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Taiwo TK, Goode K, Niles PM, Stoll K, Malhotra N, Vedam S. Perinatal Mood and Anxiety Disorder and Reproductive Justice: Examining Unmet Needs for Mental Health and Social Services in a National Cohort. Health Equity 2024; 8:3-13. [PMID: 38250299 PMCID: PMC10797170 DOI: 10.1089/heq.2022.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Perinatal Mood and Anxiety Disorders (PMADs) are the most common complications during the perinatal period. There is limited understanding of the gaps between need and provision of comprehensive health services for childbearing people, especially among racialized populations. Methods The Giving Voice to Mothers Study (GVtM; n=2700), led by a multistakeholder, Steering Council, captured experiences of engaging with perinatal services, including access, respectful care, and health systems' responsiveness across the United States. A patient-designed survey included variables to assess relationships between race, care provider type (midwife or doctor), and needs for psychosocial health services. We calculated summary statistics and tested for significant differences across racialized groups, subsequently reporting odds ratios (ORs) for each group. Results Among all respondents, 11% (n=274) reported unmet needs for social and mental health services. Indigenous women were three times as likely to have unmet needs for treatment for depression (OR [95% confidence interval, CI]: 3.1 [1.5-6.5]) or mental health counseling (OR [95% CI]: 2.8 [1.5-5.4]), followed by Black women (OR [95% CI]: 1.8 [1.2-2.8] and 2.4 [1.7-3.4]). Odds of postpartum screening for PMAD were significantly lower for Latina women (OR [95% CI]=0.6 [0.4-0.8]). Those with midwife providers were significantly more likely to report screening for anxiety or depression (OR [95% CI]=1.81 [1.45-2.23]) than those with physician providers. Discussion We found significant unmet need for mental health screening and treatment in the United States. Our results confirm racial disparities in referrals to social services and highlight differences across provider types. We discuss barriers to the integration of assessments and interventions for PMAD into routine perinatal services. Implications We propose incentivizing reimbursement schema for screening and treatment programs; for community-based organizations that provide mental health and social services; and for culture-centered midwife-led perinatal and birth centers. Addressing these gaps is essential to reproductive justice.
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Affiliation(s)
- Tanya Khemet Taiwo
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Bastyr University Department of Midwifery, Kenmore, Washington, USA
| | - Keisha Goode
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- SUNY Old Westbury, Old Westbury, New York, USA
- National Association of Certified Professional Midwives, Keene, New Hampshire, USA
| | - P. Mimi Niles
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Rtory Meyers College of Nursing, New York University, New York, New York, USA
| | - Kathrin Stoll
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Malhotra
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Saraswathi Vedam
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Johnson KK, Bennett C, Rochani H. Significant Improvement of Somatic Symptom Disorder With Brief Psychoeducational Intervention by PMHNP in Primary Care. J Am Psychiatr Nurses Assoc 2022; 28:171-180. [PMID: 32964788 DOI: 10.1177/1078390320960524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with somatic symptom disorders (SSD) are prevalent in primary care, urgent care, and emergency rooms and present with reduced quality of life, increased disability, and suicidality . Criteria for SSD include (1) somatic symptoms that cause distress and disrupt life; (2) concurrent physical illness with thoughts and feelings that are disproportionate to the seriousness of the illness; and (3) distress which is persistent and causes suffering. The frequency of SSD in the general population is 5% to 7%; however, in primary care, it is 5% to 35% . Because patients present with anxiety, depression, and/or pain, providers are flummoxed when diagnostic findings do not match symptom intensity. The purpose of this project was to provide an intervention for patients with SSD and measure its effectiveness on their somatic symptoms. METHOD This study provided a single-session, 30-minute psychoeducational intervention for patients to explain brain pathways for pain and the body's response to stress, including scientific benefits of exercise and healthy diet. Patients were asked questions using the motivational interviewing technique OARS (open-ended question, affirmation, reflection, summary) and were encouraged to talk about their concerns. The study used a pre- and post-intervention visual analogue scale and a self-reported Patient Health Questionnaire-15 both before and 3 weeks post-intervention. RESULTS Measurements showed significant symptom improvement immediately after the intervention with sustained improvement 3 weeks post-intervention. CONCLUSIONS This intervention demonstrates an effective treatment for this insidious illness, which plagues up to 35% of patients in primary care.
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Affiliation(s)
- Kim K Johnson
- Kim K. Johnson, DNP, PMHNP-BC, NP-C, RN, School of Nursing, Middle Georgia State University, Macon, GA, USA
| | - Carole Bennett
- Carole Bennett, PhD, APRN, PMHCS-BC, Waters College of Health Professions, Georgia Southern University, Statesboro, GA, USA
| | - Haresh Rochani
- Haresh Rochani, DrPH, MPH, MBBS, Biostatistics, K. E. Peace Center for Biostatistics, Georgia Southern University, Statesboro, GA, USA
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Larson S, Nemoianu A, Lawrence DF, Troup MA, Gionfriddo MR, Pousti B, Sun H, Riaz F, Wagner ES, Chrones L, Touya M. Characterizing primary care for patients with major depressive disorder using electronic health records of a US-based healthcare provider. J Affect Disord 2022; 300:377-384. [PMID: 34953925 DOI: 10.1016/j.jad.2021.12.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 10/24/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is predominantly managed in primary care. However, primary care providers (PCPs) may not consistently follow evidence-based treatment algorithms, leading to variable patient management that can impact outcomes. METHODS We retrospectively analyzed adult patients with MDD seen at Geisinger, an integrated health system. Utilizing electronic health record (EHR) data, we classified patients as having MDD based on International Classification of Disease (ICD)-9/10 codes or a Patient Health Questionnaire (PHQ)-9 score ≥5. Outcomes assessed included time to first visit with a PCP or behavioral health specialist following diagnosis, antidepressant medication switching, persistence, healthcare resource utilization (HRU), and treatment costs. RESULTS Among the 38,321 patients with MDD managed in primary care in this study, significant delays between diagnosis with antidepressant prescribing and follow-up PCP visits were observed. There was also considerable variation in care following diagnosis. Overall, 34.9% of patients with an ICD-9/10 diagnosis of MDD and 41.3% with a PHQ-9 score ≥15 switched antidepressants. An ICD-9/10 diagnosis, but not moderately severe to severe depression, was associated with higher costs and HRU. More than 75% of patients with MDD discontinued antidepressant medication within 6 months. LIMITATIONS The study population was comparable with other real-world studies of MDD, but study limitations include its retrospective nature and reliance on the accuracy of EHRs. CONCLUSIONS Management of patients with MDD in a primary care setting is variable. Addressing these gaps will have important implications for ensuring optimal patient management, which may reduce HRU and treatment medication costs, and improve treatment persistence.
