The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care

Treatment Goals and Preferences of Black Veterans with Chronic Musculoskeletal Pain

Understanding patient goals and preferences is critical in the context of complex conditions such as chronic pain. This need may be especially pronounced for Black patients, who experience significant health and healthcare disparities. The primary aim of this study was to describe the treatment goals and preferences of Black veterans with chronic musculoskeletal pain who were enrolled in the intervention arm of a randomized controlled trial testing a coaching intervention. In the coaching sessions, participants (n = 106) identified their most important pain-related treatment goals and preferences. Participants' top treatment goals were to improve physical functioning (61%), increase engagement in valued activities (45%), and reduce pain intensity (37%). Most participants (73%) preferred non-pharmacological treatments (eg, physical therapy, exercise, acupuncture, yoga). The 17% of participants who identified medications as a preferred treatment demonstrated higher levels of depression and anxiety compared to those who did not. Approximately 42% and 21% of participants stated a preference to avoid pharmacological and surgical pain treatments, respectively. Black patients with chronic pain prioritize improving physical functioning and pain intensity in service of increasing their engagement in exercise, work, relationships, and leisure activities. Also, in the current study, patients expressed a clear preference for non-pharmacological pain treatments. Future research should investigate ways to improve communication of goals and preferences with providers and facilitate access to non-pharmacological treatments for Black patients with chronic pain. PERSPECTIVE: This article describes the treatment goals and preferences of Black veterans with chronic pain. Most patients prioritized goals to improve physical functioning, pain severity, and participation in valued activities. Patients primarily preferred non-pharmacological treatments. This emphasizes the need for clear communication with Black patients regarding pain-related goals and non-pharmacological treatment options.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): a Qualitative Analysis of a Tailored Coaching Program for Black Patients with Chronic Pain

BACKGROUND

Racial inequities in pain treatment are well-documented and persist despite national priorities focused on health equity. The COOPERATE (Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity) intervention was a patient-centered, tailored intervention aimed at improving health equity by targeting patient activation-the knowledge and confidence to manage one's health. COOPERATE led to significant and sustained increases in patient activation, significant short-term increases in communication self-efficacy (confidence to communicate with clinicians), and more intervention participants experienced clinically significant (≥ 30%) reductions in pain at 3 months than control group participants.

OBJECTIVE

To understand how participants experienced the intervention, including their perspectives on its effects on their health and healthcare experiences.

DESIGN

Semi-structured qualitative interviews.

PARTICIPANTS

Black veterans with chronic pain who participated in the COOPERATE intervention.

KEY RESULTS

Participants described acquiring new tools and cultivating skills to use in their clinic visits, including preparing for their visit (writing an agenda, listing questions); asking focused, effective questions; and expressing concerns and communicating goals, values, and preferences. Participants indicated that by putting these tools to use, they felt more confident and able to take ownership of their own pain care; for some, this led to better pain management and improved pain. Participants expressed mixed views of disparities in pain care, with some believing race and racism did not play a role in their care, while others valued being part of an intervention that helped equip them with tools to exercise autonomy over their healthcare.

CONCLUSIONS

Black patients with chronic pain described gaining greater confidence to self-manage and communicate with their clinicians after participating in the COOPERATE intervention. With its focus on empowering individuals, the COOPERATE intervention represents a promising approach to help advance equity in pain care.

Communication and activation in pain to enhance relationships and treat pain with equity (COOPERATE): a randomized clinical trial

