A population health approach to workplace mental health: rationale, implementation and engagement.

Objectives: To describe a population health-based program to support employee and dependent mental health and learn from engagement trends. Methods: Retrospective analysis of a program utilizing an assessment of mental health risk. For scoring "at risk," a Care Concierge is offered to connect users with resources. Results: Participation was offered to 56,442 employees and dependents. Eight thousand seven hundred thirty-one completed the assessment (15%). Of those, 4,644 (53%) scored moderate or higher. A total of 418 (9%) engaged the Care Concierge. Factors that negatively influenced the decision to engage care included bodily pain, financial concerns. Positive influences were younger age, high stress, anxiety, PTSD and low social support. Conclusion: Proactive assessment plus access to a Care Concierge facilitates mental healthcare utilization. Several factors influence likelihood to engage in care. A better understanding of these factors may allow for more targeted outreach and improved engagement.

Facilitating Mental Health Treatment Through Proactive Screening and Concierge Services in the Workplace.

OBJECTIVE: The aim of this study is to determine if a proactive employer-sponsored mental health program closed gaps in detection and treatment of mental health conditions. METHODS: Of n = 56,442 eligible, n = 8170 (14.5%) participated in the optional screening. Participants with mental health risk were offered care concierge services including support, care planning, and connection to care. Difference in behavioral health care utilization, diagnoses, and prescriptions were evaluated postintervention through claims analysis. RESULTS: Compared with controls (n = 2433), those receiving concierge services (n = 369) were more likely to fill mental health prescriptions (adjusted hazards ratio [HR], 1.2; 1.0-1.5; P = 0.042), use professional mental health services (adjusted HR, 1.4; 1.1-1.8; P = 0.02), and use new mental health services (adjusted HR, 1.9; 1.2-2.8; P = 0.004) in the following 6 months. CONCLUSIONS: This proactive mental health program with care concierge services identified risk, connected individuals to mental health care, and facilitated mental health treatment, among program participants.

Workplace Mental Health: Application of a Population Health Approach of Proactive Screening to Identify Risk and Engage in Care.

OBJECTIVE: To evaluate a proactive, voluntary screening program designed to identify employees with emerging mental health risk and engage them in care. METHODS: Risk was proactively identified through online screening of 344 participants. At-risk participants were offered a mental health care concierge to provide support, develop a care plan, and connect to care. RESULTS: Risk for common mental health conditions was identified in 244 (71%) participants, of whom 66 (27%) connected with a care concierge. Compared with participants who did not connect to a care concierge, those who did were more likely to report a financial crisis (68.2% vs 50.8%) and less likely to report verbal abuse (9.1% vs 19.6%) and difficulty meeting daily needs (12.1% vs 25.1%). CONCLUSION: Implementation of this screening program identified employees at risk for mental health conditions and facilitated connection to care.

The influence of cognitive decline on rural identity: perspectives of older women.

PURPOSE: The purpose of this study was to examine the perspectives of community-dwelling rural, older women concerning the meaning of cognitive decline and to ascertain how cognitive decline affects their lives and the lives of those around them. DESIGN: An ethnographic design guided 1 year of cultural immersion in a rural, farming county in Nebraska. METHOD: Four life history interviews, participant observations, field notes, and cultural artifacts were collected for case-focused analysis. FINDINGS: Cognitive decline was believed to threaten one's social identity as a "good woman" because of three strongly held beliefs that (1) the rural lifestyle protected health, (2) demands of the farm were more important than personal health needs, and (3) mainstream health care services were unnatural and insensitive, and therefore best avoided. Using mainstream health care also resulted in the loss of informal social support, which existed as a protective social silence and helped sustain older women's rural identity. The older women feared developing cognitive decline and believed the loss of one's life purpose would be the outcome of the condition. CONCLUSIONS: Holistic nursing actions that preserve older women's rural identity and social support may increase the likelihood that women accept rural health care aimed at treating cognitive decline.

Addressing social determinants to improve healthcare quality and reduce cost.

UNLABELLED: Most healthcare quality improvement and cost reduction efforts currently focus on care processes, or transitions-for example, the hospital discharge process. While identification and adoption of best practices to address these aspects of healthcare are essential, more is needed for systems that serve vulnerable populations: to account for social factors that often inhibit patients' ability to take full advantage of available healthcare. Our urban safety net healthcare system developed and implemented an innovative quality improvement approach. The programs, Guided Chronic Care(TM) , and Passport to Wellness, use Assertive Care and provide social support for patients between medical encounters, enabling patients to make better use of the healthcare system and empowering them to better manage their conditions. RESULTS: The majority of patients reported problems with mobility and nearly half reported anxiety or depression. Early indications show improved quality of care and significant reduction in costs. Challenges encountered and lessons learned in implementing the programs are described, to assist others developing similar interventions.

Constructivism in cultural competence education.

