Literature Collection

BACKGROUND: People with severe mental illness (SMI) are at greater risk of earlier mortality due to physical health problems including cardiovascular disease (CVD). There is limited work exploring whether physical health interventions for people with SMI can be embedded and/or adopted within specific healthcare settings. This information is necessary to optimise the development of services and interventions within healthcare settings. This study explores the barriers and facilitators of implementing a nurse-delivered intervention ('PRIMROSE') designed to reduce CVD risk in people with SMI in primary care, using Normalisation Process Theory (NPT), a theory that explains the dynamics of embedding or 'normalising' a complex intervention within healthcare settings. METHODS: Semi-structured interviews were conducted between April-December 2016 with patients with SMI at risk of CVD who received the PRIMROSE intervention, and practice nurses and healthcare assistants who delivered it in primary care in England. Interviews were audio recorded, transcribed and analysed using thematic analysis. Emergent themes were then mapped on to constructs of NPT. RESULTS: Fifteen patients and 15 staff participated. The implementation of PRIMROSE was affected by the following as categorised by the NPT domains: 1) Coherence, where both staff and patients expressed an understanding of the purpose and value of the intervention, 2) Cognitive participation, including mental health stigma and staff perceptions of the compatibility of the intervention to primary care contexts, 3) Collective action, including 3.1. Interactional workability in terms of lack of patient engagement despite flexible appointment scheduling. The structured nature of the intervention and the need for additional nurse time were considered barriers, 3.2. Relational integration i.e. whereby positive relationships between staff and patients facilitated implementation, and access to 'in-house' staff support was considered important, 3.3. Skill-set workability in terms of staff skills, knowledge and training facilitated implementation, 3.4. Contextual integration regarding the accessibility of resources sometimes prevented collective action. 4) Reflexive monitoring, where the staff commonly appraised the intervention by suggesting designated timeslots and technology may improve the intervention. CONCLUSIONS: Future interventions for physical health in people with SMI could consider the following items to improve implementation: 1) training for practitioners in CVD risk prevention to increase practitioners knowledge of physical interventions 2) training in SMI to increase practitioner confidence to engage with people with SMI and reduce mental health stigma and 3) access to resources including specialist services, additional staff and time. Access to specialist behaviour change services may be beneficial for patients with specific health goals. Additional staff to support workload and share knowledge may also be valuable. More time for appointments with people with SMI may allow practitioners to better meet patient needs.

BACKGROUND: Approximately 20% of Canadian youth (12-25 years) experience mental health and substance use (MHSU) concerns, with the majority not receiving timely evidence-informed care. The YouthCan IMPACT study was a pragmatic randomized controlled trial (pRCT) of an integrated youth services model. The pRCT compared integrated collaborative care teams (the intervention) to youth outpatient hospital psychiatric services (the treatment as usual control). We embedded a qualitative study within the pRCT to explore youth's perceptions and experiences of the intervention and the control services. METHODS: Youth participants (14-17 years) were recruited to the study within an ongoing pRCT from hospitals. Youth were purposively sampled from the broader pRCT sample based on sex assigned at birth and pRCT arm (intervention or control group). To capture service experience across a range of follow-up intervals, youth were eligible to participate in the study if they had completed a six-month or a 12-month assessment within the pRCT. Semi-structured interviews were conducted with n = 44 youth between January 2018 and December 2019 (n = 22 intervention and n = 22 control participants). The interview focused on access; needs and preferences; decision-making; and satisfaction, among other domains. Two coders thematically analyzed the groups separately. Coding differences were resolved through discussion with the research team. RESULTS: Participants in both study arms articulated their service experiences around the themes of dignity, respect, and autonomy in care. Participants felt valued and respected when they receive tailored, consistent services; comprehensive information; were able to develop a supportive, collaborative relationship with the service provider; and used their voice in their care plan. They reported improved satisfaction, improvement in mental health status, and usefulness of services. Some youth within the hospital setting experienced services that were inappropriate, inefficient, and poorly coordinated. These experiences adversely affected youth's dignity, respect, and autonomy. CONCLUSIONS: This study is the first embedded qualitative study globally within a pRCT that explores experiences of an integrated collaborative care team model and standard hospital care. The study adds to the limited evidence base on dignity, respect, and autonomy within youth MHSU services. Determining how youth experience services in community-based and hospital settings is critical as it helps reduce treatment gaps. TRIAL REGISTRATION: Clinicaltrials.gov NCT02836080. Registration date 2016-07-14.

BACKGROUND: Continuous glucose monitoring (CGM) may improve self-management and reduce hypoglycemia risk among individuals with diabetes. However, little is known about how older adults with insulin-treated type 2 diabetes (T2D) experience and incorporate this technology into their daily lives. OBJECTIVE: To explore experiences, preferences, barriers, and questions related to using CGM among older adults with insulin-treated T2D with and without experience using CGM. DESIGN: Qualitative focus group study. PARTICIPANTS: English-speaking older adults with T2D in a large, integrated healthcare delivery system. Groups included either experienced CGM users or adults who had not previously used CGM. Recruitment efforts prioritized individuals ≥ 75 years of age. APPROACH: Transcripts were analyzed using the Framework Method to identify perspectives on CGM. Specific thematic categories were hypoglycemia-related benefits, general benefits, usefulness and ease of use concerns, and CGM questions. KEY RESULTS: The study included 26 participants: 17 (65%) were experienced CGM users, 58% were female; median age was 74 (range 62-88) years. Participants perceived and anticipated these CGM benefits: informing behavior changes, reducing in-the-moment hypoglycemia risk, improving awareness and decision-making, and strengthening clinician collaboration. Perceived CGM barriers included challenges with wearability and reliability, burdens to others, distrust of technology, sensory and learning challenges, insufficient clinician support or engagement, and access and payer hurdles. Despite these downsides, experienced users perceived CGM as a worthwhile alternative to daily fingerstick glucose checks. Non-users were able to formulate many usability questions, providing a snapshot of informational needs for this age group. CONCLUSIONS: Older adults with insulin-treated T2D experienced or anticipated benefits from CGM for diabetes management. Findings indicate a need for tailored education and self-management support for older adults to learn and gain maximal benefit from this technology.

OBJECTIVES: Individuals with co-occurring opioid use disorder (OUD) and mental health disorders experience complex treatment trajectories. The collaborative care model (CoCM) is an effective approach for improving behavioral health outcomes in primary care, but has not been tested for patients with co-occurring disorders. We sought to understand patients' experiences receiving CoCM for co-occurring OUD and depression and/or PTSD. METHODS: We conducted interviews with patients (N=24) who received CoCM for co-occurring disorders as part of a randomized trial. CoCM was delivered across 18 clinics by 10 care managers who were community health workers embedded into primary care teams. Themes were identified by 2 coders using rapid content analyses. RESULTS: We identified 4 major themes. First, patients hoped CoCM would provide an opportunity to make OUD treatment possible by helping them navigate barriers. Second, patients thought that OUD and mental health disorders were connected and that treatment should be integrated. Third, patients felt that care managers improved their treatment, emphasizing how their compassionate style and commitment facilitated access to and retention in medications for OUD and mental health disorders. Finally, patients reported experiencing barriers to accessing mental health therapy, although support from care managers sometimes helped address those barriers. CONCLUSIONS: Patients expressed how care managers facilitated their positive experience with treatment and decreased access barriers common for individuals with co-occurring conditions. Our findings inform how community health workers in the role of care managers can facilitate access to and retention in care for people with co-occurring disorders.

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.