ABSTRACT

Racialized disparities in chronic pain care are well-documented and persist despite national priorities focused on health equity. Similar disparities have been observed in patient activation (ie, having the knowledge, confidence, and skills to manage one's health). As such, interventions targeting patient activation represent a novel approach to addressing and reducing disparities in pain care. Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity is a randomized controlled trial of a 6-session telephone-delivered intervention to increase patient activation for Black patients with chronic pain. Two hundred fifty Black patients from a Midwestern Veterans Affairs medical center were randomized to the intervention or attention control. The primary outcome was patient activation; secondary outcomes included communication self-efficacy, pain, and psychological functioning. Outcomes were assessed at baseline and at 3 (primary endpoint), 6, and 9 months (sustained effects). Analyses used an intent-to-treat approach. Compared with baseline, patient activation increased 4.6 points at 3 months (versus +0.13 in control group, 95% CI: 0.48, 7.34; P = 0.03). These improvements in the intervention group were sustained, with +7 from baseline at 6 months and +5.77 at 9 months, and remained statistically significant from the control group. Communication self-efficacy increased significantly relative to the control group from baseline to 3 months. Pain intensity and interference improved at 3 months, but differences were not significant after adjusting for multiple comparisons. Most other secondary outcomes improved, but group differences were not statistically significant after controlling for multiple comparisons. Results suggest that increasing patient activation is a potentially fruitful path toward improving pain management and achieving health equity.

Factors associated with patient activation among individuals with depression within racial/ethnic groups in the United States

Increasing patient activation may be vital for improving quality of care for individuals with depression. Among adults with depression who reside in the United States, we sought to examine the association of depression severity, race/ethnicity, and household income with patient activation and within identify factors associated with patient activation within race/ethnicity groups. Data from the 2020 US National Health and Wellness Survey, a cross-sectional, general population survey, were used to identify White, Black/African American, Asian, and Hispanic respondents with self-reported physician-diagnosed depression. Generalized linear models were used to identify factors associated with patient activation. Analyses included 8,216 respondents (mean age = 44 years, 68.0% female). Depression severity was negatively associated with patient activation (β = -0.29, p < 0.001). Patient activation was significantly higher in Black vs. White respondents (β = 1.50, p = 0.001) and in respondents with a household income of $25,000-$49,999 (β = 0.96, p = 0.015), $50,000-$99,000 (β = 0.88, p = 0.031), and ≥$100,000 (β = 1.78, p < 0.001) vs. <$25,000. Adjusted mean patient activation scores were highest among Black respondents (61.1), followed by Hispanic (60.2), White (59.6), and Asian (59.0) respondents. Neither race/ethnicity nor household income moderated the relationship between depression severity and patient activation; however, the factors most strongly associated with patient activation differed by race/ethnicity. These results indicate that the pathway to improving patient activation in individuals with depression may vary by race/ethnicity. Understanding factors associated with patient activation can help inform the design of interventions to increase patient activation in individuals with depression.

Outcomes of a peer-led navigation program, PARTNER-MH, for racially minoritized Veterans receiving mental health services: a pilot randomized controlled trial to assess feasibility and acceptability

This pilot study explored the feasibility and acceptability of PARTNER-MH, which aimed to engage racially diverse Veterans in mental health services, facilitate their active participation in care, and improve their communication with providers. Fifty participants were randomized to the intervention or a waitlist control group. For primary outcomes, we assessed the feasibility of the study design and PARTNER-MH's feasibility and acceptability. For secondary outcomes, we explored preliminary effects on patient engagement, patient activation, shared decision-making, and health-related outcomes. The study had a recruitment rate of 68%, enrollment rate of 91%, and a follow-up retention rate of 72%. For intervention feasibility and acceptability, fidelity scores were satisfactory and improved over time, session attendance was modest with 33% of participants completing ≥6 sessions, and 89% of participants were satisfied with the intervention. For secondary outcomes, patients in the intervention arm showed significant improvement on self-reported mental health and depression, compared with those in the control group at both 6- and 9-month follow-ups. However, there were no significant differences between study arms on the other measures. Pilot results provide support for future testing of PARTNER-MH in a larger trial, although modifications are needed to increase session attendance and follow-up retention rate.

CLINICAL TRIAL INFORMATION

The study was preregistered at Clinical Trials.gov. The study Trial registration number is ClinicalTrials.gov NCT04515771.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain

BACKGROUND

Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse.

