Qualitative and mixed methods in mental health services and implementation research

Black Americans' perceptions of Alzheimer's disease, a healthy brain, and strategies for brain health promotion

Objectives

Lack of awareness of Alzheimer's disease (AD) among Black Americans may undermine their ability to identify potential AD risk. We examined Black Americans' perceptions and knowledge of AD, and views of a healthy brain, which may contribute to the development of effective and culturally sensitive strategies to address racial disparities in AD.

Methods

We conducted a mixed-methods study, integrating a cross-sectional survey of 258 older (>55 years) Black participants and qualitative interviews with a sub-sample of N = 29. Both data sets were integrated to inform the results.

Results

Participants endorsed having little knowledge of AD. While most participants reported practicing a healthy lifestyle to promote a healthy brain, the range of activities listed were limited. Participants made several suggestions to increase AD awareness, which includes using AD educational materials containing information that would benefit the whole family, not only older adults. Outreach approaches that address both individual behaviors and structural factors were also encouraged.

Conclusion

Our findings identify ongoing needs to improve AD awareness among traditionally under-represented groups.

Innovation

The study utilized novel approaches to examine participants' perspectives of AD that included a diverse sample of research naïve participants, and integrated exploration of participants' views of AD and brain health.

How to engage people experiencing severe and persistent mental illness in qualitative research: a descriptive and reflexive analysis

PURPOSE

People experiencing severe and persistent mental illness (SPMI) constitute a vulnerable population within the healthcare system and society. Similarly in research, there are perceived challenges in qualitative studies with this population due to several factors, including (self-)stigma, assessment of decision-making capacity, reduced communication skills and the (perceived) risk of adverse events, resulting in its scarcity.

METHODS

In this contribution, the authors share their practical experiences of conducting qualitative research among this group of people, specifically addressing sensitive topics such as ongoing intensive care within a mental health facility and end-of-life care. Both advantageous and challenging factors that were encountered during different research phases -the preliminary phase, conducting the interviews and the concluding phase are systematically outlined.

RESULTS

The findings highlight conscientious conducted in accordance with established standards, albeit with a deliberate embrace of non-conventional approaches while advocating an attitude of critical, ethical reflection. Adequate preparation, fostering creative approaches and adaptable communication to establish rapport and authentic interaction, thorough follow-up and support for all involved are equally crucial to sustain effective qualitative research.

CONCLUSION

Engaging people experiencing SPMI in research is as a cornerstone for empowerment-a feasible aspiration. Their inclusion in research endeavours is imperative, because first-hand narratives are key in shaping comprehensive and compassionate care practices for those experiencing severe and persistent mental illness.

State of the Science in Behavior Therapy: Taking Stock and Looking Forward

The scope and burdens of mental health challenges in today's world are staggering. Among the available psychological treatment approaches, cognitive and behavioral therapies, and their combinations, have garnered the strongest evidence base. That said, progress has not always been linear and most of the work is still ahead of us. Against this backdrop, Behavior Therapy has launched its State of the Science series-an exciting new journal feature offering a curated set of authoritative reviews of research in major areas of relevance to applied cognitive-behavioral science, written by distinguished scientists in each area and peer-reviewed. The vision for the Behavior Therapy State of the Science series is to launch with an initial set of articles that make up this special journal issue, with continued publication of additional State of the Science articles in future journal issues. The current article launches the State of the Science series, providing a brief summary of progress in cognitive and behavioral practice and related areas, as well as various missteps and harmful legacies that remind us that the state of the science for research focused on mental health and the alleviation of human suffering is always in flux and evolving. The 16 inaugural reviews in this special issue are then introduced one by one. Collectively, these State of the Science reviews take stock of what has been learned across key areas in the field, highlight critical knowledge gaps in need of research, and provide expert guidance for improving the effectiveness and reach of care, particularly for marginalized and underserved populations.

Psychosocial stressors of adolescents with E-cigarette, or vaping, product-use associated lung injury: A qualitative study

BACKGROUND AND OBJECTIVES

Adolescent electronic cigarette (EC) use has reached epidemic rates and has been linked to numerous mental health and psychosocial stressors (PS). There is limited qualitative data on PS for adolescents with e-cigarette, or vaping, product-use associated lung injury (EVALI), a severe complication of EC use.

METHODS

All patients hospitalized at Children's Medical Center in Dallas, Texas from 2018 to 2022 and met CDC case definitions for EVALI were included in the analysis. PS were extracted from the electronic health record and analyzed for recurring themes using the HEADSS assessment as a framework. Results were summarized using descriptive statistics, and representative quotations were selected to highlight each theme.

RESULTS

Forty-three adolescents (mean age 16.3 years; 62.8 % male; 39.5 % Non-Hispanic White, 60.5 % Hispanic) were included in the analysis, and 40 (93 %) reported PS. The most common themes were family (51 %; "restraining order issued against 28-year-old brother"), polysubstance use (77 %; "experimenting with…ecstasy, LSD, CCC, misusing Adderall"), and mental health (63 %; "has been suicidal since he was 'a toddler'"). Less commonly, patients reported PS related to peers (28 %; "spending the entire day at the cemetery where his best friend was buried"), school (49 %; "attending his second alternative school"), and the legal system (19 %; "placed in juvenile detention, released, and will be on probation").

CONCLUSIONS

Adolescents with EVALI had PS that were chronic, severe, and involving multiple domains. These findings emphasize the importance of psychosocial screening in adolescents and coordinating interdisciplinary care with mental health and social services.

Sleep quality in secure psychiatric healthcare: Inpatient & staff perspectives

The lived experiences of psychiatric inpatients are not well represented in the literature, especially when these experiences pertain to health. Reports regarding sleep health are particularly sparse, despite the increasing prevalence of sleep disorders in this population. The current study aimed to explore inpatient and staff perspectives of inpatient sleep quality to aid the future development of a sleep quality intervention. Fourteen inpatients (average age 43 years, 36 % female) were recruited for individual interviews and eleven staff members were recruited for three focus groups, from a secure psychiatric hospital (England). A semi-structured interview guide facilitated discussions regarding the prevalence and type of inpatient sleep problems, existing support for inpatient sleep problems including medication, and the bidirectional relationships between nighttime sleep and daytime behaviours, such as napping and physical activity. Using reflexive thematic analysis, four themes were developed: Irregular Sleep Schedules, Nighttime Disruptions, The Patient's Bedroom, and Keeping a Routine & Staying Physically Active. Study results can be utilised when developing inpatient sleep interventions, which were identified within the study as being sorely needed. Such interventions could focus on managing daytime sleeping, sedentary behaviour, and physical activity, in order to support good sleep hygiene, foster regular sleep/wake cycles, and improve overall health.

Marketing mental health services: a mixed-methods analysis of racially and ethnically diverse college students' engagement with and perspectives on U.S. university mental health clinics' websites

BACKGROUND

The United States (U.S.) faces a significant mental health crisis, with around 52.9 million adults experiencing mental health disorders, with young adults (18-25 years old), such as college students, having the highest prevalence and lowest service utilization rates. While efforts to expand mental health services through "push" strategies are in place (e.g., training therapists in evidence-based therapies), limited initial engagement suggests a need for "pull strategies" and targeted marketing that make services attractive to college students and increase demand. This mixed-methods study identifies U.S. university mental health clinic websites and website characteristics that are attractive and engaging to college students interested in seeking mental health services (i.e., students were considering or actively looking for mental health support).