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Affiliation(s)
- Sharon Larson
- Main Line Health Center for Population Research at the Lankenau Institute for Medical Research, Wynnewood, PA, and Thomas Jefferson University College of Population Health, Philadelphia, PA, United States.
| | | | - Debra F Lawrence
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
| | | | | | - Bobak Pousti
- Geisinger Health System, Danville, PA, United States
| | - Haiyan Sun
- Geisinger Health System, Danville, PA, United States
| | - Faisal Riaz
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
| | - Eric S Wagner
- Geisinger Health System, Danville, PA, United States
| | - Lambros Chrones
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, United States
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Wright JH, Owen J, Eells TD, Antle B, Bishop LB, Girdler R, Harris LM, Wright RB, Wells MJ, Gopalraj R, Pendleton ME, Ali S. Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2146716. [PMID: 35142833 PMCID: PMC8832170 DOI: 10.1001/jamanetworkopen.2021.46716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. OBJECTIVES To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. INTERVENTIONS CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. MAIN OUTCOMES AND MEASURES The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. RESULTS The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02700009.
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Affiliation(s)
- Jesse H. Wright
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jesse Owen
- Department of Counseling Psychology, University of Denver, Denver, Colorado
| | - Tracy D. Eells
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, Kentucky
| | - Becky Antle
- Kent School of Social Work, University of Louisville, Louisville, Kentucky
| | - Laura B. Bishop
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Renee Girdler
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Norton Healthcare, Norton Community Medical Associates, Louisville, Kentucky
| | - Lesley M. Harris
- Kent School of Social Work, University of Louisville, Louisville, Kentucky
| | - R. Brent Wright
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael J. Wells
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Baptist Health, Baptist Health Medical Group Primary Care, Louisville, Kentucky
| | - Rangaraj Gopalraj
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Norton Healthcare, Norton Community Medical Associates, Louisville, Kentucky
| | - Michael E. Pendleton
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Baptist Health, Baptist Health Medical Group Primary Care, Louisville, Kentucky
| | - Shehzad Ali
- Mental Health and Addictions Research Group, Department of Health Sciences, University of York, Heslington, United Kingdom
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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Duric P, Harhaji S, O'May F, Boderscova L, Chihai J, Como A, Hranov GL, Mihai A, Sotiri E. General practitioners' views towards diagnosing and treating depression in five southeastern European countries. Early Interv Psychiatry 2019; 13:1155-1164. [PMID: 30277313 PMCID: PMC6445789 DOI: 10.1111/eip.12747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/11/2018] [Accepted: 09/09/2018] [Indexed: 11/30/2022]
Abstract
AIM To assess and compare general practitioners' (GPs') views of diagnosing and treating depression in five southeastern European countries. METHODS A cross-sectional study was conducted in Albania, Bulgaria, Moldova, Romania, and Serbia. The sample included 467 GPs who completed a hard-copy self-administered questionnaire, consisting of self-assessment questions related to diagnosing and treating depression. RESULTS The most common barriers to managing depression in general practice reported by GPs were: patients' unwillingness to discuss depressive symptoms (92.3%); appointment time too short to take an adequate history (91.9%), barriers for prescribing appropriate treatment (90.6%); and patients' reluctance to be referred to a psychiatrist (89.1%). Most GPs (78.4%) agreed that recognizing depression was their responsibility, 71.7% were confident in diagnosing depression, but less than one-third (29.6%) considered that they should treat it. CONCLUSIONS Improvements to the organization of mental healthcare in all five countries should consider better training for GPs in depression diagnosis and treatment; the availability of mental healthcare specialists at primary care level, with ensured equal and easy access for all patients; and the removal of potential legal barriers for diagnosis and treatment of depression.
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Affiliation(s)
- Predrag Duric
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK.,Institute of Public Health of Vojvodina/Faculty of Medicine, University of Novi Sad, Novi Sad, Vojvodina, Serbia
| | - Sanja Harhaji
- Institute of Public Health of Vojvodina/Faculty of Medicine, University of Novi Sad, Novi Sad, Vojvodina, Serbia
| | - Fiona O'May
- Institute for Global Health and Development, Queen Margaret University Edinburgh, Musselburgh, UK
| | | | - Jana Chihai
- Medical Psychology and Narcology Department, State Medical and Pharmaceutical University Nicolae Testemitanu, Chisinau, Moldova
| | - Ariel Como
- Tirana University Hospital Centre, Tirana, Albania
| | - Georgi L Hranov
- Second Psychiatric Clinic, University Multi-profile Hospital for Active Treatment in Neurology and Psychiatry St. Naum, Sofia, Bulgaria
| | - Adriana Mihai
- Psychiatric Department, University of Medicine and Pharmacy, Targul Mures, Romania
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Chiauzzi E, Drahos J, Sarkey S, Curran C, Wang V, Tomori D. Patient Perspective of Cognitive Symptoms in Major Depressive Disorder: Retrospective Database and Prospective Survey Analyses. J Particip Med 2019; 11:e11167. [PMID: 33055062 PMCID: PMC7434060 DOI: 10.2196/11167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/19/2018] [Accepted: 12/02/2018] [Indexed: 11/21/2022] Open
Abstract
Background Major depressive disorder (MDD) is a common and burdensome condition. The clinical understanding of MDD is shaped by current research, which lacks insight into the patient perspective. Objective This two-part study aimed to generate data from PatientsLikeMe, an online patient network, on the perception of cognitive symptoms and their prioritization in MDD. Methods A retrospective data analysis (study 1) was used to analyze data from the PatientsLikeMe community with self-reported MDD. Information on patient demographics, comorbidities, self-rated severity of MDD, treatment effectiveness, and specific symptoms of MDD was analyzed. A prospective electronic survey (study 2) was emailed to longstanding and recently active members of the PatientsLikeMe MDD community. Study 1 analysis informed the objectives of the study 2 survey, which were to determine symptom perception and prioritization, cognitive symptoms of MDD, residual symptoms, and medication effectiveness. Results In study 1 (N=17,166), cognitive symptoms were frequently reported, including “severe” difficulty in concentrating (28%). Difficulty in concentrating was reported even among patients with no/mild depression (80%) and those who considered their treatment successful (17%). In study 2 (N=2525), 23% (118/508) of patients cited cognitive symptoms as a treatment priority. Cognitive symptoms correlated with depression severity, including difficulty in making decisions, concentrating, and thinking clearly (rs=0.32, 0.36, and 0.34, respectively). Cognitive symptoms interfered with meaningful relationships and daily life tasks and had a profound impact on patients’ ability to work and recover from depression. Conclusions Patients acknowledge that cognitive dysfunction in MDD limits their ability to recover fully and return to a normal level of social and occupational functioning. Further clinical understanding and characterization of MDD for symptom prioritization and relapse risk due to residual cognitive impairment are required to help patients return to normal cognitive function and aid their overall recovery.
