Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review

Online HIV information seeking and pre-exposure prophylaxis awareness among people who use drugs

People who use drugs (PWUD) remain at high risk for acquiring human immunodeficiency virus (HIV), both from injection and from sexual risk-taking. In 2016, 9% of 39,782 new HIV diagnoses occurred among people who inject drugs in the United States. Reaching PWUD with accurate information about and motivation for initiating pre-exposure prophylaxis (PrEP) remains challenging and remains the first crucial step in the knowledge-attitude-behavior change continuum. This study seeks to contribute to closing this information gap by examining the HIV information-seeking behaviors among PWUD who are not on PrEP, so as to identify potential strategies to increase adoption of HIV prevention such as PrEP as part of overall health and related to risk-taking behaviors. A cross-sectional survey was conducted in 2016 among HIV-negative PWUD (n = 400), 57.3% of whom reported injecting at least once in a week, chronically maintained on methadone treatment (MMT) at a large addiction treatment program. The study found that the number of hours spent online by people who use drugs was comparable to the general population. Awareness about PrEP and the seeking of HIV-related information was low in this population. Looking for sex partners online, perception of risk, having multiple partners were associated with seeking HIV information. Although using injection drugs was related to high perception of risk of acquiring HIV, it was not associated with seeking HIV information online. It is imperative to further understand the online HIV information seeking behavior of this population and provide targeted information in order to increase awareness and knowledge about HIV-related risk and methods of prevention, including information about PrEP.

The impact of rurality on opioid-related harms: A systematic review of qualitative research

INTRODUCTION

Over the past decade, there has been mounting recognition that opioid use and related mortality and morbidity is a significant public health problem in rural, non-urban areas across the globe. Taking what has been termed the 'opioid crisis' as a starting off point, this article aims to systematically review the qualitative literature on the ways in which rurality shapes the risk for opioid-related harm.

METHODS

A systematic review was undertaken using database searches and secondary reference list searches for qualitative literature on rural and non-urban opioid-related harms. A total of 32 qualitative studies met the inclusion criteria. Data extraction was performed in NVivo 12 using a codebook based on the 'risk environment' framework.

RESULTS

The findings explore how rurality shapes the risk environment for opioid-related harms through four environment influences: (1) economic conditions, including economic transition and deindustrialisation that has occurred in many rural areas, and the high levels of economic distress experienced by rural residents; (2) physical conditions, including a lack of infrastructure and recreation opportunities, larger geographic distances, and limited transportation; (3) social conditions, where social networks could be both protective but also amplify risk through a lack of knowledge about treatment and risk behaviours, a lack of anonymity and stigmatisation of people who use opioids in rural areas; and (4) policy conditions including limited coverage and availability of harm reduction and drug treatment services, and stigmatising service provider practices.

CONCLUSIONS

The impact of rurality on risk of opioid-related harm is multifaceted. We suggest that future research on rural opioid use would benefit from drawing on the theoretical toolkit of rural criminology to attend to the ways the 'rural crisis', and attendant insecurities, anxieties and strains, impacts upon rural communities and shapes risk, along with how socio-cultural characteristics of the rural 'organise' risks of drug use.

Health Status and Health Service Utilization among Vietnamese Farmers in a Mountainous Province

Problems of poor health status and low health service use among farmers in mountainous areas have not been fully investigated. A cross-sectional study was conducted in Son La, a mountainous province in Vietnam, to assess the self-rated health and health care service utilization among farmers. Visual analogue scale (VAS) was used to measure the self-rated health. Multivariate Tobit, Poisson, and logistic regression were employed to identify related factors. Among 197 farmers, the mean VAS score was 67.8 (SD = 15.5). Approximately 40% of participants reported health problems, and the most popular morbidity was hypertension—56.4%. There were 28.9% and 50.3% of farmers using inpatient and outpatient treatments in the last 12 months, respectively. Age, educational level, family income, marital status, alcohol use, and source of information have been identified as associated factors with self-rated health status and morbidities, while age, gender, education, and morbidities were related to health service utilization. Data indicated a high proportion of health issues and a high rate of health care service use among farmers in a mountainous area of Vietnam. Adaptable health policies and prevention programs or preventive health services should be implemented regularly in mountainous regions to protect farmers from the onset of morbidities and to enhance their health.

Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy

Background

Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS.

Methods

A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned.

Results

The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use.

Conclusions

There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.

Use of technology for delivery of mental health and substance use services to youth living with HIV: a mixed-methods perspective

Disparities in HIV treatment outcomes among youth living with HIV (YLWH) present a challenge for ending the HIV epidemic. Antiretroviral therapy (ART) adherence can be impacted by comorbidities such as mental health and substance use. Technology use has shown promise in increasing access to mental health and substance use services. Using a mixed-methods approach, we conducted formative research to describe the relationship between mental health, substance use, and medication adherence in 18-29 year-old YLWH, and explored technology use as an approach to supporting these services. Among 101 YLWH, ART adherence was significantly negatively associated with mental health measures such as depression, trauma, and adverse childhood experiences and marijuana and stimulants use. Depression had the highest level of relative importance in its association with ART adherence. During in-depth interviews with 29 participants, barriers to and facilitators of accessing and maintaining mental health services were identified. Most participants favored technology use for mental health and substance use service delivery, including videoconferencing with a counselor. Provision of ongoing mental health and substance use treatment is an important mechanism to achieving HIV treatment engagement. Technology, particularly videoconferencing, may have the capacity to overcome many barriers to care by increasing accessibility of these services.

Improving health access for gender diverse children, youth, and emerging adults?

Gender diverse people are individuals who define their gender as different from the sex they were assigned as birth. This incongruence leads to a sense of discomfort within oneself, which according to the DSM-V is called gender dysphoria. The combination of dysphoria, ongoing stress, as outlined in the Minority Stress Theory (Meyer, 2003, Dohrenwend, 2000) and the stigma related to living in a society which traditionally defines gender as binary and rejects the notion of gender as fluid, is associated with psycho-social, mental, and physical health problems. Gender diverse children and young people require support from health practitioner to assist them not only in transitioning, if this is what they choose, but also to manage ongoing and preventive health care in a system which is not always welcoming and frequently hostile to them. In 2012 the United Nations General Assembly called for universal health coverage as a goal in the post-2015 Millennium Development Goal Framework. One step in attaining this goal is universal health access which is not currently being met for gender diverse individuals. Hence, we need to work together, with those that we serve, to develop appropriate, sensitive and accessible health care for all.

Rationale and design of a systematic review: effectiveness and acceptance of technology-based psychological interventions in different clinical phases of depression management

INTRODUCTION

Although many effective treatment options exist, depression is still undertreated indicating gaps in the healthcare system. The complementary provision of mental healthcare through technologies (eg, computer, smartphone) has the potential to fill treatment gaps and to overcome access barriers to mental healthcare. Until now, no systematic review integrates the evidence on different technology-based psychological interventions (TBIs) concerning their effectiveness and acceptance in different clinical phases of depression management (bridging waiting periods, acute treatment and aftercare). The aim of this project is to structure evidence on TBIs regarding different phases of depression management, and to determine effectiveness and acceptance for each clinical phase considering both active (eg, face-to-face treatment) and inactive (eg, waitlist) controls as comparators.

METHODS AND ANALYSIS

We will include studies on adults with a formal diagnosis of unipolar depression. Treatments delivered by technologies based on scientific psychological theories will be considered as experimental interventions. The primary effectiveness outcome will be depressive symptoms at study endpoint measured by symptom severity rating scales, and the primary acceptance outcome will be dropping out of the study due to any reason. We will consider only randomised controlled trials, which will be identified by key database searches (including Cochrane Central Register of Controlled Trials, Medline, PsycINFO, PSYNDEX, CINAHL) complemented through searches in clinical trial registries (eg, clinicaltrials.gov) and grey literature searches (eg, Open Grey). Two review authors will independently conduct study selection, data extraction and quality assessment of included studies (using the Cochrane Collaboration's tool for assessing risk of bias). Meta-analyses applying random-effect models as well as subgroup, meta-regression and sensitivity analyses will be performed.