METHODS

Eleven U.S. university websites were chosen (10 randomly and one from the university where students were attending) from a pool of 44 Psychological Clinical Science Accreditation System training clinics websites. Fifty-seven college students (Mage = 20.95, SD = 2.97; 81% female; 68% racial/ethnic minority) were videorecorded engaging with two U.S. university mental health clinic websites, completed self-report engagement measures, and gave detailed feedback about websites through semi-structured interviews.

RESULTS

Likert scale scores revealed moderate engagement with all websites (e.g., they were interesting and helpful). Qualitative results indicated that websites that provided important and easily understood information about key features of services (e.g., types, evidence-base, and cost), therapist backgrounds, psychoeducation, used lay language, and had an appealing website layout (e.g., color, font, images, organization, and interactive components) generated greater consumer interest and trust in their mental health services.

CONCLUSIONS

This study emphasizes the importance of using marketing strategies to enhance college students' engagement through mental health service websites. Salient features, psychoeducation, and effective promotional strategies (e.g., how information is presented) were identified as crucial for website engagement and subsequent mental health service uptake. Using marketing strategies, such as tailoring language to consumer literacy levels, describing the evidence-base of services, and improving website design may address college students' needs and enhance initial mental health service engagement.

Occupational Therapy in Psychiatric Short-Term Hospitalization Units: Scoping Review

Given the context, the overarching aim is to identify scientific publications on occupational therapy in Psychiatric-Short-Term-Hospitalization-Units. Specific objectives include: (a) Analyzing the historical development of this research area; (b) Synthesizing existing evidence on the nature of documentary sources on occupational therapy in in Psychiatric-Short-Term-Hospitalization-Units; (c) Detailing the volume of scientific literature on occupational therapy in these units; (e) Evaluating available evidence on occupational therapy interventions to improve functionality, quality of life, and recovery in individuals admitted to in Psychiatric-Short-Term-Hospitalization-Units. A scoping review method was employed to conduct a historical mapping of research on in Psychiatric-Short-Term-Hospitalization-Units. The review proceeded in five stages following PRISMA guidelines. After applying selection criteria, the search identified 446 references. Findings are presented under three headings: (a) Historical trends in the scientific literature on occupational therapy and in Psychiatric-Short-Term-Hospitalization-Units; (b) Nature and volume of articles included in the occupational therapy synthesis in Psychiatric Short-Term Hospitalization Units; (c) Data extraction on methodological variables in the research of occupational therapy articles in in Psychiatric-Short-Term-Hospitalization-Units; and (d) Data extraction on research outcome variables of occupational therapy articles in Psychiatric Short-Term Hospitalization Units. The growth of occupational therapy in in Psychiatric-Short-Term-Hospitalization-Units is emphasized, with an increase in qualitative studies. Occupational therapy is underscored as an integral part of care, supporting the diversity and effectiveness of interventions. Common diagnoses include schizophrenia and depressive disorders. Group interventions and the spiritual dimension positively influence the quality of care and meaningful routines for recovery in in Psychiatric-Short-Term-Hospitalization-Units.

"It's all about setting the stage." The nurse facilitator trial: perceived outcomes and implementation issues. A qualitative study among ICU clinicians and nurse facilitators

PURPOSE

For the first time in France, a randomised controlled trial was conducted to evaluate the impact of a nurse facilitator on family psychological symptoms. We sought to explore the implementation of the intervention, how it was experienced by clinicians, as well as the barriers and facilitators to implementing the change.

METHODS

We conducted qualitative semi-structured interviews with intensive care unit (ICU) clinicians and facilitators involved in the trial. Interview questions focused on participants' perceptions of the intervention and its outcomes, including the effect of the intervention on patients, families and the health care team, and barriers and facilitators to its implementation. Interviews were conducted by two social science researchers, audio recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Twenty-three clinicians were interviewed from the five participating ICUs. Three themes emerged, capturing clinicians' perspectives on implementing the intervention: (1) improved communication and enhanced care for families and the ICU team, albeit with some associated risks; (2) active listening and support, both for families and ICU clinicians but with certain limitations; (3) barriers to implementation including lack of organizational readiness, exclusion of under-represented groups, and facilitator challenges including role ambiguity and the need for role support.

CONCLUSION

Participants believed the facilitator intervention potentially improved families' experience. However, they also highlighted emotional difficulties and tensions with some members of the participating teams, due to competing territories and ambiguous role definitions. Facilitators' failure to affect decision-making suggests their role in enhancing goal-concordant care was inadequate within the setting.

How Do Patients and Their Supports Experience Temperament Based Therapy With Support (TBT-S)? A Qualitative Study

BACKGROUND

Temperament Based Therapy with Support (TBT-S) is an emerging intervention based on empirically supported neurobiological models. Due to its novelty, only a handful of studies to date have examined TBT-S, and none of these previous studies have provided a qualitative evaluation of how TBT-S is perceived by the target population. Therefore, the aim of the current study was to provide an increased understanding of how TBT-S is experienced by patients with an eating disorder and their supports.

METHOD

Forty-six patients with an eating disorder and 63 supports consented to be included in the study. The participants provided written responses to six open-ended questions during the post-treatment assessment, detailing their treatment experiences and offering additional feedback. Thematic analysis (TA) was used to analyze their written responses, aiming for a combination of latent and semantic themes.

RESULTS

The results reveal a substantial overlap between patients' and supports' experiences with TBT-S. In both groups, identified themes suggest increased knowledge and hopefulness as key benefits of the intervention. While both patients and support persons considered TBT-S to be worthwhile, patients also reported finding the intervention quite challenging. Additionally, both groups emphasized the neurobiological rationale as an essential component of TBT-S.

CONCLUSIONS

The qualitative evaluations from this study offer new insights into how TBT-S is experienced by the target population. The findings provide an opportunity to incorporate participant suggestions for improving the treatment, and serve as an important building block for future studies aimed at assessing the effectiveness of TBT-S as an augmentation to treatment-as-usual.

Going virtual: mixed methods evaluation of online versus in-person learning in the NIH mixed methods research training program retreat

BACKGROUND

Despite the central role of mixed methods in health research, studies evaluating online methods training in the health sciences are nonexistent. The focused goal was to evaluate online training by comparing the self-rated skills of scholars who experienced an in-person retreat to scholars in an online retreat in specific domains of mixed methods research for the health sciences from 2015-2023.

METHODS

The authors administered a scholar Mixed Methods Skills Self-Assessment instrument based on an educational competency scale that included domains on: "research questions," "design/approach," "sampling," "analysis," and "dissemination" to participants of the Mixed Methods Research Training Program for the Health Sciences (MMRTP). Self-ratings on confidence on domains were compared before and after retreat participation within cohorts who attended in person (n = 73) or online (n = 57) as well as comparing across in-person to online cohorts. Responses to open-ended questions about experiences with the retreat were analyzed.

RESULTS

Scholars in an interactive program to improve mixed methods skills reported significantly increased confidence in ability to define or explain concepts and in ability to apply the concepts to practical problems, whether the program was attended in-person or synchronously online. Scholars in the online retreat had self-rated skill improvements as good or better than scholars who participated in person. With the possible exception of networking, scholars found the online format was associated with advantages such as accessibility and reduced burden of travel and finding childcare. No differences in difficulty of learning concepts was described.