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Affiliation(s)
| | - Jennifer Drahos
- PatientsLikeMe, Cambridge, MA, United States.,Takeda Pharmaceuticals, Cambridge, MA, United States
| | - Sara Sarkey
- Takeda Pharmaceuticals, Deerfield, IL, United States
| | | | - Victor Wang
- PatientsLikeMe, Cambridge, MA, United States
| | - Dapo Tomori
- Takeda Pharmaceuticals, Deerfield, IL, United States
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Wakida EK, Okello ES, Rukundo GZ, Akena D, Alele PE, Talib ZM, Obua C. Health system constraints in integrating mental health services into primary healthcare in rural Uganda: perspectives of primary care providers. Int J Ment Health Syst 2019; 13:16. [PMID: 30949234 PMCID: PMC6429816 DOI: 10.1186/s13033-019-0272-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/14/2019] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization issued recommendations to guide the process of integrating mental health services into primary healthcare. However, there has been general as well as context specific shortcomings in the implementation of these recommendations. In Uganda, mental health services are intended to be decentralized and integrated into general healthcare, but, the services are still underutilized especially in rural areas. Purpose The purpose of this study was to explore the health systems constraints to the integration of mental health services into PHC in Uganda from the perspective of primary health care providers (PHCPs). Methods This was a cross sectional qualitative study guided by the Supporting the Use of Research Evidence (SURE) framework. We used a semi-structured interview guide to gain insight into the health systems constraints faced by PHCPs in integrating mental health services into PHC. Results Key health systems constraints to integrating mental health services into PHC identified included inadequate practical experience during training, patient flow processes, facilities, human resources, gender related factors and challenges with accessibility of care. Conclusion There is need to strengthen the training of healthcare providers as well as improving the health care system that supports health workers. This would include periodic mental healthcare in-service training for PHCPs; the provision of adequate processes for outreach, and receiving, referring and transferring patients with mental health problems; empowering PHCPs at all levels to manage and treat mental health problems and adequately provide the necessary medical supplies; and increase the distribution of health workers across the health facilities to address the issue of high workload and compromised quality of care provided. Electronic supplementary material The online version of this article (10.1186/s13033-019-0272-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edith K Wakida
- 1Department of Psychiatry, Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Elialilia S Okello
- Mwanza Intervention Trials Unit, Tanzania National Institute for Medical, Mwanza Centre, Mwanza, Tanzania
| | - Godfrey Z Rukundo
- 1Department of Psychiatry, Mbarara University of Science and Technology, P. O. Box 1410, Mbarara, Uganda
| | - Dickens Akena
- 3Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul E Alele
- 4Department of Pharmacology and Therapeutics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zohray M Talib
- Department of Medical Education, California University of Science and Medicine, San Bernardino, CA USA.,6Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- 7Department of Pharmacology and Therapeutics and Vice Chancellor, Mbarara University of Science and Technology, Mbarara, Uganda
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Wakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, Obua C. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review. Syst Rev 2018; 7:211. [PMID: 30486900 PMCID: PMC6264616 DOI: 10.1186/s13643-018-0882-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 11/12/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies. METHODS Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. RESULTS Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. DISCUSSION We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted. SYSTEMATIC REVIEW REGISTRATION PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.
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Affiliation(s)
- Edith K. Wakida
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zohray M. Talib
- Department of Medical Education, California University of Science and Medicine, California, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dickens Akena
- Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences Makerere University, Kampala, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | | | - Alison Kinengyere
- Department of Psychiatry, Makerere University, Kampala, Uganda
- Library, Africa Center for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Arnold Mindra
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Celestino Obua
- Department of Pharmacology and Therapeutics, Mbarara University of Science and Technology, Mbarara, Uganda
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Kovanur Sampath K, Roy DE. Barriers to identifying mood disorders in clients by New Zealand osteopaths: Findings of a thematic analysis. INT J OSTEOPATH MED 2018. [DOI: 10.1016/j.ijosm.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Wener P, Woodgate RL. Looking for Help: Primary Care Providers’ Need for Collaboration to Deliver Primary Mental Healthcare Services. ACTA ACUST UNITED AC 2017. [DOI: 10.7870/cjcmh-2017-016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Miake-Lye IM, Chuang E, Rodriguez HP, Kominski GF, Yano EM, Shortell SM. Random or predictable?: Adoption patterns of chronic care management practices in physician organizations. Implement Sci 2017; 12:106. [PMID: 28836996 PMCID: PMC5571615 DOI: 10.1186/s13012-017-0639-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/16/2017] [Indexed: 11/21/2022] Open
Abstract
Background Theories, models, and frameworks used by implementation science, including Diffusion of Innovations, tend to focus on the adoption of one innovation, when often organizations may be facing multiple simultaneous adoption decisions. For instance, despite evidence that care management practices (CMPs) are helpful in managing chronic illness, there is still uneven adoption by physician organizations. This exploratory paper leverages this natural variation in uptake to describe inter-organizational patterns in adoption of CMPs and to better understand how adoption choices may be related to one another. Methods We assessed a cross section of national survey data from physician organizations reporting on the use of 20 CMPs (5 each for asthma, congestive heart failure, depression, and diabetes). Item response theory was used to explore patterns in adoption, first considering all 20 CMPs together and then by subsets according to disease focus or CMP type (e.g., registries, patient reminders). Mokken scale analysis explored whether adoption choices were linked by disease focus or CMP type and whether a consistent ordering of adoption choices was present. Results The Mokken scale for all 20 CMPs demonstrated medium scalability (H = 0.43), but no consistent ordering. Scales for subsets of CMPs sharing a disease focus had medium scalability (0.4 < H < 0.5), while subsets sharing a CMP type had strong scalability (H > 0.5). Scales for CMP type consistently ranked diabetes CMPs as most adoptable and depression CMPs as least adoptable. Within disease focus scales, patient reminders were ranked as the most adoptable CMP, while clinician feedback and patient education were ranked the least adoptable. Conclusions Patterns of adoption indicate that innovation characteristics may influence adoption. CMP dissemination efforts may be strengthened by encouraging traditionally non-adopting organizations to focus on more adoptable practices first and then describing a pathway for the adoption of subsequent CMPs. Clarifying why certain CMPs are “less adoptable” may also provide insights into how to overcome CMP adoption constraints. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0639-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isomi M Miake-Lye
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA. .,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA.