ETHICS AND DISSEMINATION

Ethics approval is not required for this study, as we conduct research on secondary data. We will disseminate results via peer-reviewed journal publications, presentations on conferences and via plain language summaries.

PROSPERO REGISTRATION NUMBER

CRD42016050413; Pre-results.

The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis

BACKGROUND

Depressive and anxiety disorders are highly prevalent and detrimental in primary care settings. However, there are gaps in the literature concerning effectiveness and generalizability of empirically supported interventions and treatment of both depression and anxiety in primary care settings. The aim of this review is to systematically assess and meta-analyze the effectiveness of brief empirically-supported psychotherapies for treating depression and/or anxiety in primary care.

METHODS

Seven electronic databases, five professional websites and manual search of reference lists were searched through April 2017 for randomized controlled trials (RCTs) of four psychotherapies treating primary care depression and anxiety: cognitive-behavior therapy (CBT), problem-solving therapy (PST), motivational interviewing (MI), and solution-focused brief therapy (SFBT).

RESULTS

From an initial pool of 1140 articles, 179 articles were eligible for full-text review and 65 articles were included for final analysis. Sixty-five articles containing 198 effect sizes reported an overall treatment effect size of d = 0.462, p < 0.001. Single-predictor meta-regression indicated that marital status, treatment modality (individual versus group), and treatment composition were significant moderators. Multiple-predictor meta-regression discovered treatment setting (inside versus outside primary care) significantly moderated treatment effect, b = -0.863, p = 0.039 after controlling for other intervention characteristics.

CONCLUSION

Treatment effects were found for CBT and PST, both for depressive and anxiety disorders. Interventions delivered outside primary care settings were more effective than those within, individual treatment had greater treatment effects compared to group treatment, and both technology-assisted and in-person treatments were found to be effective.

Clinician identified barriers to treatment for individuals in Appalachia with opioid use disorder following release from prison: a social ecological approach

BACKGROUND

The non-medical use of opioids has reached epidemic levels nationwide, and rural areas have been particularly affected by increasing rates of overdose mortality as well as increases in the prison population. Individuals with opioid use disorder (OUD) are at increased risk for relapse and overdose upon reentry to the community due to decreased tolerance during incarceration. It is crucial to identify barriers to substance use disorder treatment post-release from prison because treatment can be particularly difficult to access in resource-limited rural Appalachia.

METHODS

A social ecological framework was utilized to examine barriers to community-based substance use treatment among individuals with OUD in Appalachian Kentucky following release from prison. Semi-structured qualitative interviews with 15 social service clinicians (SSCs) employed by the Department of Corrections were conducted to identify barriers at the individual, interpersonal, organizational/institutional level, community, and systems levels. Two independent coders conducted line-by-line coding to identify key themes.

RESULTS

Treatment barriers were identified across the social ecological spectrum. At the individual-level, SSCs highlighted high-risk drug use and a lack of motivation. At the interpersonal level, homogenous social networks (i.e., homophilious drug-using networks) and networks with limited treatment knowledge inhibited treatment. SSC's high case load and probation/parole officer's limited understanding of treatment were organizational/institutional barriers. Easy access to opioids, few treatment resources, and a lack of community support for treatment were barriers at the community level. SSC's noted system-level barriers such as lack of transportation options, cost, and uncertainty about the implementation of the Affordable Care Act.

CONCLUSIONS

More rural infrastructure resources as well as additional education for family networks, corrections staff, and the community at large in Appalachia are needed to address barriers to OUD treatment. Future research should examine barriers from the perspective of other key stakeholders (e.g., clients, families of clients) and test interventions to increase access to OUD treatment.

Telementoring of primary care providers delivering hepatitis C treatment in New York City: Results from Project INSPIRE

INTRODUCTION

The recent availability of highly effective, easily administered, and relatively nontoxic treatments for hepatitis C virus (HCV) infection provides an opportunity for clinicians to treat HCV in nonspecialist settings with appropriate support. Project INSPIRE provides care coordination to HCV patients and a web-based training program (telementoring) on disease management and treatment by HCV specialists to primary care providers inexperienced in HCV treatment. Weekly telementoring sessions use a didactic and case-based approach to instruct non-HCV providers on how to identify and assess HCV treatment candidates and prescribe appropriate treatment.

