Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities

FAIRSTEPS study - Framework Addressing Inequities in pRimary care using STakEholder PerspectiveS: Integrative evidence review and Delphi consensus

OBJECTIVES

Health inequities are unjust and avoidable differences in health outcomes across populations and between population groups. Though these arise predominantly from social determinants of health, healthcare is estimated to contribute around 20 % and primary healthcare reduces inequities in healthcare outcomes. As each provider works in their local context, we sought to provide an evidence-informed framework for designing, implementing, and evaluating local health inequity interventions in primary care.

STUDY DESIGN

Mixed methods approach: an integrative evidence review, a multidisciplinary Delphi consensus study and collaborative patient and public participation.

METHODS

We searched published and grey literature for examples of primary care health inequity interventions. Our Delphi survey then asked primary care professionals how feasible and useful similar interventions would be in their local contexts. We incorporated an ongoing dialogue people with lived experience of health inequity in our design, implementation, and analysis.

RESULTS

Sixty-nine published papers and 19 grey literature papers were included. Interventions included multiple objectives (e.g., tailored provision, practitioner training) or focus (e.g., medical care, screening). Theory underpinning intervention design was rarely explicit but some specific tools and theory was identified for the framework. Practitioners and our patient group prioritised 28 example interventions to aid the design of local contextually sensitive interventions.

CONCLUSIONS

We combined evidence synthesis, practitioner consultation and dialogue with people with lived experience produced an evidence-informed framework for the design, implementation and evaluation of local primary care health inequity interventions. The public and practitioner voice increases the credibility of our framework as a useful tool for service development.

Pediatric Mental Health and the Power of Primary Care: Practical Approaches and Validating Challenges

INTRODUCTION

With over 300 school shootings in the past 5 years, the unprecedented use of online social media, and the growing demands of academia, mental illness is quickly becoming one of the top causes of morbidity and mortality in the pediatric population. In the past year, 90% of children in the U.S. visited their pediatric primary care provider (PCP), giving PCPs a unique opportunity to address the mental health needs of their patients.

METHODS

The author conducted a comprehensive review of the literature.

RESULTS

This clinical paper seeks to validate the mental health competency of pediatric PCPs, identifies current challenges, and outlines practical approaches to care.

DISCUSSION

The consequences of untreated pediatric mental illness are indisputable. Pediatric PCPs have an obligation to address the growing pediatric mental health crisis directly. By utilizing standardized screening tools, referring to established clinical guidelines, seeking continuing education, and developing a comprehensive list of available resources, pediatric PCPs can incorporate mental health care into primary care.

Improving access to mental health care in an Orthodox Jewish community: a critical reflection upon the accommodation of otherness

Background

The English National Health Service (NHS) has significantly extended the supply of evidence based psychological interventions in primary care for people experiencing common mental health problems. Yet despite the extra resources, the accessibility of services for ‘under-served’ ethnic and religious minority groups, is considerably short of the levels of access that may be necessary to offset the health inequalities created by their different exposure to services, resulting in negative health outcomes. This paper offers a critical reflection upon an initiative that sought to improve access to an NHS funded primary care mental health service to one ‘under-served’ population, an Orthodox Jewish community in the North West of England.

Methods

A combination of qualitative and quantitative data were drawn upon including naturally occurring data, observational notes, e-mail correspondence, routinely collected demographic data and clinical outcomes measures, as well as written feedback and recorded discussions with 12 key informants.

Results

Improvements in access to mental health care for some people from the Orthodox Jewish community were achieved through the collaborative efforts of a distributed leadership team. The members of this leadership team were a self-selecting group of stakeholders which had a combination of local knowledge, cultural understanding, power to negotiate on behalf of their respective constituencies and expertise in mental health care. Through a process of dialogic engagement the team was able to work with the community to develop a bespoke service that accommodated its wish to maintain a distinct sense of cultural otherness.

Conclusions

This critical reflection illustrates how dialogic engagement can further the mechanisms of candidacy, concordance and recursivity that are associated with improvements in access to care in under-served sections of the population, whilst simultaneously recognising the limits of constructive dialogue. Dialogue can change the dynamic of community engagement. However, the full alignment of the goals of differing constituencies may not always be possible, due the complex interaction between the multiple positions and understandings of stakeholders that are involved and the need to respect the other’-s’ autonomy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2509-4) contains supplementary material, which is available to authorized users.

Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: a mixed methods study

BACKGROUND

Community-based primary mental health care is recommended in low and middle-income countries. The Brazilian Health System has been restructuring primary care by expanding its Family Health Strategy. Due to mental health problems, psychosocial vulnerability and accessibility, Matrix Support teams are being set up to broaden the professional scope of primary care. This paper aims to analyse the perceptions of health professionals and managers about the integration of primary care and mental health.