| | - Emmeline Chuang
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Hector P Rodriguez
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Elizabeth M Yano
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA.,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA
| | - Stephen M Shortell
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
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12
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Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 42:533-44. [PMID: 24193818 DOI: 10.1007/s10488-013-0528-y] [Citation(s) in RCA: 3059] [Impact Index Per Article: 382.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.
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Affiliation(s)
- Lawrence A Palinkas
- School of Social Work, University of Southern California, 669 W. 34th Street, Los Angeles, CA, 90089-0411, USA,
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13
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Hasche LK, Lenze S, Brown T, Lawrence L, Nickel M, Morrow-Howell N, Proctor EK. Adapting collaborative depression care for public community long-term care: using research-practice partnerships. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 41:687-96. [PMID: 24072560 DOI: 10.1007/s10488-013-0519-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This manuscript details potential benefits for using a research-practice partnership to adapt collaborative depression care for public community long-term care agencies serving older adults. We used sequential, multi-phase, and mixed methods approaches for documenting the process of adaptation within a case study. Systematic adaptation strategies are described, such as leveraging long-term research-practice collaborations, consulting with multiple stakeholders across all levels and disciplines, and balancing demands to monitor treatment fidelity, clinical outcomes, and implementation results. These examples demonstrate that researchers interested in implementation science need skills to negotiate the competing demands that arise from both the research and practice settings.
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Affiliation(s)
- Leslie K Hasche
- Graduate School of Social Work, University of Denver, 2148 S. High Street, Denver, CO, 80208, USA,
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14
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Wener P, Woodgate RL. Collaborating in the context of co-location: a grounded theory study. BMC FAMILY PRACTICE 2016; 17:30. [PMID: 26965307 PMCID: PMC4785669 DOI: 10.1186/s12875-016-0427-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 03/02/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Most individuals with mental health concerns seek care from their primary care provider, who may lack comfort, knowledge, and time to provide care. Interprofessional collaboration between providers improves access to primary mental health services and increases primary care providers' comfort offering these services. Building and sustaining interprofessional relationships is foundational to collaborative practice in primary care settings. However, little is known about the relationship building process within these collaborative relationships. The purpose of this grounded theory study was to gain a theoretical understanding of the interprofessional collaborative relationship-building process to guide health care providers and leaders as they integrate mental health services into primary care settings. METHODS Forty primary and mental health care providers completed a demographic questionnaire and participated in either an individual or group interview. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed several times and then individually coded. Codes were reviewed and similar codes were collapsed to form categories using using constant comparison. All codes and categories were discussed amongst the researchers and the final categories and core category was agreed upon using constant comparison and consensus. RESULTS A four-stage developmental interprofessional collaborative relationship-building model explained the emergent core category of Collaboration in the Context of Co-location. The four stages included 1) Looking for Help, 2) Initiating Co-location, 3) Fitting-in, and 4) Growing Reciprocity. A patient-focus and communication strategies were essential processes throughout the interprofessional collaborative relationship-building process. CONCLUSIONS Building interprofessional collaborative relationships amongst health care providers are essential to delivering mental health services in primary care settings. This developmental model describes the process of how these relationships are co-created and supported by the health care region. Furthermore, the model emphasizes that all providers must develop and sustain a patient-focus and communication strategies that are flexible. Applying this model, health care providers can guide the creation and sustainability of primary care interprofessional collaborative relationships. Moreover, this model may guide health care leaders and policy makers as they initiate interprofessional collaborative practice in other health care settings.
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Affiliation(s)
- Pamela Wener
- />Department of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, R125-771 McDermot Ave., Winnipeg, MB R3E 0T6 Canada
| | - Roberta L. Woodgate
- />College of Nursing, University of Manitoba, 465 Helen Glass Centre, 89 Curry Place, Winnipeg, MB R3T 2N2 Canada
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15
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Kwan BM, Valeras AB, Levey SB, Nease DE, Talen ME. An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act. AIMS Public Health 2015; 2:691-717. [PMID: 29546130 PMCID: PMC5690436 DOI: 10.3934/publichealth.2015.4.691] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/14/2015] [Indexed: 01/18/2023] Open
Abstract
The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.
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Affiliation(s)
- Bethany M Kwan
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Aimee B Valeras
- NH Dartmouth Family Medicine Residency, Concord Hospital Family Health Center, Concord, NH, United States
| | - Shandra Brown Levey
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Donald E Nease
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Mary E Talen
- Northwestern Family Medicine Residency, Northwestern McGaw Medical Center and University, Chicago, IL, United States
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16
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Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2015. [PMID: 24193818 DOI: 10.1007/s10488-013-0528-y.purposeful] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.