METHODS

We used mixed methods to assess the telementoring service, including provider surveys and semistructured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed to identify dominant themes.

RESULTS

Provider survey responses indicated an increased ability to identify and evaluate HCV treatment candidates and increased confidence in sharing knowledge with peers and patients. Interviews revealed a high degree of satisfaction with the telementoring service and Project INSPIRE overall. The telementoring service was viewed as having enhanced providers' knowledge, confidence, and ability to treat their own HCV-infected patients rather than having to refer them to an HCV specialist with resulting benefits for continuity of care. Providers reported comradery and collegiality with other INSPIRE providers and satisfaction with professional growth from attaining new knowledge and skills via the telementoring service.

CONCLUSIONS

Using readily available web conferencing technology, telementoring can facilitate knowledge transfer between specialists and primary care providers, facilitating continuity of care for patients and increased provider satisfaction.

Understanding the Business Case for Telemental Health in Rural Communities

Telemental health has been promoted to address long-standing access barriers to rural mental health care, including low supply and long travel distances. Examples of rural telemental health programs are common; there is a less clear picture of how widely implemented these programs are, their organization, staffing, and services. There is also a need to understand the business case for these programs and assess whether and how they might realize their promise. To address these gaps, a national study was conducted of rural telemental health programs including an online survey of 53 programs and follow-up interviews with 23 programs. This article describes the current landscape and characteristics of these programs and then examines their business case. Can rural telemental health programs be sustained within current delivery systems and reimbursement structures? This question is explored in four areas: need and demand, infrastructure and workforce, funding and reimbursement, and organizational fit and alignment.

Differences in Perceptions of and Practices Regarding Treatment of Alcohol Use Disorders Among VA Primary Care Providers in Urban and Rural Clinics

BACKGROUND

Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas.

METHODS

A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources.

CONCLUSIONS

Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.

Justice Involvement and Treatment Use Among Rural Veterans

Veterans in rural areas and veterans involved in the criminal justice system have experienced less access to, and use of, health care. However, there is limited information on the treatment needs and health care access of justice-involved veterans who live in rural areas. This study used national Veterans Health Administration data from fiscal year 2014 to examine the interactive effect of rural/urban residence and justice involvement on mental health and substance use disorder treatment entry among veterans diagnosed with mental health or substance use disorders. Of veterans residing in rural areas, 15,328 (2.5%) were justice-involved and 607,819 (97.5%) veterans had no known justice involvement. Among veterans in urban areas, 54,525 (4.3%) were justice-involved and 1,213,766 (95.7%) had no known justice involvement. Rural residence was associated with lower access to mental health or substance use disorder treatment in the non-justice-involved sample but not the justice-involved sample. Justice-involvement was associated with higher odds of entering mental health or substance use disorder treatment for veterans in rural and in urban areas. Substance use disorder treatment entry could be improved for all veterans, particularly rural veterans who are not justice-involved. Telehealth, outreach services, and integrated treatment may help address challenges to treatment entry experienced by rural veterans and justice-involved veterans.

Secondary Prevention of Alcohol Problems in Rural Areas Using a Bibliotherapy-Based Approach

This study investigated the relative effects of three 12-week secondary prevention interventions for problem drinking men and women in rural counties in New York State. The participants were 111 self-referred men and women without severe dependence on alcohol who nevertheless reported heavy drinking and a desire to reduce their alcohol consumption. They were assigned randomly to one of three 12-week interventions focused on reducing alcohol intake: bibliotherapy (a self-directed manual) alone, bibliotherapy with one telephone-administered motivational interview, or bibliotherapy with one telephone-administered motivational interview and six biweekly telephone therapy sessions. Results showed that, across conditions, participants significantly increased their abstinent and light drinking days and significantly decreased their heavy drinking days over the course of treatment and a 12-month follow-up period. In addition, participants reported moderate reductions in alcohol consequences and increases in confidence not to drink heavily across a variety of situations from pre- to posttreatment, with these changes remaining stable across the course of the follow-up. Use of the drinking reduction strategies presented in the self-directed manual also remained stable from posttreatment to the 12-month follow-up. These results provide support for consideration of bibliotherapy for rural problem drinkers who are not severely dependent on alcohol, with or without the addition of telephone contacts.