CONCLUSIONS

Keeping in mind that the retreat is only one component of the MMRTP, this study provides evidence that mixed methods training online was associated with the same increases in self-rated skills as persons attending online and can be a key component to increasing the capacity for mixed methods research in the health sciences.

Artificial intelligence in perinatal mental health research: A scoping review

The intersection of Artificial Intelligence (AI) and perinatal mental health research presents promising avenues, yet uncovers significant challenges for innovation. This review explicitly focuses on this multidisciplinary field and undertakes a comprehensive exploration of existing research therein. Through a scoping review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, we searched relevant literature spanning a decade (2013-2023) and selected fourteen studies for our analysis. We first provide an overview of the main AI techniques and their development, including traditional methods across different categories, as well as recent emerging methods in the field. Then, through our analysis of the literature, we summarize the predominant AI and ML techniques adopted and their applications in perinatal mental health studies, such as identifying risk factors, predicting perinatal mental health disorders, voice assistants, and Q&A chatbots. We also discuss existing limitations and potential challenges that hinder AI technologies from improving perinatal mental health outcomes, and suggest several promising directions for future research to meet real needs in the field and facilitate the translation of research into clinical settings.

Towards identifying the characteristics of youth with severe and enduring mental health problems in practice: a qualitative study

A group of youth with severe and enduring mental health problems (SEMHP) falls between the cracks of the child-and-adolescent psychiatry (CAP) system. An insufficient understanding of these youth's mental health problems results in a failure to accurately identify and provide support to these youth. To gain a deeper understanding, the aim of this study is to explore characteristics of youth with SEMHP in clinical practice based on the experiences of youth and clinicians in CAP. This qualitative study consisted of 20 semi-structured interviews with 10 youth with lived experience and 10 specialized clinicians in CAP. Both a thematic and content analysis was conducted to identify, assess, and report themes associated with youth with SEMHP. Themes were individual characteristics such as trauma, masking, self-destructive behavior, interpersonal distrust as well as environmental and systematic characteristics including parental stressors, social isolation and societal stressors, which go beyond the existing classifications. These characteristics profoundly impact youth's daily functioning across various life domains, creating an interactive process, ultimately leading to elusive mental health problems and overwhelming feelings of hopelessness. The authors recommend proper assessment of characteristics in all life domains affected and their perpetuating effect on SEMHP during diagnostics in CAP. Engaging in a dialogue with youth themselves is crucial due to the nature of youth's characteristics, which frequently transcend traditional classifications and may not be immediately discernible. It also requires an integrated care approach, entailing collaborations between educational institutions and mental healthcare providers, and attention to potential indicators of deficits in the healthcare system and society.

What Really Matters in the Implementation of Evidence-based Practices in Community Mental Health? Insight and Recommendations from Experts, Providers, and Clients

Perceptions of evidence-based practices (EBPs) and implementation are inherent drivers of implementation outcomes. Most studies on implementation perceptions have focused on direct service providers, but clients and EBP experts may offer additional meaningful information about implementing EBPs in community settings. EBP providers (n = 21), EBP experts (n = 12), and clients who received EBPs (n = 6) participated in focus groups to ascertain their perceptions of and experiences with EBP implementation, as part of a program evaluation. Thematic analysis indicated that provider and expert perceptions of EBP implementation in community settings converged around themes of implementation supports and training and client outcomes, along with several subthemes. Client perceptions centered on themes regarding the importance of their personal experiences, their impressions of EBPs, as well as their recommendation for increasing public awareness and use of EBPs. Findings suggest that the perspectives of EBP providers and experts are closely aligned, focusing on system-level, individual-level, and training issues that impact EBP implementation within a public mental health system. The themes that were important to clients were primarily related to their experiences as recipients of an EBP which produced insightful recommendations for promoting EBPs in the community.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): a modified Delphi study

BACKGROUND

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

METHOD

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability and inclusion (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

RESULTS

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

DISCUSSION

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

How Does Individual Psychotherapy Promote Recovery for Persons with Psychosis? A Systematic Review of Qualitative Studies to Understand the Patient's Experience

Psychotherapy for individuals with psychosis is an effective treatment that promotes recovery in various ways. While there is strong quantitative evidence across modalities, less is known from the patient's perspective. There are many varied forms of psychotherapy, and gaining the patient's perspective can improve understanding of salient elements of psychotherapy and increase engagement, ultimately improving recovery rates. The purpose of this review is to identify and integrate data from published studies of patient perspectives of psychotherapy for psychosis to understand essential elements across approaches, differences between approaches, and how psychotherapy impacts recovery. We aimed to understand further: what are the perceptions about individual psychotherapy from the perspective of individuals with psychosis? The current study was a systematic review using PRISMA guidelines of studies that included qualitative interviews with persons with experiences of psychosis who participated in psychotherapy. All three authors participated in the literature search using Pubmed, APA PsycInfo, and Psychiatry Online. We identified N = 33 studies. Studies included cognitive therapies, acceptance and mindfulness approaches, trauma therapies, metacognitive therapy, and music therapy. All studies reported participants' perceived benefit with the therapeutic relationship as especially salient. Participants described diverse aspects of objective (e.g., symptoms, functioning) and subjective (e.g., self-experience or quality of life) recovery improvements, with perceived mechanisms of change, and with music therapy having some unique benefits. Participants also reported challenges and suggestions for improvement. Study findings highlight the salient aspects of psychotherapy identified by patients that may help therapists to individualize and improve approaches to psychotherapy when working with individuals experiencing psychosis. Overall, findings support the potential for integrative psychotherapy approaches for maximal treatment personalization.

In Their Own Words: Content Analysis of Open-Ended Survey Responses for a More Nuanced, Local Understanding of Mental Illness Stigma

This content analysis seeks to extend what is already known in nursing and public health about the stigma attached to mental illness, and further understand the following evaluation question: How do members of communities targeted by Make It OK, a community initiative to reduce mental illness stigma, describe that stigma? The analysis of responses to open-ended questions included in a community-based survey followed deductive and inductive coding based on published frameworks and survey responses. The domains of stigma were categorized as actions toward people living with mental illness, beliefs about mental illness, and beliefs about people living with mental illness. These identified constructs build on the existing literature base of mental illness stigma in nursing and public health, illuminate the nuance of stigma, and can help tailor anti-stigma efforts.

Attitudes Toward the Adoption of Remote Patient Monitoring and Artificial Intelligence in Parkinson's Disease Management: Perspectives of Patients and Neurologists

OBJECTIVE

Early detection of Parkinson's Disease (PD) progression remains a challenge. As remote patient monitoring solutions (RMS) and artificial intelligence (AI) technologies emerge as potential aids for PD management, there's a gap in understanding how end users view these technologies. This research explores patient and neurologist perspectives on AI-assisted RMS.

METHODS

Qualitative interviews and focus-groups were conducted with 27 persons with PD (PwPD) and six neurologists from Finland and Italy. The discussions covered traditional disease progression detection and the prospects of integrating AI and RMS. Sessions were recorded, transcribed, and underwent thematic analysis.