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Affiliation(s)
- Lawrence A Palinkas
- School of Social Work, University of Southern California, 669 W. 34th Street, Los Angeles, CA, 90089-0411, USA,
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17
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Sinnema H, Majo MC, Volker D, Hoogendoorn A, Terluin B, Wensing M, van Balkom A. Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: a cluster randomised controlled trial. Implement Sci 2015; 10:33. [PMID: 25884819 PMCID: PMC4360947 DOI: 10.1186/s13012-015-0210-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 01/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anxiety and depression are not always diagnosed and treated in primary care as has been recommended. A tailored implementation programme, which addresses key barriers for change by targeted interventions, may help to remedy this. METHODS The effectiveness of an individually tailored implementation programme, additional to standardised training and feedback on the recognition and treatment of patients with anxiety or depression in general practice, was examined in a cluster randomised controlled trial. Participants were 46 general practitioners (GPs) from 23 general practices (12 intervention, 11 control) and 444 patients aged 18 years or older (198 intervention, 246 control) who screened positive on the extended Kessler 10. In the control group, GPs received a 1-day training in guidelines for recognition and stepped treatment for anxiety and depression. Ten months after the training session, GPs received feedback on their performance over the preceding 6 months. In the intervention group, GPs received the same training and feedback as those in the control condition; in addition, they were offered support, tailored to perceived local barriers to change. The support was delivered in the format of peer group supervisions and personalised telephone consultations. Data were based on an audit of patient records and patient surveys at baseline and after 3 and 6 months. RESULTS The tailored implementation programme led to recognition of a higher proportion of patients presenting with anxiety and depression (42% versus 31%; odds ratio (OR) = 1.60; 95% CI: 1.01-2.53), more consultations after recognition (IRR = 1.78; 95% CI: 1.14-2.78) and did not lead to more prescription of antidepressants (OR = 1.07; 95% CI: 0.52-2.19) or referral to specialist mental health services (OR = 1.62; 95% CI: 0.72-3.64). Patients in the intervention group reported better accessibility of care (effect size (ES) = 0.4; p < 0.05) and provision of information and advice (ES = 0.5; p < 0.05). CONCLUSIONS A tailored implementation programme may enhance the recognition and treatment of patients with anxiety or depression. Further development and evaluation of the programme is warranted to determine its cost-effectiveness. TRAIL REGISTRATION Dutch Trial Register identifier NTR1912 .
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Affiliation(s)
- Henny Sinnema
- Netherlands Institute of Mental Health and Addiction, Trimbos Institute, 3500 AS, Utrecht, The Netherlands.
| | - Maria Cristina Majo
- Netherlands Institute of Mental Health and Addiction, Trimbos Institute, 3500 AS, Utrecht, The Netherlands.
| | - Daniëlle Volker
- Netherlands Institute of Mental Health and Addiction, Trimbos Institute, 3500 AS, Utrecht, The Netherlands.
| | - Adriaan Hoogendoorn
- Department of Psychiatry, VU University Medical Centre and GGZinGeest, 1081 HL, Amsterdam, The Netherlands.
| | - Berend Terluin
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, 1000 SN, Amsterdam, The Netherlands.
| | - Michel Wensing
- Radboud University Medical Centre, Scientific Institute for Quality, 6500 HB, Nijmegen, The Netherlands.
| | - Anton van Balkom
- Department of Psychiatry, VU University Medical Centre and GGZinGeest, 1081 HL, Amsterdam, The Netherlands.
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18
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Meyerson BE, Sayegh MA, Davis A, Arno JN, Zimet GD, LeMonte AM, Williams JA, Barclay L, Van Der Pol B. Cervical cancer screening in a sexually transmitted disease clinic: screening adoption experiences from a midwestern clinic. Am J Public Health 2015; 105 Suppl 2:e8-14. [PMID: 25689199 DOI: 10.2105/ajph.2014.302272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined whether a sexually transmitted disease (STD) clinic could reach women who had not received a Papanicolau (Pap) test in the past 3 years. We also explored staff attitudes and implementation of cervical cancer screening. METHODS Women (n = 123) aged 30 to 50 years were offered cervical cancer screening in an Indiana STD clinic. We measured effectiveness by the patients' self-reported last Pap test. We explored adoption of screening through focus groups with 34 staff members by documenting their attitudes about cervical cancer screening and screening strategy adaptation. We also documented recruitment and screening implementation. RESULTS Almost half (47.9%) of participants reported a last Pap test 3 or more years previously; 30% had reported a last Pap more than 5 years ago, and 11.4% had a high-risk test outcome that required referral to colposcopy. Staff supported screening because of mission alignment and perceived patient benefit. Screening adaptations included eligibility, results provision, and follow-up. CONCLUSIONS Cervical cancer screening was possible and potentially beneficial in STD clinics. Future effectiveness-implementation studies should expand to include all female patients, and should examine the degree to which adaptation of selected adoption frameworks is feasible.
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Affiliation(s)
- Beth E Meyerson
- Beth E. Meyerson is with the Indiana University School of Public Health-Bloomington. M. Aaron Sayegh and Alissa Davis are with Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington. Janet N. Arno is with the Marion County Health and Hospital Corporation, Bell Flower Clinic, Indianapolis, IN. Gregory D. Zimet is with the Center for HPV Research, School of Medicine, Indiana University, Indianapolis. Ann M. LeMonte and James A. Williams are with the Infectious Disease Laboratory, Indiana University, Indianapolis. Lynn Barclay is with the American Sexual Health Association, Research Triangle Park, NC. Barbara Van Der Pol is with the University of Alabama, Birmingham
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Kadu MK, Stolee P. Facilitators and barriers of implementing the chronic care model in primary care: a systematic review. BMC FAMILY PRACTICE 2015; 16:12. [PMID: 25655401 PMCID: PMC4340610 DOI: 10.1186/s12875-014-0219-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/30/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND The Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identify facilitators and barriers encountered during implementation. METHODS This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Article abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies published after 2003 that described or evaluated the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study was adults over the age of 18 with chronic conditions. Studies were categorized by reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis of cited barriers and facilitators using the Consolidating Framework for Research Implementation. RESULTS This review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs. CONCLUSIONS These findings highlight the importance of assessing organizational capacity and needs prior to and during the implementation of the CCM, as well as gaining a better understanding of health care providers' and organizational perspective.