OBJECTIVE

The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse.

DESIGN

A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain.

PARTICIPANTS

Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans.

MAIN MEASURES

Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse.

KEY RESULTS

Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c =  - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' =  - 0.147, p = 0.007).

CONCLUSIONS

Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

An Analysis of the Role of Mental Health in a Randomized Trial of a Walking Intervention for Black Veterans With Chronic Pain

Black patients and those with co-occurring mental health disorders are disproportionately affected by chronic pain, but few interventions target these populations. This is a secondary analysis of a randomized trial of a walking-focused proactive counseling intervention for Black Veterans with chronic musculoskeletal pain (ACTION). The primary aim was to examine intervention effectiveness among Veterans with an electronic health record-documented mental health diagnosis [depressive disorder, anxiety disorder, substance use disorder, post-traumatic stress disorder or serious mental illness (n = 205)] and those without a diagnosis (n = 175). About 380 Black Veterans receiving care at the Atlanta VA Health Care System were enrolled from 2016 to 2019 and randomized to the intervention or usual care (UC) (1:1). The intervention featured 6 telephone coaching sessions over 8-14 weeks to encourage walking. Participants with a mental health disorder were more likely to complete all counseling sessions (56% vs 38%) and reported improvements in global perceptions of pain and pain intensity/interference (secondary outcomes) at 3-months vs UC. Among participants without a mental health disorder, the intervention was associated with an improvement in pain-related disability at 6-months (primary outcome). Black chronic pain patients with co-occurring mental health disorders may require more intensive treatment to affect improvement in pain-related disability. PERSPECTIVE: This study examines the effectiveness of a walking intervention for chronic pain among Black Veterans with a mental health disorder. These patients were more engaged with the intervention than those without a mental health disorder. However, they did not experience reductions in pain-related disability, suggesting more intensive treatment is needed.

Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH), a Peer-Led Patient Navigation Intervention for Racially and Ethnically Minoritized Veterans in Veterans Health Administration Mental Health Services: Protocol for a Mixed Methods Randomized Controlled Feasibility Study

BACKGROUND

Mental health care disparities are persistent and have increased in recent years. Compared with their White counterparts, members of racially and ethnically minoritized groups have less access to mental health care. Minoritized groups also have lower engagement in mental health treatment and are more likely to experience ineffective patient-provider communication, which contribute to negative mental health care experiences and poor mental health outcomes. Interventions that embrace recovery-oriented practices to support patient engagement and empower patients to participate in their mental health care and treatment decisions may help reduce mental health care disparities. Designed to achieve this goal, the Proactive, Recovery-Oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) is a peer-led patient navigation intervention that aims to engage minoritized patients in mental health treatment, support them to play a greater role in their care, and facilitate their participation in shared treatment decision-making.

OBJECTIVE

The primary aim of this study is to assess the feasibility and acceptability of PARTNER-MH delivered to patients over 6 months. The second aim is to evaluate the preliminary effects of PARTNER-MH on patient activation, patient engagement, and shared decision-making. The third aim is to examine patient-perceived barriers to and facilitators of engagement in PARTNER-MH as well as contextual factors that may inhibit or promote the integration, sustainability, and scalability of PARTNER-MH using the Consolidated Framework for Implementation Research.

METHODS

This pilot study evaluates the feasibility and acceptability of PARTNER-MH in a Veterans Health Administration (VHA) mental health setting using a mixed methods, randomized controlled trial study design. PARTNER-MH is tested under real-world conditions using certified VHA peer specialists (peers) selected through usual VHA hiring practices and assigned to the mental health service line. Peers provide PARTNER-MH and usual peer support services. The study compares the impact of PARTNER-MH versus a wait-list control group on patient activation, patient engagement, and shared decision-making as well as other patient-level outcomes. PARTNER-MH also examines organizational factors that could impact its future implementation in VHA settings.