RESULTS

The study involved five individual interviews (four Italian participants and one Finnish) and six focus-groups (four Finnish and two Italian) with PwPD. Additionally, six neurologists (three from each country) were interviewed. Both cohorts voiced frustration with current monitoring methods due to their limited real-time detection capabilities. However, there was enthusiasm for AI-assisted RMS, contingent upon its value addition, user-friendliness, and preservation of the doctor-patient bond. While some PwPD had privacy and trust concerns, the anticipated advantages in symptom regulation seemed to outweigh these apprehensions.

DISCUSSION

The study reveals a willingness among PwPD and neurologists to integrate RMS and AI into PD management. Widespread adoption requires these technologies to provide tangible clinical benefits, remain user-friendly, and uphold trust within the physician-patient relationship.

CONCLUSION

This study offers insights into the potential drivers and barriers for adopting AI-assisted RMS in PD care. Recognizing these factors is pivotal for the successful integration of these digital health tools in PD management.

Current methodologies of greenspace exposure and mental health research-a scoping review

Introduction

Greenspaces can provide an important resource for human mental health. A growing body of literature investigates the interaction and the influence of diverse greenspace exposures. In order to gain a comprehensive understanding of the complex connection between greenspace and mental health, a variety of perspectives and methodological combinations are needed. The aim of this review is to assess the current methodologies researching greenspace and mental health.

Methods

A scoping review was conducted. Four electronic databases (Pubmed, Embase, PsycInfo, Web of Science) were searched for relevant studies. A wide range of greenspace and mental health keywords were included to provide a comprehensive representation of the body of research. Relevant information on publication characteristics, types of greenspaces, mental health outcomes, and measurements of greenspace exposure and mental health was extracted and assessed.

Results

338 studies were included. The included studies encompassed a multitude of methods, as well as outcomes for both greenspace and mental health. 28 combinations were found between seven categories each for greenspace and mental health assessment. Some pairings such as geoinformation systems for greenspace assessment and questionnaires investigating mental health were used much more frequently than others, implying possible research gaps. Furthermore, we identified problems and inconsistences in reporting of greenspace types and mental health outcomes.

Discussion

The identified methodological variety is a potential for researching the complex connections between greenspace and mental health. Commonly used combinations can provide important insights. However, future research needs to emphasize other perspectives in order to understand how to create living environments with mental health benefits. For this purpose, interdisciplinary research is necessary.

From theory to practice: challenges and rewards of implementing ketogenic metabolic therapy in mental health

This perspective article delves into the implementation of Ketogenic Metabolic Therapy (KMT) by a mental health counselor who attempts to bridge the gap between emerging research and real-world clinical application. Grounded in the author's clinical experiences, the article communicates the potential of KMT in mental health care, highlighting both its therapeutic promise and the insights gained from hands-on patient interactions. While the adoption of KMT necessitates adjustments in societal, emotional, and dietary domains, especially within diverse mental health contexts, these challenges are surmountable with appropriate guidance and support. The article encourages the capture of qualitative data alongside quantitative measures and advocates for an approach that considers the broader implications of improved mental well-being on families and communities. As the field advances, interdisciplinary collaborations between researchers and clinicians will be pivotal in refining and expanding the application of KMT, ultimately enhancing patient outcomes and elevating the standard of mental health care.

Supporting self-determination in mental health recovery: Strategies employed by occupational therapists

INTRODUCTION

Self-determination is a core component of mental health recovery and a predictor of positive outcomes. The literature calls for occupational therapists to lead practice change to greater recovery-orientation, including facilitating people's self-determination. However, systemic challenges thwart translation of policy into practice and therapists report a lack of confidence in implementing recovery-oriented principles. This study aimed to understand the strategies that mental health occupational therapists employ to support people's self-determination.

METHODS

Data were collected through an international on-line questionnaire principally comprising two open-ended questions designed to elicit deep reflective personal accounts. Participants were asked about an experience in which they supported a person's self-determination and the factors that either facilitated or hindered this experience. Qualitative data were analysed using inductive thematic analysis, guided by constant comparative methods.

FINDINGS

Thirty-four therapists, predominantly from Australia (n = 30), participated. Therapists described supporting self-determination as a multifaceted process that involved: (1) working on myself, (2) working with the person, and (3) working with others. They emphasised that the combined use of various strategies across these three areas of work was important to support people's self-determination. Further, awareness of and addressing issues of power in their practice was key.

CONCLUSION

This study supports the translation of recovery-oriented principles into practice by revealing the nuanced strategies implemented by occupational therapists striving to support self-determination. Participants employed diverse strategies to empower people to take the 'driver's seat' in their mental health recovery journey. Insights from this study will support other occupational therapists to actualise recovery-oriented principles and better support self-determination in their practice. To effectively implement self-determination strategies, therapists must reflect on and address existing power differentials within mental health services, particularly between themselves and the people they support.

Pediatric Primary Care Provider Perspectives on Universal Suicide Screening

INTRODUCTION

Given the increase in youth mental health concerns, the American Academy of Pediatrics (AAP) recommends universal suicide screening for ages 12 and older, with positive screens followed by a brief suicide risk assessment. However, it is unclear how pediatric clinicians incorporate this recommendation into practice. Therefore, the objective of this qualitative study was to identify pediatric clinicians' current practice, attitudes, and barriers to implement the updated universal suicide screening recommendation in primary care.

METHODS

Community-based pediatric primary care providers (PCPs) in the St. Louis Metropolitan area who by self-report provide mental health care for patients participated. Participants completed a 30-minute semi-structured interview with invitations extended through an electronic listserv in a local Pediatric PCP Learning Collaborative. Interviews were transcribed and analyzed using consensual deductive and inductive approaches until data saturation.

RESULTS

Eighteen PCPs participated in the interviews. Interviews described themes related to acceptability of the recommendations, PCPs' current screening practices, and perceived barriers for implementing the recommendations. Overall, PCPs agreed with, but expressed hesitancy about, the recommendation. Frequently mentioned barriers to suicide screening included time, training, and inadequate access to resources for follow-up care for at-risk patients. Yet, PCPs were optimistic they could learn with support and were interested in working in this subject area through quality improvement interventions.

CONCLUSIONS

PCPs agree with the AAP recommendation about suicide screening but need support to implement into practice. Specifically, PCPs need time sensitive strategies, resources, training, and practice change support to assist these efforts.

"We want to be heard": A Qualitative Study of Mental Health Care Access among Patients of an Urban Federally Qualified Health Center

Introduction

Although depression is common in primary care, challenges to timely intervention exist, particularly for communities of color and lower socioeconomic status. Our objective was to understand barriers and facilitators to mental healthcare access among a sample of patients receiving care at a federally qualified health center (FQHC) in Minnesota, United States.

Methods

We qualitatively interviewed 34 patients of an urban FQHC, purposively sampled on race/ethnicity, insurance status, language, and depression symptom status (based on Patient Health Questionnaire-9 responses). We inductively and deductively analyzed interview data, leveraging theory in both the codebook development and analysis processes.

Results

Participants, who were predominantly English-speaking, female, not privately insured, and people of color, shared numerous barriers and facilitators to accessing mental healthcare. Prominent barriers primarily concerned healthcare providers, including perceived dismissal of mental health concerns and challenges with provider continuity. Additional barriers included the costs of mental health care, communication breakdowns, the patient portal, and community-specific perceptions of mental health. Prominent facilitators included clinic organizational factors (internal and external) and staff friendliness and warmth. Other factors including consideration of patients' financial situation, integrated management of behavioral and physical health conditions, language concordant staff, the telehealth visit modality, and the clinic's social mission were also raised as facilitating access.