Web-based therapeutic interventions for assessing, managing and treating health conditions in Indigenous people: a scoping review protocol

REVIEW OBJECTIVES/QUESTIONS

The objective of the scoping review is to map the international scientific literature on web-based therapeutic interventions (WBTI) used by Indigenous people for assessing, managing and treating health conditions. The focus of this review is WBTIs for a broad range of health conditions, including but not limited to, communicable and non-communicable diseases, mental health conditions (including the broader concept of social and emotional wellbeing), use of harmful substances and gambling.The questions for the scoping review are.

Substance use disorders in military veterans: prevalence and treatment challenges

Substance use disorders (SUDs) are a significant problem among our nation's military veterans. In the following overview, we provide information on the prevalence of SUDs among military veterans, clinical characteristics of SUDs, options for screening and evidence-based treatment, as well as relevant treatment challenges. Among psychotherapeutic approaches, behavioral interventions for the management of SUDs typically involve short-term, cognitive-behavioral therapy interventions. These interventions focus on the identification and modification of maladaptive thoughts and behaviors associated with increased craving, use, or relapse to substances. Additionally, client-centered motivational interviewing approaches focus on increasing motivation to engage in treatment and reduce substance use. A variety of pharmacotherapies have received some support in the management of SUDs, primarily to help with the reduction of craving or withdrawal symptoms. Currently approved medications as well as treatment challenges are discussed.

Rural and Appalachian Disparities in Neonatal Abstinence Syndrome Incidence and Access to Opioid Abuse Treatment

OBJECTIVE

Incidence of neonatal abstinence syndrome (NAS) is increasing due to the rise in opioid use. Rural states like Kentucky have been disproportionally impacted by opioid abuse, and this study determines NAS burden nationally and in Kentucky while quantifying differences in access to care between Appalachian and non-Appalachian counties.

METHODS

NAS rates were calculated using National (2013) and Kentucky (2008-2014) National Inpatient Sample discharge data. Births were identified using International Classification of Diseases v9 code 779.5 and live birth codes V30.x-V38.x. Counties were classified as rural, micropolitan, or metropolitan using census data. Proximity analysis was conducted via mapping from ZIP code centroid to nearest opioid treatment facility. Distance to treatment facilities was calculated and then compared using nonparametric testing for counties by rural and Appalachian status.

RESULTS

NAS cases tripled from 2008 to 2014 in Kentucky counties, with a 2013 NAS rate more than double the national NAS rate. Rural and Appalachian counties experienced an NAS increase per 1,000 births that was 2-2.5 times higher than urban/non-Appalachian counties, with a greater number of NAS births overall in Appalachian counties. All opioid treatment facility types were further from rural patients than micropolitan/metropolitan patients (P < .001), as well as further for Appalachians versus non-Appalachians (P < .001, all facility types).

CONCLUSIONS

NAS burden disparately affects rural and Appalachian Kentucky counties, while treatment options are disproportionately further away for these residents. Policy efforts to increase NAS prevention and encourage opioid abuse treatment uptake in pregnant women should address rural and Appalachian disparities.

The effect of insurance type on trauma patient access to psychiatric care under the Affordable Care Act

OBJECTIVE

The objective of the study was to assess the effect of insurance type (Medicaid, Medicare, private insurance or cash pay) on patients' access to psychiatrists for a new patient consultation.

METHOD

240 psychiatrists identified as interested in treating patients with PTSD were called across 8 states. The caller requested an appointment for her fictitious boyfriend who had been in a car accident to be evaluated for PTSD. Each office was called four times to assess the responses for each payment type. From each call, whether an appointment was offered and barriers to an appointment were recorded.

RESULTS

21% of psychiatrists would see new patients. 15% of offices scheduled an appointment for a patient with Medicaid, compared to 34% for Medicare, 54% for BlueCross and 93% for cash pay (p<0.001). Medicaid patients confronted more barriers to receiving appointments and had more trouble scheduling appointments in states with expanded Medicaid eligibility. The overall number of Medicaid patients who would be able to theoretically schedule an appointment in states with versus states without expanded Medicaid eligibility was approximately equivalent. Psychiatry practice characteristics, such as whether the practice was academic, were not significantly associated with acceptance of Medicaid.