RESULTS

Participants (N=50) were Veterans who were mostly male (n=31, 62%) and self-identified as non-Hispanic (n=44, 88%) and Black (n=35, 70%) with a median age of 45 to 54 years. Most had at least some college education, and 32% (16/50) had completed ≥4 years of college. Randomization produced comparable groups in terms of characteristics and outcome measures at baseline, except for sex.

CONCLUSIONS

Rather than simply documenting health disparities among vulnerable populations, PARTNER-MH offers opportunities to evaluate a tailored, culturally sensitive, system-based intervention to improve patient engagement and patient-provider communication in mental health care for racially and ethnically minoritized individuals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04515771; https://clinicaltrials.gov/ct2/show/NCT04515771.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37712.

Communication and Activation in Pain to Enhance Relationships and Treat Pain with Equity (COOPERATE): Rationale, study design, methods, and sample characteristics

BACKGROUND

Chronic pain is associated with profound negative effects, and racial disparities are well-documented in chronic pain treatment. In addition, Black patients report poorer communication with providers and exhibit lower levels of patient activation (self-management self-efficacy) than White patients. Although the causes of healthcare disparities are complex and require intervention at multiple levels, empowering patients is one critical path to achieving health equity. The current study is a coaching intervention focused on increasing patient activation and building communication skills for Black patients with chronic pain.

METHODS

In this randomized controlled trial, 250 Black patients with chronic pain were randomized to either the coaching intervention or an attention control arm. Intervention patients attended 6 telephone-delivered individual coaching sessions over 12 weeks. Coaching focused on clarifying and prioritizing goals and on communication skills, such as agenda setting. The primary outcome is patient activation. Secondary outcomes include communication self-efficacy, pain intensity and interference, and psychological functioning.

DISCUSSION

Having the knowledge and confidence to participate in one's pain care, coupled with the skills needed to effectively communicate with providers, is essential to optimize chronic pain care. This is particularly important for Black patients who often experience lower quality pain care. Interventions such as COOPERATE hold promise for helping patients to acquire the requisite tools to take greater control of their chronic pain care.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT03562793.

Knowledge about Treatment (KaT) in Mental Health Services

This study developed and psychometrically evaluated a brief measure of mental health treatment knowledge (N = 726). Scores from Knowledge about Treatment (KaT) demonstrated a unidimensional measure with good model fit, internal consistency reliability, convergent and predictive validity, test-retest reliability, and measurement invariance across gender, ethnicity, education, and poverty status.

Racial Disparities in Clinical Outcomes of Veterans Affairs Residential PTSD Treatment Between Black and White Veterans

OBJECTIVE

Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs).

METHODS

Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment.

RESULTS

Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans.

CONCLUSIONS

This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.

Between and within race differences in patient-centeredness and activation in mental health care

OBJECTIVES

The aim of this study was to compare Black and White mental health care patients' perceptions of their providers' and their own participation in patient-centered mental health care. Perceptions of patient-centered care (PCC) in relation to the Multidimensional Model of Racial Identity were explored.

METHODS

Black and White veterans receiving mental health care (n = 82) completed surveys assessing patient activation, involvement in care, perceptions of PCC, and therapeutic alliance. Black participants (n = 40) also completed the Multidimensional Inventory of Black Identity.

RESULTS

There were no differences by race in perceived PCC, though Black participants had lower levels of therapeutic alliance with their mental health care provider and were less activated. Black identity centrality, private regard, and public regard were positively related to PCC and elements of PCC such as patient information seeking/sharing.

CONCLUSIONS

Intragroup identity variables such as racial centrality, regard, and ideology influenced perceived PCC among Black participants. Race identity variables should be explored in future research on racial disparities and PCC.

PRACTICE IMPLICATIONS

Mental health care providers serving Black patients should create opportunities to discuss racial identity and race-related experiences as part of their efforts to improve therapeutic alliance and increase the patient-centeredness of care.