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Affiliation(s)
- Mudathira K Kadu
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave W, Waterloo, Ontario, N2L 3G1, Canada.
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, 200 University Ave W, Waterloo, Ontario, N2L 3G1, Canada.
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Chang ET, Wells KB, Young AS, Stockdale S, Johnson MD, Fickel JJ, Jou K, Rubenstein LV. The anatomy of primary care and mental health clinician communication: a quality improvement case study. J Gen Intern Med 2014; 29 Suppl 2:S598-606. [PMID: 24715400 PMCID: PMC4070235 DOI: 10.1007/s11606-013-2731-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging. OBJECTIVE To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy. DESIGN, PARTICIPANTS, AND APPROACH An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement. KEY RESULTS Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication. CONCLUSIONS CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.
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Affiliation(s)
- Evelyn T Chang
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA,
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21
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Chang ET, Magnabosco JL, Chaney E, Lanto A, Simon B, Yano EM, Rubenstein LV. Predictors of primary care management of depression in the Veterans Affairs healthcare system. J Gen Intern Med 2014; 29:1017-25. [PMID: 24567200 PMCID: PMC4061347 DOI: 10.1007/s11606-014-2807-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 12/17/2013] [Accepted: 01/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care. OBJECTIVE To assess relationships between various CCM features, PCP characteristics, and PCP depression management. DESIGN Cross-sectional analysis of a provider survey. PARTICIPANTS 180 PCPs in eight VA sites nationwide. MAIN MEASURES Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months. KEY RESULTS Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels. CONCLUSIONS PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.
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Affiliation(s)
- Evelyn T Chang
- Department of General Internal Medicine, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA,
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22
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Sinnema H, Terluin B, Wensing M, Volker D, Franx G, van Balkom A, de Lange J. Systematic tailoring for the implementation of guideline recommendations for anxiety and depressive disorders in general practice: perceived usefulness of tailored interventions. BMC FAMILY PRACTICE 2013; 14:94. [PMID: 23826887 PMCID: PMC3726506 DOI: 10.1186/1471-2296-14-94] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 05/30/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND The uptake of guideline recommendations in general practice can potentially be improved by designing implementation interventions that are tailored to prospectively identify barriers. However, there is insufficient evidence regarding the most effective and efficient approaches to tailoring. Our study provides an insight into the usefulness of tailored interventions to prospectively identified barriers affecting the uptake of guideline recommendations for anxiety and depressive disorders experienced by general practitioners (GPs) in their local context. METHODS A qualitative study was conducted, in which 23 GPs gave informed consent and 14 finally participated. To explore the barriers affecting the uptake of guideline recommendations, a face-to-face interview was conducted with each GP to generate a personalised list. In response to this list, interventions were tailored to remove the barriers experienced by the GPs. To examine the perceived usefulness of the tailored interventions, telephone interviews were conducted after one year and coded through thematic coding. The analysis was descriptive in nature. RESULTS The most frequently perceived barriers were: a lack of knowledge and skills, no agreement on guideline recommendations, negative outcome expectancy, low self-efficacy, no consensus with patients, and a lack of information about treatments provided by mental health professionals, together with waiting lists. The tailored interventions 'peer group supervision' and 'individualised telephone consultations' were perceived as useful by most GPs. Besides the tailored interventions, a perceived benefit of using a self-rating scale, measuring depressive and anxiety symptoms, and the idea of delivering better patient care, were supportive in the uptake of guideline recommendations. CONCLUSIONS Our findings suggest that tailoring interventions to prospectively identified barriers, affecting the uptake of guideline recommendations for anxiety and depressive disorders, as perceived by GPs, may enhance the implementation of these guideline recommendations.
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Affiliation(s)
- Henny Sinnema
- Netherlands Institute of Mental Health and Addiction Trimbos Institute, Trimbos, The Netherlands.
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Grazier KL, Smith JE, Song J, Smiley ML. Integration of depression and primary care: barriers to adoption. J Prim Care Community Health 2013; 5:67-73. [PMID: 23799678 DOI: 10.1177/2150131913491290] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Despite the prevailing consensus as to its value, the adoption of integrated care models is not widespread. Thus, the objective of this article it to examine the barriers to the adoption of depression and primary care models in the United States. METHODS A literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on previously existing searches. The search included: MeSH terms combined with targeted keywords; iterative citation searches in Scopus; searches for grey literature (literature not traditionally indexed by commercial publishers) in Google and organization websites, examination of reference lists, and discussions with researchers. FINDINGS Integration of depression care and primary care faces multiple barriers. Patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party, including the following: vulnerable populations with special needs, patient and family factors, medical and mental health comorbidities, provider supply and culture, financing and costs, and organizational issues. CONCLUSIONS An analysis of barriers impeding integration of depression and primary care presents information for future implementation of services.
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Hooper LM, Epstein SA, Weinfurt KP, DeCoster J, Qu L, Hannah NJ. Predictors of primary care physicians' self-reported intention to conduct suicide risk assessments. J Behav Health Serv Res 2012; 39:103-15. [PMID: 22218814 PMCID: PMC3586785 DOI: 10.1007/s11414-011-9268-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Primary care physicians play a significant role in depression care, suicide assessment, and suicide prevention. However, little is known about what factors relate to and predict quality of depression care (assessment, diagnosis, and treatment), including suicide assessment. The authors explored the extent to which select patient and physician factors increase the probability of one element of quality of care: namely, intention to conduct suicide assessment. Data were collected from 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying major depression with moderate levels of severity. The authors examined which patient factors and physician factors increase the likelihood of physicians' intention to conduct a suicide assessment. Data from the study revealed that physician-participants inquired about suicide 36% of the time. A random effects logistic model indicated that several factors were predictive of physicians' intention to conduct a suicide assessment: patient's comorbidity status (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.37-1.00), physicians' age (OR = 0.67; 95% CI = 0.49-0.92), physicians' race (OR = 1.84; 95% CI = 1.08-3.13), and how depressed the physician perceived the virtual patient to be (OR = 0.58; 95% CI = 0.39-0.87). A substantial number of primary care physicians in this study indicated they would not assess for suicide, even though most physicians perceived the virtual patient to be depressed or very depressed. Further study is needed to establish factors that may be modified and targeted to increase the likelihood of physicians' providing one element of quality of care--suicide assessment--for depressed patients.