CONCLUSIONS

Access to a psychiatrist for a new patient consultation is challenging. Despite expansion of the Affordable Care Act, substantial barriers remain for Medicaid patients in accessing psychiatric care compared to patients with Medicare, private insurance or those who pay cash.

Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review

PURPOSE

Rural areas persistently face a shortage of mental health specialists. Task shifting, or task sharing, is an approach in global mental health that may help address unmet mental health needs in rural and other low-resource areas. This review focuses on task-shifting approaches and highlights future directions for research in this area.

METHODS

Systematic review on task sharing of mental health care in rural areas of high-income countries included: (1) PubMed, (2) gray literature for innovations not yet published in peer-reviewed journals, and (3) outreach to experts for additional articles. We included English language articles published before August 31, 2013, on interventions sharing mental health care tasks across a team in rural settings. We excluded literature: (1) from low- and middle-income countries, (2) involving direct transfer of care to another provider, and (3) describing clinical guidelines and shared decision-making tools.

FINDINGS

The review identified approaches to task sharing focused mainly on community health workers and primary care providers. Technology was identified as a way to leverage mental health specialists to support care across settings both within primary care and out in the community. The review also highlighted how provider education, supervision, and partnerships with local communities can support task sharing. Challenges, such as confidentiality, are often not addressed in the literature.

CONCLUSIONS

Approaches to task sharing may improve reach and effectiveness of mental health care in rural and other low-resource settings, though important questions remain. We recommend promising research directions to address these questions.

Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update)

Background

There is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health.

Methods

MEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR).

Results

Forty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation.

Conclusion

This systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary.

Trial registration

PROSPERO, CRD42015017661

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0510-7) contains supplementary material, which is available to authorized users.

Rural and Urban/Suburban Families' Use of a Web-Based Mental Health Intervention

Background/Introduction: Access to mental healthcare among rural residents is a national concern because unique barriers (e.g., fewer providers, distance to services) create significant challenges for the 60 million Americans who live in these settings. There is now a large body of literature demonstrating the efficacy of a wide range of Internet-based interventions. However, little is known about the extent to which individuals in rural settings will use these approaches and find them acceptable. Research with youths and their caregivers within this scope is particularly limited and, therefore, of great importance.

METHODS

We examined access and completion of a Web-based disaster mental health intervention in a population-based sample of 1,997 rural (n = 676) and urban/suburban (n = 1,321) adolescents and their caregivers who were affected by the Spring 2011 tornadoes that touched down in parts of Missouri and Alabama.

RESULTS

Results indicated no differences in the rate of access or completion of Web-based modules based on geographical location. Furthermore, for those who did not access the Web-based resource, no differences were observed with respect to reasons for not accessing modules based on geographical location.

DISCUSSION

These data have promising implications for the reach of Web-based resources to both rural and urban/suburban communities, as well as the willingness of adolescents and their caregivers to access and complete such resources, regardless of geographical location.

Community pharmacy staff perceptions on preventing alcohol and medication interactions in older adults

OBJECTIVES

To examine rural and urban pharmacy staff perceptions on messaging, barriers, and motivators for preventing alcohol and medication interactions (AMI) in older adults (≥65 years of age).

METHODS

A survey was distributed through the local pharmacist association and statewide pharmacy registry in Kentucky. A total of 255 responses were received from pharmacists, pharmacy technicians, and pharmacy students.

RESULTS

Across rural and urban regions alike, among the AMI prevention messages provided, participants identified the most important messages to be: AMI can be potentially dangerous and life threatening; emergency rooms should be used when experiencing an AMI; and doctors and pharmacists should be consulted about AMI. The most common AMI prevention barriers indicated were stigma, costs, and low perceived risks. The most common AMI prevention motivators indicated were physical health improvement, promoting a healthy lifestyle, convenient setting, and financial incentives.

CONCLUSION

Regardless of geography, participants similarly rated the presented AMI prevention messages, barriers, and motivators. With the use of these findings, the development of an AMI prevention program is suggested to use messaging about AMI threat, behavioral management, and behavioral prevention.