Activation in persons with mental health disorders: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Evidence indicates a strong relationship between patient activation (i.e. confidence, knowledge and skills to self-manage health) and positive health behaviours and outcomes in a variety of clinical populations. Because persons with mental health disorders experience significant disease burden but often underutilize mental health treatment or experience poor treatment outcomes, they would likely benefit from increases in activation. No systematic reviews have been conducted to summarize and synthesize research on patient activation in persons with mental health disorders. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, this is the first comprehensive review to identify factors associated with activation and interventions that have shown to be effective in persons with mental health disorders. This integrative review indicates that better health status, less depression, positive health attitudes and behaviours, and higher quality therapeutic relationships may be associated with higher levels of activation in persons with mental health disorders. This review also indicates that a variety of interventions, most notably educational programs, are effective in increasing levels of patient activation in persons with mental health disorders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Psychiatric mental health nurses and other clinicians should consider routine assessment of patient activation to inform individualized treatment plans for their clients. Clinicians should aim to form high-quality therapeutic relationships with clients as a way to promote higher levels of activation. Interventions that have been found to be effective in improving activation could be offered in a variety of mental health settings. ABSTRACT: Introduction Patient activation is understanding one's role in the healthcare process and having confidence, knowledge, and skills to self-manage one's health and health care. Researchers have begun to investigate patient activation in persons with mental health disorders, but no systematic reviews have been conducted to summarize and synthesize this research. For psychiatric mental health nurses and other clinicians to develop strategies to increase patient activation in this population, more information is needed about factors associated with activation and interventions that increase activation. Review Questions (1) What factors are associated with levels of activation in persons diagnosed with mental health disorders? (2) What interventions have shown to be effective at increasing levels of activation in persons diagnosed with mental health disorders? Method A 5-stage integrative review as described by Whittemore & Knafl. Results Twenty-nine articles were included in the review. Ten provided correlations between activation and other factors, and 20 examined the effects of interventions on activation. Some studies revealed significant correlations between a variety of health and treatment-related factors, and others revealed that some interventions, most notably educational programs, were shown to increase activation. Discussion The findings of this comprehensive review can inform psychiatric mental health nurses and other clinicians in developing strategies to increase activation in the patients with whom they work. More research is needed to provide a deeper understanding of the role of activation in the recovery and treatment of persons with mental health disorders. Implications for Practice Psychiatric nurses and other clinicians should assess for patient activation and incorporate strategies to increase levels of activation in patients in their practice. Positive therapeutic relationships likely enhance activation in persons with mental health disorders.

Patient Perspectives on Detox: Practical and Personal Considerations through a Lens of Patient-Centered Care

Inpatient detoxification is often required before a client can move on to additional substance abuse treatment services. Although often short-term, time spent in inpatient detoxification tends to have long-lasting effects on the recovery process. This qualitative study focuses on one treatment facility in Tampa, Florida that offers a range of recovery services, including inpatient detox and outpatient treatment. Focus groups (N = 70 participants) captured client perceptions of direct clinical care operations, access to resources, and relationships with direct care staff within the inpatient detox program. Perceptions were then assessed using a thematic analysis approach with attention to the literature on person-centered care best practices, behavior change, and patient engagement theories to better understand how facility practices affect treatment engagement and retention. Findings elucidated several practical facilitators and barriers to recovery such as facility resources, services offered, transition to aftercare, and sustainability of treatment. Findings also illuminated several personal facilitators and barriers including patient-staff interactions, personal motivation, and family and community support. The resulting recommendations for practice and research are discussed.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

Pre-implementation Evaluation of PARTNER-MH: A Mental Healthcare Disparity Intervention for Minority Veterans in the VHA

