengths of our study include the 5-year register-based information about actual use of mental health services in primary health care for the adult population living in the study region. Although address-level information about the residential locations of the service users was not available for privacy reasons, postal code areas and population-weighted distances based on 250 m × 250 m grid cells can be regarded as reasonably good approximations of residential locations and travel distances.

We also acknowledge certain limitations of this study. Because our study was based on register data with limited information about individual characteristics, some of the important factors associated with health service use may have been left out, such as socioeconomic status or ability to use a car [61]. In the sparsely populated areas of Kainuu, having a car may be the only feasible way to travel to health services, as the availability of public transport is very limited in the area [62]. However, people who are not able to travel to health services by themselves can use taxi transport with compensated travel costs in Finland [63, 64]. We also did not have information about the quality of mental health care in each contact, or the actual resources available in different health centres, which could have strengthened the interpretation of our findings.

In this study, we assumed that the patients used the services of the nearest health centre in their home municipality. While the majority of contacts have likely taken place in the nearest health centre or other facility in the vicinity of it in the municipal centre, it is possible that some patients may have used services in other health centres or service facilities. One factor which may obscure the associations of mental health service use and distance is that people may not always want to use the closest service provider, though once people make contact with care, they may make more frequent visits if the travel time is short. The actual premises of service use should be taken into more accurate consideration in further studies. Also, the information of patients’ residential locations was based on the last recorded postal code area from 2015 to 2019, which leaves the possibility that the patient may have also had a different home location at some point in the follow-up.

As it was not possible to account for self-selection, we are not able to know if, for example, an onset of a health problem has induced a move closer to the services, thereby increasing the use of services in postal code areas near the service facilities. People may have a propensity to move because of health-based reasons [65]. Some of the contacts that have been related to mental health service use may have been recorded as other types of visits, such as substance abuse-related visits, meaning that the mental health-related visits may be under-represented in some cases. Also, those having mental health problems, but not having diagnosis and never seeking services, are missing from the data. On the other hand, people who have visited health services more frequently are more likely to have had more disorders diagnosed, though the use of disease groups rather than individual diagnoses as a confounder decreases the impact of this. It should also be noted that the use of mental health services should not be taken as an indicator of the need for mental health care in different areas, because several factors may either promote or hinder the user of services [2]. The generalisability of the findings in this study may be partly limited to other similar, sparsely populated areas with publicly funded health care systems.

While previous research suggests that the geographical accessibility of Finnish primary health care is mostly good [62], the ageing population and lack of skilled personnel in certain areas may deter the situation in the coming years. It is important to make potential inequalities in health service use and provision visible so that they can be considered when planning and providing health services. According to Anderson & Newman [8], it may be more feasible to bring about a change through the enabling (e.g. travel time to service) than the predisposing variables (e.g. age, gender). Earlier policy decisions concerning service provision may have been made with very limited information, signifying that studies calling attention to the importance of different societal and individual determinants of health and health service use are valuable.

The present study revealed significant differences in primary health care mental health service use in relation to travel time and according to how services were contacted in the Kainuu region, Finland. The mental health in-person visits and home visits decreased with longer travel time, whereas remote contacts were used more uniformly across distances. Policy decisions concerning service provision should be informed about the importance of the individual, societal and provider-side determinants of health and health service use and possible inequalities related to these factors. Especially with conditions that call for the continuation and regularity of care, enabling factors, such as travel time, may be crucial. Providing services remotely may partly compensate for the barrier effects of long travel times in mental health services. Because of the study context, the results may be best applicable to sparsely populated areas with publicly funded health care systems.