Acceptance of the German e-mental health portal www.psychenet.de: an online survey

Background. Taking into account the high prevalence of mental disorders and the multiple barriers to the use of mental health services, new forms of fostering patient information, involvement, and self-management are needed to complement existing mental health services. The study aimed at investigating acceptance regarding design and content of the e-mental health portal www.psychenet.de.

Methods. An online cross-sectional survey was conducted between May 2013 and May 2015 using a self-administered questionnaire including items on perceived ease of use, perceived usefulness, attitude towards using, and perceived trust. Effects of different participants’ characteristics on the portals’ acceptance were analyzed.

Results. The majority of the N = 252 respondents suffered from mental disorders (n = 139) or were relatives from persons with mental disorders (n = 65). The portal was assessed as “good” or “very good” by 71% of the respondents. High levels of agreement (89–96%) were shown for statements on the perceived ease of use, the behavioral intention to use the portal, and the trustworthiness of the portal. Lower levels of agreement were shown for some statements on the perceived usefulness of the portals’ content. There were no effects of different participants’ characteristics on the perceived ease of use, the perceived usefulness, the attitude towards using the website and the perceived trust.

Discussion. This survey provides preliminary evidence that the e-mental health portal www.psychenet.de appears to be a usable, useful and trustworthy information resource for a broad target group. The behavioral usefulness of the portals’ content might be improved by integrating more activating patient decision aids.

Developing a measure of engagement with telehealth systems: The mHealth Technology Engagement Index

Introduction Telehealth systems and mobile health (mHealth) devices allow for the exchange of both physical and mental healthcare data, as well as information from a patient to a practitioner, or care recipient to caregiver; but there has been little research on why users are motivated to engage with telehealth systems. Given this, we sought to create a measure that satisfactorily assesses human motivation to use telehealth devices. Methods 532 survey responses were used in an exploratory factor analysis and confirmatory factor analysis, which tested and retested the feasibility of this new measure. Convergent and divergent validity analyses indicated that the mHealth Technology Engagement Index (mTEI) is a unique measure of motivation. Results The results indicated that autonomy, competence, relatedness, goal attainment, and goal setting underpin motivation to use telehealth systems. Discussion The mTEI shows promise in indexing human motivation to use telehealth technologies. We also discuss the importance of developing measurement tools based on theory and how practitioners can best utilize the mTEI.

Considerations for the Telehealth Systems of Tomorrow: An Analysis of Student Perceptions of Telehealth Technologies

BACKGROUND

While much is known about factors that facilitate telehealth adoption, less is known about why adoption does or does not occur in specific populations, such as students.

OBJECTIVE

This study aims to examine the perceptions of telehealth systems within a large student sample.

METHODS

Undergraduate students (N=315) participated in a survey of the perceived advantages and disadvantages of telehealth technologies. The responses to the survey were analyzed using thematic analysis.

RESULTS

We found that students were likely to adopt telehealth systems for the following reasons: (1) the system worked efficiently, (2) the convenience of telehealth, and (3) to gain access to health services. Students also perceived several disadvantages to telehealth systems, such as issues of trust (ie, security, privacy), the impersonal nature of telehealth systems, and they were concerned about the potential for major system errors.

CONCLUSION

By understanding the current barriers to telehealth adoption in a cohort of students, we can not only better anticipate the future needs of this group, but also incorporate such needs into the design of future telehealth systems.

Service providers' experiences of using a telehealth network 12 months after digitisation of a large Australian rural mental health service

BACKGROUND

Despite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits.

OBJECTIVE

Within the framework of Innovation Diffusion Theory, to study service providers' experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia.

METHODS

Qualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility.

RESULTS

Five themes with 11 sub-themes were identified: (1) "Existing Uses", with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) "Relative Advantage", with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) "Technical Complexity"; (4) "Technical Compatibility" with two sub-themes: technical-clinical and technical-administrative; and (5) "Broader Organisational Culture", with two sub-themes: organizational policy support and 'digital telehealth' culture.

CONCLUSIONS

The digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less "drop-out", less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture.