To design PARTNER-MH, a peer-led, patient navigation program for implementation in Veterans Health Administration (VHA) mental health care settings, we conducted a pre-implementation evaluation during intervention development to assess stakeholders' views of the intervention and to explore implementation factors critical to its future adoption. This is a convergent mixed-methods study that involved qualitative semi-structured interviews and survey data. Data collection was guided by the Consolidated Framework for Implementation Research (CFIR). We interviewed and administered the surveys to 23 peers and 10 supervisors from 12 midwestern VHA facilities. We used deductive and inductive approaches to analyze the qualitative data. We also conducted descriptive analysis and Fisher Exact Test to compare peers and supervisors' survey responses. We triangulated findings to refine the intervention. Overall, participants viewed PARTNER-MH favorably. However, they saw the intervention's focus on minority Veterans and social determinants of health framework as potential barriers, believing this could negatively affect the packaging of the intervention, complicate its delivery process, and impact its adoption. They also viewed clinic structures, available resources, and learning climate as potential barriers. Peers and supervisors' selections and discussions of CFIR items were similar. Our findings informed PARTNER-MH development and helped identify factors that could impact its implementation. This project is responsive to the increasing recognition of the need to incorporate implementation science in healthcare disparities research. Understanding the resistance to the intervention's focus on minority Veterans and the potential barriers presented by contextual factors positions us to adjust the intervention prior to testing, in an effort to maximize implementation success.

Co-production for service improvement: Developing a training programme for mental health professionals to enhance medication adherence in Black, Asian and Minority Ethnic Service Users

Aim

To co‐produce consensus on the key issues important in educating mental health‐care professionals to optimize mental health medication adherence in Black, Asian and Minority Ethnic (BAME) groups.

Objectives

To identify perceptions of factors enabling or disabling medication adherence. To achieve consensus on content and delivery of an educational intervention for mental health‐care professionals.

Methods

Data were collected from 2016 to 2018. Using individual interviews and a consensus workshop with carers and service users (SUs treated under the 1983 Mental Health Act 1983/revised 2007 for England and Wales), the experience of taking prescribed mental health medication and perspectives on adherence were explored. Data were analysed using 2‐stage qualitative coding via the software tool NVivo version 11 to analyse transcribed data and to produce the main explanatory categories.

Results

SU and carer participants' perspectives substantially altered the original research design. The need to educate students rather than trained professionals was emphasized, and they suggested that educational content should be packaged in a contemporary manner (a virtual reality experience). Findings indicated that education should focus upon understanding the impact of taking prescribed antipsychotic medication on both SUs and carers.

Discussion

The importance of effective communication between health professionals, SUs and carers and a willingness to learn about and appreciate how BAME culture influences perception of mental illness and mental well‐being were highlighted.

Conclusion

In working co‐productively, researchers need to be flexible and adaptable to change.

Peer Support: a Human Factor to Enhance Engagement in Digital Health Behavior Change Interventions

The purpose of this report is to develop a theoretical model based on empirical evidence that can serve as a foundation for the science of peer-support factors that facilitate engagement in digital health interventions for people with serious mental illness (SMI). A review of the literature on how peer-support specialist interaction with consumers with SMI in digital health behavior change interventions enhances engagement. Unlike relationships with other health providers, peer-to-consumer relationships are based on reciprocal accountability -meaning that peer-support specialists and consumer mutually help and learn from each other. Under the recovery model of mental illness, reciprocal accountability suggests autonomy, flexible expectations, shared lived experience, and bonding influence engagement in digital interventions. Separate yet related components of reciprocal accountability in the context of digital health intervention engagement include (1) goal setting, (2) task agreement, and (3) bonding. Hope and sense of belonging are hypothesized moderators of peer-support factors in digital health interventions. Peer-support factors help people with SMI learn to live sucessfully both in the clinic and community. Peer-support specialists add value and complement traditional mental health treatment through their professional training and lived experience with a mental illness. The proposed model is a pioneering step towards understanding how peer-support factors impact engagement in digital health behavior change interventions among people with a lived experience of SMI. The model presents proposed factors underlying the reciprocal accountability processes in the context of digital health intervention engagement. This model and related support factors can be used to examine or identify research questions and hypotheses.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.