A new multinational study finds that individuals with poor mental health consistently report lower-quality healthcare experiences across diverse health systems.
Published May 5 in PLOS Medicine, the study was led by Margaret E. Kruk, MD, of Washington University School of Medicine in St. Louis, in collaboration with an international team of researchers.
The findings come as rates of depression and anxiety have risen sharply worldwide since the COVID-19 pandemic, increasing demand for care and placing new strain on health systems.
The World Health Organization estimates that cases of anxiety and depression increased by about 25% globally during the first year of the pandemic, and it has warned that gaps in mental health services and access remain a major challenge.
In this study, nearly one in five adults across 18 countries reported poor or fair mental health. Researchers say data remain limited on how people with poor mental health use and experience care across countries — information needed to design services that can keep pace with growing demand.
The paper, “Health System Use and Experience Among People With Poor Mental Health: A Cross-Sectional Analysis of the People’s Voice Survey in 18 Countries,” analyzed nationally representative survey data from more than 32,000 adults in high-, middle- and low-income countries across Africa, Asia, Europe and the Americas. More than 1,000 people from each country responded. First, respondents rated their physical and mental health. They were also asked about their experiences navigating care, including how often they used services, how they rated the quality of care, and how confident they felt managing their overall health.
The data were collected in 2022 and 2023 through phone, online and in-person interviews as part of the People’s Voice Survey, a global effort to understand how people experience and trust their health systems.
The survey is part of an ongoing global effort developed and implemented by the Quality Evidence for Health System Transformation (QuEST) Network, led by Kruk, the Distinguished Endowed Professor of Health Systems & Medicine at WashU Medicine, a professor at WashU Public Health and director of the universitywide QuEST Center and the international QuEST Centers and Network.
Widespread impact
Rates of poor mental health varied widely across countries, from about 5% in Nigeria, the lowest share reporting poor mental health, to nearly 40% in China, the highest — with no clear link to a country’s income level. In most countries, women were more likely than men to report poor mental health.
People with poor mental health were significantly more likely to report worse overall health — nearly 70% rated their health as poor or fair, compared with about 20% of those with better mental health — and were also more likely to report chronic conditions. These findings show that mental and physical health are closely linked and likely influence each other in both directions.
“Health systems need to assess and respond to mental and physical health concerns holistically — this is a big shift from current practice,” Kruk said.
People with poor mental health also reported lower-quality care. They described poorer experiences during visits, higher rates of unfair treatment or discrimination, and more unmet health needs — even when access to care was similar. They were less engaged in managing their health, including less confidence in raising concerns with providers and taking an active role in their care, and less confident they could obtain and afford good care.
Researchers say improving patient activation — people’s confidence and ability to manage their own health — may lead to better outcomes. This could include health education, clear care instructions, more empathetic communication and shared decision-making with providers, support from care navigators or community health workers, and help overcoming barriers such as transportation.
Mental health care use ranged from less than 1% of respondents in some countries to more than half in others, with access strongly linked to national income levels. Despite these differences, the gap in care experience remained consistent across countries.
“People with poor mental health had worse care, more unmet needs, and less trust in the system, regardless of where they lived,” Kruk said.
System gaps
The findings suggest that people with poor mental health often have more complex health needs and may have a harder time navigating the health system, affecting how they seek care and experience treatment. Researchers say this underscores the need to better integrate mental health into primary and front-line care, rather than treating it as separate from other health needs. Differences across countries in access and confidence also point to where health systems can learn from each other and improve care over time.
The study brought together researchers from universities, health institutes and government agencies across multiple continents. Patricia Cavazos-Rehg, PhD, a professor of psychiatry at WashU Medicine and a professor at WashU Public Health, is the study’s senior author. Todd P. Lewis, PhD, an assistant professor at WashU Medicine, and Eric J. Lenze, MD, the Wallace and Lucille K. Renard Professor of Psychiatry at WashU Medicine, also contributed. Co-authors also represent institutions such as the Harvard T.H. Chan School of Public Health, Johns Hopkins Bloomberg School of Public Health, George Washington University and the World Health Organization Regional Office for Europe, along with national research centers and ministries of health in countries including Peru, Ethiopia, Nigeria, India and Argentina.
Researchers caution that the findings are based on self-reported mental health rather than clinical diagnoses and reflect associations at a single point in time, meaning they cannot establish cause and effect. Still, they say tracking these measures across countries and over time could help health systems identify gaps and track progress.