A Review of Mental Health Approaches for Rural Communities: Complexities and Opportunities in the Canadian Context

Three mental health approaches with potential relevance to rural Canada were reviewed: telepsychiatry, integrated mental health models, and community-based approaches. These approaches have been evaluated in relation to their cost-effectiveness, comprehensiveness, client-centredness, cultural appropriateness, acceptability, feasibility and fidelity; criteria that may vary amidst rural contexts. Collaborative approaches to care, technologies fully integrated into local health systems, multi-sectoral capacity-building, and further engagement with informal social support networks may be particularly promising strategies in rural communities. More research is required to determine rural mental health pathways among diverse social groups, and further, to establish the acceptability of novel approaches in mental health.

The effectiveness of telephone counselling in the treatment of illicit drug and alcohol use concerns

INTRODUCTION

Technology-assisted substance use interventions such as 'high-tech' internet-based treatments are thought to be effective; however, the relatively 'low-tech' use of telephone counselling does not yet have an established evidence base. This paper reviews the literature including articles with information on the use of telephone counselling for the treatment of illicit drug or alcohol use.

METHODS

A systematic literature search using a set of telephone counselling and substance-related terms was conducted across four electronic databases. English studies prior to June 2014 that involved the use of telephone counselling with the treatment of illicit drug or alcohol use as a primary or secondary outcome were included. Review papers, opinion pieces, letters or editorials, case studies, published abstracts, and posters were excluded. In all, 94 publications were included in the review.

RESULTS AND DISCUSSION

The literature was supportive of telephone counselling for the treatment of alcohol use in the short term; however, literature regarding illicit drug use was particularly scarce. The generalisability of findings was limited by evident methodological issues in the included studies.

Psychenet.de: Development and process evaluation of an e-mental health portal

BACKGROUND

E-mental health interventions can have a positive impact on patient-reported and clinical outcomes. The purpose of this project was to develop a user-centered e-mental health portal.

METHODS

The development of the portal www.psychenet.de included mixed-methods techniques for needs assessment to identify user-relevant content. Furthermore, user-centered design techniques were applied by utilizing individual usability testing with cognitive task analysis. First, a basic version of the portal was created and introduced to the public by means of a media campaign. After the development of module-specific content, exposure and use of the portal was investigated as part of a process evaluation.

RESULTS

Relevant content identified by needs assessment covered both, overarching and diagnosis-specific topics. Results of the process evaluation showed a highly accessed website. During the first 18 months, 119,423 visits were tracked. The portal was predominantly accessed by Google searches (73.9%), while 17.6% of visits were related to direct traffic.

DISCUSSION

Serving as a complement to face-to-face consultations, www.psychenet.de attempts to inform about mental disorders, and engage patients in the course of their treatment. Results of the process evaluation confirm the high relevance and potential of the portal and can be used for further improvements and extensions in the future.

Innovative strategies for closing the mental health treatment gap globally

PURPOSE OF REVIEW

In the field of global mental health, an enormous gap between what we know and what we do exists in the delivery of clinical care. Creative and effective strategies that surmount the barriers to provision of mental healthcare are essential to improve the lives of millions affected by mental illness. This article provides a review of three classes of innovative strategies currently being developed and implemented to diminish the mental health treatment gap globally.

RECENT FINDINGS

This review provides recent evidence related to the feasibility of implementation and efficacy for the following three classes of innovation that show promise for building clinical capacity and expanding mental health coverage: integration of mental health services into primary care; expansion of human capacity through task sharing and training of nonspecialists; and innovative use of technological platforms to enhance access, cut costs, and reduce stigma.

SUMMARY

The strategies outlined in this review hold great potential for enhancing mental health treatment services, and address some of the major barriers globally to accessing mental healthcare, such as scarcity of resources (infrastructure, capacity, and funding) and stigma. Despite much evidence supporting the efficacy of these models, thorough studies that test their feasibility, acceptability, utility, and effectiveness in various contexts, including low-income and middle-income countries, are required. Moreover, these innovations require social support and political will in order to be successfully implemented and scaled-up such that they have a meaningful impact on the burden of disease associated with mental illness worldwide.