Conclusion

Patient voices from a single FQHC illustrate the challenges and possibilities of providing mental healthcare in safety net settings. Clinical, strategy, and policy solutions can be tailored to minimize barriers and optimize facilitators documented herein.

Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients

BACKGROUND

Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors.

OBJECTIVES

To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates.

METHODS AND ANALYSIS

Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program.

ETHICS AND DISSEMINATION

The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.

The lived experience of Omani adolescents and young adults with mental illness: A qualitative study

There is currently limited knowledge about the firsthand experiences of adolescents and young adults with mental health problems and the meanings they ascribe to these experiences, particularly within Arab countries. This study, therefore, aimed to explore the lived experience of Omani adolescents and young adults with a mental health problem. A sample of 15 participants aged 13-22 diagnosed with a range of mental health problems took part in the study. A qualitative interview guide consisting of open-ended questions was used to allow participants to speak in-depth about their experiences. Using the thematic analysis approach to uncover patterns in the data, three major themes emerged: "living in darkness", "perilous journey" and "uncertain future". Results show that the progress of adolescents and young adults with mental health problems is characterized by several challenges; the most significant of which is having insufficient knowledge about their illness, leading to unnecessary delays in their treatment. These findings shed light on the breadth and depth of the experience of adolescents and young adults with mental health problems and lay the groundwork for further examinations. Implications lie in the development of approaches for preventing or mitigating difficulties faced by adolescents and young adults with mental health problems.

Study protocol: assessment of the usefulness and practicability of a psychoeducational intervention to prevent the negative psychological impact of the COVID-19 pandemic on primary care health workers

BACKGROUND

The COVID-19 pandemic has constituted an extraordinarily stressful situation for healthcare professionals and has led to psychological distress and an increase in various mental disorders. In the post-pandemic context, it is necessary to provide professionals with strategies and skills to manage this stressful situation and prevent or minimize its negative impact.

METHODS

Aims: To assess the feasibility and clinical effects of a group psychoeducational program focused on preventing the adverse psychological and emotional effects of the pandemic on primary care workers, and to explore the experience and perceptions of participants with regard to the program from a qualitative perspective.

DESIGN

A single-arm, before-and-after study conducted in primary care.

SETTING

The 332 primary care centers of the Catalan Institute of Health (Catalonia, Spain) Participants: The target population of the intervention is primary care workers, including clinical profiles (e.g., nurses and doctors), and non-clinical profiles (e.g., administrative staff). The implementation strategy will also involve community psychologists, who will lead the psychoeducational groups, and the health organization promoting the implementation.

INTERVENTION

A group psychoeducational program targeting primary care workers to promote emotional well-being and the ability to cope with stressful situations. Community psychologists will deliver it in the primary care centers they are linked to.

MEASURES

Mixed-methods evaluation, combining quantitative and qualitative research. A prospective assessment of the main outcomes (professional quality of life, psychological state, and resilience) will be performed using online questionnaires before and immediately after the intervention, and at 3 and 6 months. A qualitative study will be conducted, comprising focus groups and individual in-depth interviews with the participants in the intervention and the psychologists who provide it.

ETHICS

The Research Ethics Committee of the Jordi Gol Primary Care Research Institute (IDIAP) has approved the protocol (22/086-PCV).

DISCUSSION

This project proposes an intervention to promote mental health and psychological well-being in primary care workers by learning skills and integrating them into personal and professional life. The expected results will allow us to determine the usefulness and effectiveness of this psychoeducational intervention under the conditions of real clinical practice, provide data to model and perfect it, and promote its dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05720429; registered on 09/02/2023.

Development of a method for Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI): A modified Delphi study

Background

Intervention adaptation is often necessary to improve the fit between evidence-based practices/programs and implementation contexts. Existing frameworks describe intervention adaptation processes but do not provide detailed steps for prospectively designing adaptations, are designed for researchers, and require substantial time and resources to complete. A pragmatic approach to guide implementers through developing and assessing adaptations in local contexts is needed. The goal of this project was to develop Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI), a method for intervention adaptation that leverages human centered design methods and is tailored to the needs of intervention implementers working in applied settings with limited time and resources.

Method

MODIFI was iteratively developed via a mixed-methods modified Delphi process. Feedback was collected from 43 implementation research and practice experts. Two rounds of data collection gathered quantitative ratings of acceptability (Round 1) and feasibility (Round 2), as well as qualitative feedback regarding MODIFI revisions analyzed using conventional content analysis.

Results

In Round 1, most participants rated all proposed components as essential but identified important avenues for revision which were incorporated into MODIFI prior to Round 2. Round 2 emphasized feasibility, where ratings were generally high and fewer substantive revisions were recommended. Round 2 changes largely surrounded operationalization of terms/processes and sequencing of content. Results include a detailed presentation of the final version of the three-step MODIFI method (Step 1: Learn about the users, local context, and intervention; Step 2: Adapt the intervention; Step 3: Evaluate the adaptation) along with a case example of its application.

Discussion

MODIFI is a pragmatic method that was developed to extend the contributions of other research-based adaptation theories, models, and frameworks while integrating methods that are tailored to the needs of intervention implementers. Guiding teams to tailor evidence-based interventions to their local context may extend for whom, where, and under what conditions an intervention can be effective.

Pragmatic randomised controlled trial of guided self-help versus individual cognitive behavioural therapy with a trauma focus for post-traumatic stress disorder (RAPID)

Background

Guided self-help has been shown to be effective for other mental conditions and, if effective for post-traumatic stress disorder, would offer a time-efficient and accessible treatment option, with the potential to reduce waiting times and costs.

Objective

To determine if trauma-focused guided self-help is non-inferior to individual, face-to-face cognitive-behavioural therapy with a trauma focus for mild to moderate post-traumatic stress disorder to a single traumatic event.

Design

Multicentre pragmatic randomised controlled non-inferiority trial with economic evaluation to determine cost-effectiveness and nested process evaluation to assess fidelity and adherence, dose and factors that influence outcome (including context, acceptability, facilitators and barriers, measured qualitatively). Participants were randomised in a 1 : 1 ratio. The primary analysis was intention to treat using multilevel analysis of covariance.

Setting

Primary and secondary mental health settings across the United Kingdom's National Health Service.

Participants

One hundred and ninety-six adults with a primary diagnosis of mild to moderate post-traumatic stress disorder were randomised with 82% retention at 16 weeks and 71% at 52 weeks. Nineteen participants and ten therapists were interviewed for the process evaluation.

Interventions

Up to 12 face-to-face, manualised, individual cognitive-behavioural therapy with a trauma focus sessions, each lasting 60-90 minutes, or to guided self-help using Spring, an eight-step online guided self-help programme based on cognitive-behavioural therapy with a trauma focus, with up to five face-to-face meetings of up to 3 hours in total and four brief telephone calls or e-mail contacts between sessions.