METHOD

In this mixed-method study 18 health managers and 24 professionals were interviewed from different primary and mental health care services in Rio de Janeiro. A semi-structured survey was conducted with 185 closed questions ranging from 1 to 5 and one open-ended question, to evaluate: access, gateway, trust, family focus, primary mental health interventions, mental health records, mental health problems, team collaboration, integration with community resources and primary mental health education. Two comparisons were made: health managers and professionals' (Mann-Whitney non-parametric test) and health managers' perceptions (Kruskall-Wallis non parametric-test) in 4 service designs (General Traditional Outpatients, Mental Health Specialised Outpatients, Psychosocial Community Centre and Family Health Strategy)(SPSS version 17.0). Qualitative data were subjected to Framework Analysis.

RESULTS

Firstly, health managers and professionals' perceptions converged in all components, except the health record system. Secondly, managers' perceptions in traditional services contrasted with managers' perceptions in community-based services in components such as mental health interventions and team collaboration, and converged in gateway, trust, record system and primary mental health education. Qualitative data revealed an acceptance of mental health and primary care integration, but a lack of communication between institutions. The Mixed Method demonstrated that interviewees consider mental health and primary care integration as a requirement of the system, while their perceptions and the model of work produced by the institutional culture are inextricably linked.

CONCLUSION

There is a gap between health managers' and professionals' understanding of community-based primary mental health care. The integration of different processes of work entails both rethinking workforce actions and institutional support to help make changes.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study

BACKGROUND

Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions.

METHODS

We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data.

RESULTS

Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement.

CONCLUSIONS

We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model.

TRIAL REGISTRATION

Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women

BACKGROUND

Postnatal depression affects 10-15 % of all mothers in Western societies and remains a major public health concern for women from diverse cultures. British Pakistani and Indian women have a higher prevalence of depression in comparison to their white counterparts. Research has shown that culturally adapted interventions using Cognitive Behavioural Therapy (CBT) may be acceptable and may help to address the needs of this population. The aim of this study was to assess the acceptability and overall experience of the Positive Health Programme by British South Asian mothers.

METHODS

This was a nested qualitative study, part of an exploratory randomized controlled trial (RCT) conducted to test the feasibility and acceptability of a culturally-adapted intervention (Positive Health Programme or PHP) for postnatal depression in British South Asian women. In-depth interviews (N = 17) were conducted to determine the views of the participants on the feasibility and acceptability of the intervention.

RESULTS

The participants found the intervention acceptable and experienced an overall positive change in their attitudes, behaviour, and increased self-confidence.

CONCLUSIONS

The findings suggest that the culturally adapted Positive Health Programme is acceptable to British South Asian women. These results support that culturally sensitive interventions may lead to better health outcomes and overall satisfaction.

TRIAL REGISTRATION

Protocol registered on Clinicaltrials.gov NCT01838889.

Addressing psychological, mental health and other behavioural healthcare needs of the underserved populations in the United States: the role of local health departments

Aims:

(1) To assess the extent to which local health departments (LHDs) implement and evaluate strategies to target the behavioural healthcare needs for the underserved populations and (2) to identify factors that are associated with these undertakings.

Methods:

Data for this study were drawn from the 2013 National Profile of Local Health Departments Study conducted by National Association of County and City Health Officials. A total of 505 LHDs completed the Module 2 questionnaire of the Profile Study, in which LHDs were asked whether they implemented strategies and evaluated strategies to target the behavioural healthcare needs of the underserved populations. To assess LHDs’ level of engagement in assuring access to behavioural healthcare services, descriptive statistics were computed, whereas the factors associated with assuring access to these services were examined by using logistic regression analyses. To account for complex survey design, we used SVY routine in Stata 11.

Results:

Only about 24.9% of LHDs in small jurisdiction (<50,000 population) and 35.3% of LHDs in medium-size jurisdiction implemented/evaluated strategies to target the behavioural healthcare services needs of underserved populations in their jurisdiction in 2013. Logistic regression model results showed that LHDs having city/multicity jurisdiction (adjusted odds ratio (AOR) = .16, 95% confidence interval (CI): .04–.77), centralised governance (AOR = .12, 95% CI: .02–.85), and those located in South Region (AOR = .25, 95% CI: .08–.74) or the West Region (AOR = .36, 95% CI: 14–.94), were less likely to have implemented/evaluated strategies to target the behavioural healthcare needs of the underserved.

Conclusions:

The extent to which the LHDs implemented or evaluated strategies to target the behavioural healthcare needs of the underserved population varied by geographic regions and jurisdiction types. Different community needs or different state Medicaid programmes may have accounted for these variations. LHDs could play an important role in improving equity in access to care, including behavioural healthcare services in the communities.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care

BACKGROUND

Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.

METHODS

We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.

RESULTS

We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.

CONCLUSIONS

This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.

TRIAL REGISTRATION

Current controlled trials ISRCTN68572159.