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Affiliation(s)
- Lisa M. Hooper
- Department of Educational Studies in Psychology, Research Methodology, and Counseling, The University of Alabama, Box 870231; 315-B Graves Hall, Tuscaloosa, AL 35487, USA. Phone: 1+205-348-5611; Fax: 1+205-348-7584;
| | - Steven A. Epstein
- Department of Psychiatry, Georgetown University Hospital and School of Medicine, 2115Wisconsin Avenue NW, Suite 200, Washington, DC 20007, USA. Phone: 1+202-944-5444;
| | - Kevin P. Weinfurt
- Duke Clinical Research Institute, P.O. Box 17969, Durham, NC, USA. Phone: +1-919-6688019; Fax: +1-919-6687124;
| | - Jamie DeCoster
- University of Virginia, Charlottesville, VA, USA. Phone: +1-205-5340939;
| | - Lixin Qu
- The University of Alabama, Box 870348 Tuscaloosa, AL, USA. Phone: +1-205-3484254; Fax: +1-205-3483526;
| | - Natalie J. Hannah
- Department of Educational Studies in Psychology, Research Methodology, and Counseling, The University of Alabama, Tuscaloosa, AL, USA. Phone: +1-205-3485611; Fax: +1-205-3485487;
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Dillard DA, Muller CJ, Smith JJ, Hiratsuka VY, Manson SM. The impact of patient and provider factors on depression screening of american Indian and alaska native people in primary care. J Prim Care Community Health 2011; 3:120-4. [PMID: 23803455 DOI: 10.1177/2150131911420724] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The US Preventive Services Task Force recommends routine depression screening in primary care, yet regular screening does not occur in most health systems serving Alaska Native and American Indian people. The authors examined factors associated with administration of depression screening among Alaska Native and American Indian people in a large urban clinic. METHODS Medical records of 18 625 Alaska Native and American Indian adults were examined 1 year after implementation of a depression screening initiative. Multilevel logistic regression models examined associations between patient and provider factors and administration of the Patient Health Questionnaire-9. RESULTS Forty-seven percent of patients were screened. Women were more likely than men to be screened (50% vs 43%, P < .001). Increased screening odds were associated with older age, increased service use, and chronic disease (P < .001) but not with substance abuse disorders or prior antidepressant dispensation. Women previously diagnosed with depression had higher odds of screening (P = .002). Men seen by male providers had higher odds of screening than did men seen by female providers (P = .040). Screening rates peaked among providers with 2 to 5 years of employment with the clinic. LIMITATIONS Cross-sectional analysis of medical record data was of unknown reliability; there were limited sociodemographic data. CONCLUSIONS Even with significant organizational support for annual depression screening, primary care providers systematically missed men and patients with infrequent primary care visits. Outreach to male patients and additional supports for primary care providers, especially in the first years of practice, may improve screening and treatment for depression among Alaska Native and American Indian people.
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Sinnema H, Franx G, Volker D, Majo C, Terluin B, Wensing M, van Balkom A. Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care. Implement Sci 2011; 6:75. [PMID: 21777463 PMCID: PMC3161882 DOI: 10.1186/1748-5908-6-75] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 07/21/2011] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care. The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors. Designing implementation strategies tailored to prospectively identified barriers could lead to more guideline-recommended care. Although tailoring of implementation strategies is promoted in practice, little is known about the effect on improving the quality of care for the early recognition, diagnosis, and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice. This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone. METHODS In this cluster randomised controlled trial, a total of 22 general practices will be assigned to one of two conditions: (1) training, feedback, and tailored interventions and (2) training and feedback. The primary outcome measure is the proportion of patients who have been recognised to have anxiety and/or depressive disorder. The secondary outcome measures in patients are severity of anxiety and depressive symptoms, level of functioning, expectation towards and experience with care, quality of life, and economic costs. Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups. Secondary outcome measures in general practitioners are adherence to guideline-recommended care in care that has been delivered, the proportion of antidepressant prescriptions, and number of referrals to specialised mental healthcare facilities. Data will be gathered from the electronic medical patient records from the patients included in the study. In a process evaluation, the identification of barriers to change and the relations between prospectively identified barriers and improvement interventions selected for use will be described, as well as the factors that influence the provision of guideline-recommended care. DISCUSSION It is hypothesised that the adherence to guideline recommendations will be improved by designing implementation interventions that are tailored to prospectively identified barriers in the local context of general practitioners. Currently, there is insufficient evidence on the most effective and efficient approaches to tailoring, including how barriers should be identified and how interventions should be selected to address the barriers. TRIAL REGISTRATION NTR1912.