Main outcome measures

Primary outcome: the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, at 16 weeks post-randomisation. Secondary outcomes: included severity of post-traumatic stress disorder symptoms at 52 weeks, and functioning, symptoms of depression, symptoms of anxiety, alcohol use and perceived social support at both 16 and 52 weeks post-randomisation. Those assessing outcomes were blinded to group assignment.

Results

Non-inferiority was demonstrated at the primary end point of 16 weeks on the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [mean difference 1.01 (one-sided 95% CI -∞ to 3.90, non-inferiority p = 0.012)]. Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, score improvements of over 60% in both groups were maintained at 52 weeks but the non-inferiority results were inconclusive in favour of cognitive-behavioural therapy with a trauma focus at this timepoint [mean difference 3.20 (one-sided 95% confidence interval -∞ to 6.00, non-inferiority p = 0.15)]. Guided self-help using Spring was not shown to be more cost-effective than face-to-face cognitive-behavioural therapy with a trauma focus although there was no significant difference in accruing quality-adjusted life-years, incremental quality-adjusted life-years -0.04 (95% confidence interval -0.10 to 0.01) and guided self-help using Spring was significantly cheaper to deliver [£277 (95% confidence interval £253 to £301) vs. £729 (95% CI £671 to £788)]. Guided self-help using Spring appeared to be acceptable and well tolerated by participants. No important adverse events or side effects were identified.

Limitations

The results are not generalisable to people with post-traumatic stress disorder to more than one traumatic event.

Conclusions

Guided self-help using Spring for mild to moderate post-traumatic stress disorder to a single traumatic event appears to be non-inferior to individual face-to-face cognitive-behavioural therapy with a trauma focus and the results suggest it should be considered a first-line treatment for people with this condition.

Future work

Work is now needed to determine how best to effectively disseminate and implement guided self-help using Spring at scale.

Trial registration

This trial is registered as ISRCTN13697710.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/97) and is published in full in Health Technology Assessment; Vol. 27, No. 26. See the NIHR Funding and Awards website for further award information.

Body mapping for arts-based inquiry in mental health research: a scoping review

Traditional research methods have not yet yielded highly effective long-term mental health treatments and might not reflect diverse lived experiences. Body mapping, which is an arts-based research method, could complement the verbal data of existing approaches through its focus on visual and symbolic processes to understand subjective, embodied experiences related to mental health. We did a scoping review on the use of body mapping in research on mental health experiences and outcomes. We searched Web of Science, PubMed, Scopus, PsycINFO, Embase, Ovid Medline, and Google Scholar to retrieve peer-reviewed articles in English. In 19 articles representing 17 studies, participant numbers for body mapping ranged from three to 48, and some studies exclusively recruited women or children and young people. Study domains included primary mental health experiences and mental health in relation to physical health or social experiences. The benefits of body mapping included its exploration of difficult-to-access emotions and experiences, its focus on strength and resilience, the therapeutic effect, its participatory and collaborative nature, its empowerment and dissemination of participants' voices, and the engagement of children and young people. Body mapping holds promise for research with marginalised groups typically excluded from mental health research.

Implementation measurement in global mental health: Results from a modified Delphi panel and investigator survey

Limited guidance exists to support investigators in the choice, adaptation, validation and use of implementation measures for global mental health implementation research. Our objectives were to develop consensus on best practices for implementation measurement and identify strengths and opportunities in current practice. We convened seven expert panelists. Participants rated approaches to measure adaptation and validation according to appropriateness and feasibility. Follow-up interviews were conducted and a group discussion was held. We then surveyed investigators who have used quantitative implementation measures in global mental health implementation research. Participants described their use of implementation measures, including approaches to adaptation and validation, alongside challenges and opportunities. Panelists agreed that investigators could rely on evidence of a measure's validity, reliability and dimensionality from similar contexts. Panelists did not reach consensus on whether to establish the pragmatic qualities of measures in novel settings. Survey respondents (n = 28) most commonly reported using the Consolidated Framework for Implementation Research Inner Setting Measures (n = 9) and the Program Assessment Sustainability Tool (n = 5). All reported adapting measures to their settings; only two reported validating their measures. These results will support guidance for implementation measurement in support of mental health services in diverse global settings.

The What and the How: A pilot study of feedback from service providers and consumers about service development in new urban mental health hub

OBJECTIVE

An inner-city hospital purchased a local hotel to provide support, digital engagement, skill development groups and referrals to partner agencies. Being aware of the hotel's importance to the local community, we sought feedback on a model of care relevant to perceived gaps and needs in support for mental health.

METHODS

Four online focus groups included healthcare professionals, nominated opinion leaders from local Non-Government Organisations (NGOs), consumers and carers to reflect a range of views. Focus group data were qualitatively analysed.

RESULTS

Participants made useful suggestions about WHAT educational, preventative and therapeutic services were needed. They emphasised the importance of HOW people engage with the service, the balance between accessibility and security. Other themes included targeting people with limited health literacy, integration with existing services, building on site heritage and ongoing evaluation of objectives and needs.

CONCLUSIONS

This pilot study demonstrated clear support for providing safe and welcoming access to services, with resources and access to services to improve their health and wellbeing built on principles of social justice and inclusion. Participants had constructive ideas of what was needed, and ongoing patient and public research is anticipated.

Challenges and recommendations for measuring time devoted to implementation and intervention activities in health equity-focused, resource-constrained settings: a qualitative analysis

BACKGROUND

There is little guidance for conducting health equity-focused economic evaluations of evidence-based practices in resource-constrained settings, particularly with respect to staff time use. Investigators must balance the need for low-touch, non-disruptive cost data collection with the need for data on providing services to priority subpopulations.

METHODS

This investigation took place within a pilot study examining the implementation of a bundled screening intervention combining screening for social determinants of health and colorectal cancer at four federally qualified health centers (FQHCs) in the Boston metropolitan area. Methods for collecting data on personnel costs for implementation and intervention activities, including passive (automatic) and active (non-automatic, requiring staff time and effort) data collection, as well as three alternate wordings for self-reporting time-use, were evaluated qualitatively using data collected through interviews with FQHC staff (including clinicians, population health staff, and community health workers) and assessments of data completeness.

RESULTS

Passive data collection methods were simple to execute and resulted in no missing data, but missed implementation and intervention activities that took place outside planned meetings. Active cost data collection using spreadsheets was simple for users when applied to care processes already tracked in this fashion and yielded accurate time use data. However, for tasks where this was not typical, and when tasks were broken up over multiple sessions, spreadsheets were more challenging to use. Questions asking about time use for a typical rather than specific time period, and for typical patients, yielded the most reliable and actionable data. Still, even the best-performing question had substantial variability in time use estimates. Participants noted that patient characteristics of interest for equity-focused research, including language spoken, adverse social determinants of health, and issues related to poverty or mental health, all contributed significantly to this variability.

CONCLUSIONS

Passively collected time use data are the least burdensome and should be pursued in research efforts when possible, but should be accompanied by qualitative assessments to ensure the data are an accurate reflection of effort. When workflows are already tracked by active data collection, these are also strong data collection methods. Self-reported time use will be most accurate when questions inquire about "typical" tasks and specific types of patients.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

A Phenomenological Exploration of Families' Experiences of the Mental Health System of Care in the Monadnock Region

Accessing mental health treatment in rural locations is a unique challenge for families with youth experiencing adverse mental health conditions. Families often experience a variety of difficulties accessing and negotiating changes within the system of care. This study aimed to understand the experiences of families and their youth in navigating the mental health system in a rural community. Interpretative phenomenological analysis was used to examine how participants interpret their experiences within the local system of care. Qualitative interviews were conducted with eight families. Results included five main themes: youth experience, family experience, access to a system of care, relationships between stakeholders, and larger societal beliefs. Families highlighted their experiences accessing the local care system and their hope for strengthening community access and partnerships. Findings indicate that prioritizing family voices should be encouraged by local systems.