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Affiliation(s)
- Henny Sinnema
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, the Netherlands
| | - Gerdien Franx
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, the Netherlands
| | - Daniëlle Volker
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, the Netherlands
| | - Cristina Majo
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, the Netherlands
| | - Berend Terluin
- The EMGO Institute for Health and Care Research (EMGO+), Amsterdam, the Netherlands
- Department of General Practice, VU University Medical Centre, Amsterdam, the Netherlands
| | - Michel Wensing
- IQ Healthcare, Radboud University, Nijmegen, the Netherlands
| | - Anton van Balkom
- The EMGO Institute for Health and Care Research (EMGO+), Amsterdam, the Netherlands
- Department of Psychiatry, VU University Medical Centre, Amsterdam, the Netherlands
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Liberman KM, Meah YS, Chow A, Tornheim J, Rolon O, Thomas DC. Quality of Mental Health Care at a Student-Run Clinic: Care for the Uninsured Exceeds that of Publicly and Privately Insured Populations. J Community Health 2011; 36:733-40. [DOI: 10.1007/s10900-011-9367-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prins M, Meadows G, Bobevski I, Graham A, Verhaak P, van der Meer K, Penninx B, Bensing J. Perceived need for mental health care and barriers to care in the Netherlands and Australia. Soc Psychiatry Psychiatr Epidemiol 2011; 46:1033-44. [PMID: 20686887 PMCID: PMC3173635 DOI: 10.1007/s00127-010-0266-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 06/25/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE This study of Australian and Dutch people with anxiety or depressive disorder aims to examine people's perceived needs and barriers to care, and to identify possible similarities and differences. METHODS Data from the Australian National Survey of Mental Health and Well-Being and the Netherlands Study of Depression and Anxiety were combined into one data set. The Perceived Need for Care Questionnaire was taken in both studies. Logistic regression analyses were performed to check if similarities or differences between Australia and the Netherlands could be observed. RESULTS In both countries, a large proportion had unfulfilled needs and self-reliance was the most frequently named barrier to receive care. People from the Australian sample (N = 372) were more likely to perceive a need for medication (OR 1.8; 95% CI 1.3-2.5), counselling (OR 1.4; 95% CI 1.0-2.0) and practical support (OR 1.8; 95% CI 1.2-2.7), and people's overall needs in Australia were more often fully met compared with those of the Dutch sample (N = 610). Australians were more often pessimistic about the helpfulness of medication (OR 3.8; 95% CI 1.4-10.7) and skills training (OR 3.0; 95% CI 1.1-8.2) and reported more often financial barriers for not having received (enough) information (OR 2.4; 95% CI 1.1-5.5) or counselling (OR 5.9; 95% CI 2.9-11.9). CONCLUSIONS In both countries, the vast majority of mental health care needs are not fulfilled. Solutions could be found in improving professionals' skills or better collaboration. Possible explanations for the found differences in perceived need and barriers to care are discussed; these illustrate the value of examining perceived need across nations and suggest substantial commonalities of experience across the two countries.
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Affiliation(s)
- Marijn Prins
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
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Palinkas LA, Aarons GA, Horwitz S, Chamberlain P, Hurlburt M, Landsverk J. Mixed method designs in implementation research. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2011; 38:44-53. [PMID: 20967495 PMCID: PMC3025112 DOI: 10.1007/s10488-010-0314-z] [Citation(s) in RCA: 593] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This paper describes the application of mixed method designs in implementation research in 22 mental health services research studies published in peer-reviewed journals over the last 5 years. Our analyses revealed 7 different structural arrangements of qualitative and quantitative methods, 5 different functions of mixed methods, and 3 different ways of linking quantitative and qualitative data together. Complexity of design was associated with number of aims or objectives, study context, and phase of implementation examined. The findings provide suggestions for the use of mixed method designs in implementation research.
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Affiliation(s)
- Lawrence A Palinkas
- School of Social Work, University of Southern California, Los Angeles, CA 90089-0411, USA.
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Abstract
OBJECTIVE The aim of this study is to explore primary care physicians' (PCPs) and depression care managers' (DCMs) approaches to diagnosing and treating depression in older men. The authors focus on older men because studies have shown that they are undertreated compared with women and younger groups. The authors contribute to previous research by identifying facilitators of care for older men from the perspective of clinicians. METHODS Participants in this study were part of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, an effectiveness study of collaborative care for late-life depression in 18 diverse primary care practices. Nine PCPs and 11 DCMs were interviewed to collect information on specific roles in caring for depressed patients and their experiences in working with depressed older men. All interviews were tape-recorded, transcribed verbatim, and analyzed thematically in several steps using standard qualitative data analysis techniques. RESULTS : The authors identified three general approaches to building trust and talking about the depression: 1) an indirect approach ("call it something else"), 2) a gradual approach ("building up to depression"), and 3) a direct approach ("shock and awe"). The authors also found specific strategies that PCPs and DCMs used to manage depression among elderly male patients, such as increased monitoring of mood, treating somatic symptoms first, medicalizing depression, and enlisting the cooperation of family. In our interviews, enlisting family involvement was the most prominent strategy used by clinicians. CONCLUSIONS A variety of approaches and strategies are used by clinicians for diagnosing and treating depressed older men. Clinicians change strategies as a response to a patient's compliance with treatment and the decision about which strategy to pursue is usually made on an "on-the-go" basis throughout the course of clinician-patient interaction. Based on clinicians' experience, depression management requires concerted efforts and persistence, and the family seems to play an important role in how older men receive the diagnosis of depression and adhere to clinicians' prescribed treatment. However, more research is needed to discover the best way of engaging and working with family members to facilitate effective depression care for older adults.
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Loegstrup L, Edwards A, Waldorff FB, Siersma VD, Buch MS, Eriksson T. GP and staff evaluation of the maturity matrix as a tool to assess and improve organisational development in primary care. Int J Health Care Qual Assur 2009; 22:686-700. [PMID: 19957823 DOI: 10.1108/09526860910995029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This paper aims to evaluate the maturity matrix (MM) a facilitated formative self-assessment tool for organisational development in primary care) on satisfaction, differences between GP and staff, the extent to which practice teams worked on goals set, and to identify suggestions for change to MM. DESIGN/METHODOLOGY/APPROACH The approach taken was a cross-sectional survey administered to all participants by mail in 57 family practices, 278 participants, (143 GPs; 135 staff) in Denmark, one year after participating in the MM project. FINDINGS At practice level 44 returned at least one questionnaire. At participant level, 144 returned the questionnaire: 82 GPs; 62 staff. A total of 93 gave positive statements on satisfaction with MM, 16 stated initial expectations were not met, 79 would recommend MM to colleagues. Differences between GPs and staff were only statistically significant regarding "increased insight into organisation of work after participation in the MM project". There was a tendency that GPs were more positive and likely to give an opinion. A total of 22 planned how to meet the goals set at the first MM meeting and 18 felt that they achieved them. In 24 out of 44 practices MM was stated to contribute new ways of working. A total of 12 of 144 stated that they needed more follow-up support. PRACTICAL IMPLICATIONS The results indicate that MM is a workable method to assess and gain insight into practice organisation with no major differences between GPs and staff. ORIGINALITY/VALUE The paper examines participants views' on MM one year after introduction.
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Affiliation(s)
- Louise Loegstrup
- Institute of Public Health, Research Unit and Department of General Practice, University of Copenhagen, Copenhagen, Denmark.
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