A systematic review of mixed studies on malaria in Colombia 1980-2022: what the "bifocal vision" discovers

Mixed methods are essential in public health research and malaria control, because they allow grasping part of the complexity and diversity of the factors that determine health-disease. This study analyzes the mixed studies on malaria in Colombia, 1980-2022, through a systematic review in 15 databases and institutional repositories. The methodological quality was assessed with Mixed Methods Appraisal Tool (MMAT), STrengthening the Reporting of OBservational studies in Epidemiology (STROBE), and Standards for Reporting Qualitative Research (SRQR). The qualitative and quantitative findings were grouped into a four-level hierarchical matrix. The epidemiological profile of malaria morbidity, from traditional epidemiology, has been sustained by environmental problems, armed conflict, individual risk behaviors, and low adherence to recommendations from health institutions. However, the qualitative component reveals deeper causes that are less studied, of greater theoretical complexity, and that reflect challenges to design and implement health interventions, such as socioeconomic and political crises, poverty, and the neoliberal orientation in the malaria control policy; the latter reflected in the change in the role of the State, the fragmentation of control actions, the predominance of insurance over social assistance, the privatization of the provision of health services, the individualistic and economistic predominance of health, and low connection with popular tradition and community initiatives. The above confirms the importance of expanding mixed studies as a source of evidence to improve malaria research and control models in Colombia, and to identify the underlying causes of the epidemiological profile.

Effects of a Parenting Intervention for Emotional and Behavioral Problems in Young Autistic Children Under Conditions of Enhanced Uncertainty: Two-Year Follow-up of a Pilot Randomized Controlled Trial Cohort (ASTAR) During the United Kingdom COVID-19 Pandemic

OBJECTIVE

Most young autistic children display emotional and behavioral problems (EBPs). There is evidence that behavioral parenting interventions (BPIs) reduce these. The COVID-19 pandemic and associated lockdowns can be seen as a natural experiment to test the longer-term effect of BPIs under conditions of increased uncertainty.

METHOD

Opportunistic follow-up (n = 49) of a pilot randomized controlled trial (RCT) cohort (n = 62 autistic children aged 6-11 years; originally randomized to a 12-week group BPI [Predictive Parenting; n = 31] or an attention control [Psychoeducation; n = 31]) was conducted during COVID-19-related lockdowns. Measures of parent-reported child irritability and parenting stress were collected at 3 time points (baseline: mean age = 6.7 years; primary endpoint: mean age = 7.1 years, ∼5 months after randomization; and COVID-19 follow-up: mean age = 8.8 years, ∼2 years after randomization). We tested the magnitude of intervention effects using point estimates of differences in child irritability and parenting stress between arms at primary endpoint and COVID-19 follow-up, covarying for baseline scores. We used area under the curve (AUC) analyses to obtain overall estimates of the average intervention effect across all 3 timepoints. Semi-structured qualitative interviews were conducted with a subsample of parents (n = 18).

RESULTS

A small but significant intervention effect was found from baseline to COVID-19 follow-up in favor of Predictive Parenting on parent-reported child irritability (d = -0.33, 95% CI = -0.65, -0.01) and parenting stress (d = -0.31, 95% CI = -0.59, -0.03). No overall mean intervention effect for these measures as estimated by the AUC analyses (which takes into account the nonsignificant effect at primary endpoint) was found. Interview feedback on the both interventions was positive, and parents reported using strategies from Predictive Parenting during COVID-19-related restrictions.

CONCLUSION

This opportunistic follow-up study at a time of stress indicates the need for careful consideration of how and when to measure the effects of BPIs in autistic child populations. Future trials should consider both the most appropriate endpoint and in what context effects may be more likely to be seen.

CLINICAL TRIAL REGISTRATION INFORMATION

Autism Spectrum Treatment and Resilience (ASTAR); https://www.isrctn.com; 91411078.

Caregiver Insights and Improvement Strategies for Youth with Autism Undergoing Gastrointestinal Endoscopy

Limited guidance is available for families of youth with ASD (YASD) to prepare for invasive medical procedures. This study examined caregiver perspectives regarding YASD's gastrointestinal endoscopy (GE) experience to improve the endoscopy experience for YASD. Thirty-four caregivers of YASD, (M = 9.85 years, SD = 4.6) who underwent GE at Rady Children's Hospital, San Diego between May 2018 and July 2019 (identified via electronic health record) participated in a structured phone interview. Caregivers reported a positive experience due to the procedural team's responsiveness to the needs of YASD and appropriately answering/addressing questions/concerns. Caregivers reported a need for ASD-specific information on how to prepare for GE. Specific recommendations are discussed. Study findings offer strategies to improve the care experience of YASD undergoing GE.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

Views of female genital mutilation survivors, men and health-care professionals on timing of deinfibulation surgery and NHS service provision: qualitative FGM Sister Study

Background

Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal.

Objectives

We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision.

Methods

This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method.

Results

There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor's choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals' awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families.

Limitations

Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation.

Conclusions

In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision.

Future work

Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services.

Trial registration

Current Controlled Trials ISRCTN14710507.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.

My Home Quarantine on an App: A Qualitative Visual Analysis of Changes in Family Routines During the COVID-19 Pandemic in Chile

This article presents original findings from a longitudinal qualitative study on changes in individual and family life associated with safety and health measures implemented during the COVID-19 pandemic in three regions of Chile. We developed a methodological approach based on multimodal diaries in a mobile application, in which participants submitted photographs and texts to express changes in their daily lives under residential confinement. Content and semiotic visual analyses show a significant loss in instances of collective recreation, partially compensated through new personal and productive activities performed at home. Our results suggest that modal diaries serve as potential tools to capture people's perceptions and meanings as their lives go through exceptional and traumatic times. We assert that using digital and mobile technologies in qualitative studies could allow subjects to actively participate in the co-construction of fieldwork and produce quality knowledge from their situated perspectives.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11133-023-09531-z.

Outreach to the Veterans Crisis Line During the COVID-19 Pandemic: A Mixed-Methods Analysis

OBJECTIVE

The mental health impacts of the COVID-19 pandemic have been widely felt among already vulnerable populations, such as U.S. military veterans, including a heightened risk for depression and suicidal ideation. Support hotlines such as the Veterans Crisis Line (VCL) took a central role in addressing various concerns from callers in distress; research has yet to examine the concerns of veterans who used the VCL during the early months of the pandemic.

METHODS

A mixed-methods analysis of characteristics of veteran outreach to the VCL during the first year of the COVID-19 pandemic in the United States was conducted on 342,248 calls during April-December 2020; 3.8% (N=12,869) of calls were coded as related to COVID-19. Quantitative examination was conducted regarding COVID-19-related reasons for contact, suicide risk screens, and caller concerns; 360 unique calls with synopsis notes that included a COVID-19 flag were qualitatively analyzed.

RESULTS

Quantitative analysis of the calls with a COVID-19 flag revealed mental health concerns, loneliness, and suicidal thoughts as top reasons veterans contacted the VCL during the pandemic. Qualitative analysis identified specific economic and mental health concerns, including negative impacts on income and housing, increased feelings of depression or anxiety, and pandemic-specific concerns such as testing and vaccine availability. Disrupted access to resources for coping, including support groups or gyms, had negative perceived impacts and sometimes exacerbated preexisting problems such as substance abuse or depression.

CONCLUSIONS

These findings emphasize the role of VCL as providing general support to veterans experiencing loneliness and supplying assistance in coping with pandemic-related distress.

Optimizing ATTAIN implementation in a federally qualified health center guided by the FRAME-IS

Implementation strategies are methods or techniques used to adopt, implement, and sustain evidence-based practices (EBPs). Implementation strategies are dynamic and may require adaptation to fit implementation contexts, especially in low-resource settings, which are most likely to serve racially and ethnically diverse patients. The framework for reporting adaptations and modifications to evidence-based implementation strategies (FRAME-IS) was used to document adaptations to implementation strategies to inform an optimization pilot of Access to Tailored Autism Integrated Care (ATTAIN; an integrated care model for children with autism and co-occurring mental health needs) in a federally qualified health center (FQHC) near the United States/Mexico border. Quantitative and qualitative data were collected from 36 primary care providers who participated in the initial ATTAIN feasibility pilot to inform adaptations. Adaptations were mapped to the FRAME-IS through an iterative template analysis to inform an optimization pilot at a FQHC 1-year from the start of the COVID-19 pandemic. Four implementation strategies (training and workflow reminders, provider/clinic champions, periodic reflections, and technical assistance) were employed during the feasibility pilot and were adapted for the optimization pilot to fit the needs of the FQHC and service delivery changes prompted by the pandemic. Findings demonstrate the utility of using the FRAME-IS to systematically inform EBP optimization in a FQHC providing care to underserved communities. Findings will inform future research studies implementing integrated mental health models in low-resourced primary care settings. Implementation outcomes and provider perceptions of ATTAIN at the FQHC are also reported. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.

Qualitative study to explore UK medical students' and junior doctors' experiences of occupational stress and mental health during the COVID-19 pandemic

OBJECTIVES

This qualitative study aimed to explore the occupational experiences of medical students and junior doctors working during the COVID-19 pandemic. In particular, the research sought to identify factors which mediated work stress, barriers to disclosing mental health problems and levels of support medical students and junior doctors received during the pandemic.

DESIGN

This study was a form of thematic analysis and adopted an inductive, 'bottom-up' approach, in which coded categories were derived from rich, descriptive data.

SETTING

Semistructured interviews were conducted online with UK-based medical students and junior doctors. Interviews were recorded, and analysis was done by coding salient quotes into themes.

PARTICIPANTS

The final sample consisted of seven junior doctors and eight medical students, during the summer of 2021.

RESULTS

High levels of occupational stress were identified, which were exacerbated by COVID-19. A number of organisational difficulties associated with the pandemic compounded participants' experiences of work stress. Participants recognised progress towards promoting and managing mental health within the profession but may still be reluctant to access support services. Barriers to disclosure included fear of stigmatisation, concerns about adding to colleagues' workloads, lack of clarity about career implications and mistrust of occupational health services.

CONCLUSIONS

While attitudes towards mental health have improved, medical students and junior doctors may avoid seeking help. Given the immense pressures faced by health services, it is imperative that extra measures are implemented to minimise work-stress, encourage help-seeking behaviours and promote supportive work cultures.

Therapeutic alliance in a cognitive rehabilitation programme for people with serious mental illness: A qualitative analysis

OBJECTIVE

Therapeutic alliance is an important element of evidence-based treatments for people diagnosed with a serious mental illness. Cognitive enhancement therapy (CET) is an efficacious cognitive rehabilitation programme that emphasizes coach-participant relationships. The purpose of this study was to examine experiences of therapeutic alliance among CET participants.

DESIGN

We used an exploratory qualitative approach.

METHODS

Semi-structured interviews were conducted with 24 participants diagnosed with a serious mental illness. Interview transcripts were analysed by three independent coders using thematic analysis.

RESULTS

Four themes related to therapeutic alliance emerged: (1) positive regard; (2) collaboration; (3) authenticity; (4) negative alliance.

CONCLUSIONS

Findings suggest that therapeutic alliance is an important component of CET that bolsters the learning environment and ensures a positive group experience. Our qualitative analyses contribute greater understanding of how strong therapeutic relationships impact people with serious mental illnesses participating in evidence-based treatments beyond psychotherapy context.

Thematic analysis of the raters' experiences administering scales to assess depression and suicide in Arab schizophrenia patients

BACKGROUND

This study aimed to enhance the cultural adaptation and training on administering the Arabic versions of the Calgary Depression Scale in Schizophrenia (CDSS) and The International Scale for Suicidal Thinking (ISST) to Arab schizophrenia patients in Doha, Qatar.

METHODS

We applied the qualitative thematic analysis of the focus group discussions with clinical research coordinators (CRCs). Five CRCs met with the principal investigator for two sessions; we transcribed the conversations and analyzed the content.

RESULTS

This study revealed one set of themes related to the scales themselves, like the role of the clinician-patient relationship during administration, the semantic variations in Arabic dialects, and the design of scales to assess suicide and differentiate between negative symptoms and depression. The other set of themes is relevant to the sociocultural domains of Muslim Arabs, covering religion, families' roles, and stigma. It also covered the approaches to culturally sensitive issues like suicide, taboos in Islam, and the gender roles in Arab countries and their impact on the patients' reports of their symptoms.

CONCLUSIONS

Our results highlight several cultural and religious aspects to tackle when approaching schizophrenia patients through in-depth discussions and training to improve the validity of the assessment tools and treatment services.

Community voices on factors influencing COVID-19 concerns and health decisions among racial and ethnic minorities in the school setting

Racial and ethnic minority communities have been disproportionately affected by COVID-19, but the uptake of COVID-19 mitigation strategies like vaccination and testing have been slower in these populations. With the continued spread of COVID-19 while in-person learning is a priority, school-aged youth and their caregivers must make health-related decisions daily to ensure health at school. It is critical to understand factors associated with COVID-related health decisions such as vaccination, testing, and other health behaviors (e.g., wearing masks, hand washing). Community-engaged campaigns are necessary to overcome barriers to these health behaviors and promote health equity. The aim of this study was to examine COVID-19-related concerns and influences on health decisions in middle and high schools serving primarily racial and ethnic minority, low-income families. Seven focus groups were conducted with school staff, parents, and students (aged 16 years and older). Qualitative data were analyzed using a general inductive approach. Factors related to COVID-19 concerns and health decisions centered on (1) vaccine hesitancy, (2) testing hesitancy, (3) developmental stage (i.e., ability to engage in health behaviors based on developmental factors like age), (4) cultural and family traditions and beliefs, (5) compatibility of policies and places with recommended health behaviors, (6) reliability of information, and (7) perceived risk. We explore sub-themes in further detail. It is important to understand the community's level of concern and identify factors that influence COVID-19 medical decision making to better address disparities in COVID-19 testing and vaccination uptake.