A graduate course on cultural diversity, based in constructivist theory and structured on the Process of Cultural Competence in the Delivery of Healthcare Services model, was developed and taught through classroom and online methods. The following research questions were explored: 1) Can an educational experience, built on constructivist learning theory tenets, change students' perceptions, attitudes, knowledge, and skills in the area of cultural competence? 2) Does the delivery method, online or traditional classroom, influence the degree of change? The study used a quasi-experimental, pretest-posttest control group design using the Inventory for Assessing the Process of Cultural Competence Among healthcare Professionals Revised. Findings showed significant changes (p<0.001) in cultural competence scores and subscores for all learners with both teaching modalities based on interval scale and in categories of cultural knowledge, skills, desire, and overall competence based on a nominal scale. The untaught construct of cultural desire showed the most significant improvement.

Applying constructivism to nursing education in cultural competence: a course that bears repeating.

A graduate course on culture, diversity, and cultural competence was developed based on constructivist learning theory and Campinha-Bacote's constructs of cultural awareness, knowledge, skill, and encounters. The epistemology, structure, assignments, and activities used in both online and classroom courses were highly effective and well received by the students. Student course evaluations and outcome assessments of students' cultural competence levels, as compared to precourse levels, provided supportive evidence that the course design produced intended outcomes. Course resources are shared, making them available for use by others in cultural competence education.

Better late than never: reflections on the delayed prioritization of cervical cancer in international health.

Cervical cancer has disproportionately affected the world's most vulnerable women for generations, yet only recently has the disease become an international health priority. Using ethnographic evidence from a study in Iquitos, Peru, I identify three factors that have contributed to a historic blind spot regarding cervical cancer in underdeveloped regions: (a) transition theories predicting the emergence of cancer with increasing societal development, (b) chronic vs. infectious disease categories that miss the significance of infectious-associated cancers, and (c) dependence on epidemiologic statistics from underdeveloped regions for determining health care priorities. Implications for theory and education are discussed.

Cervical cancer educational pamphlets: Do they miss the mark for Mexican immigrant women's needs?

The rate of invasive cervical cancer in US Hispanic women is nearly doubled that of non-Hispanics. Using in-depth interviews and content/grade level analysis of educational materials, this study explores the relevance of cervical cancer education materials to the needs of Mexican immigrant women. It also addresses health literacy issues that create barriers to learning. Findings show aspects of language, content, reading level, structure, and visual images in 22 cervical cancer pamphlets from 11 health care sites in a Midwest city were not relevant to the learning needs or health literacy levels of local Mexican immigrant women. Further research is recommended to establish an evidence base regarding optimal presentation of key elements of the cervical cancer educational message for Mexican immigrant women.

Emelda's story: applying ethnographic insights to cultural assessment and cervical cancer control.

This article builds a bridge between cultural research and clinical practice by applying insights from an ethnographic study of cervical cancer in Iquitos, Peru, to a cervical cancer focused cultural assessment tool and teaching guide for use with immigrant patients. This application is grounded in Campinha-Bacote's model of cultural competency. Ethnographic research is recommended as a source of knowledge from which insights can be drawn to build assessment skill in cross-cultural clinical encounters-insights into asking the right questions.

Cervical cancer in Iquitos, Peru: local realities to guide prevention planning.

Cervical cancer is a major public health problem in Latin America, and in much of the underdeveloped world. This issue has not historically been addressed as a health priority, but in recent years is receiving increased attention and funding. This ethnographic study on the experience of cervical cancer was conducted in Iquitos, Peru, between August 1998 and May 1999. Research methodologies included: (1) observation and household interviews to obtain background knowledge about the region, medical systems, and local cultural understanding of illness; (2) cancer experience interviews; and (3) case studies of women in various stages of cervical cancer or diagnosis. Findings are presented related to local knowledge and experience of Pap smears and cervical cancer and the ineffectiveness of a recently initiated cervical cancer screening program. The findings guide recommendations for interventions in the region in relation to: (1) needed changes in health education, (2) screening frequency and age, (3) sites for screening and treatment, (4) type and availability of treatment, (5) payment issues, (6) documentation of care, and (7) the potential of herbal remedies.

Cervical cancer in Iquitos, Peru: local realities to guide prevention planning

O câncer cérvico-uterino representa um desafio para a saúde pública na América Latina e em grande parte do mundo subdesenvolvido como um todo. Historicamente, a questão não tem sido tratada como prioridade de saúde; entretanto, nos últimos anos houve um aumento de interesse e de financiamento para enfrentar o problema. Este estudo etnográfico sobre a experiência com o câncer cérvico-uterino foi realizado em Iquitos, Peru, entre agosto de 1998 e maio de 1999. As metodologias de pesquisa incluíram: (1) observação e entrevistas domiciliares para levantar dados sobre a ocorrência na região, sobre os sistemas de saúde e a cultura local em relação ao processo da doença; (2) entrevistas sobre experiências pessoais e familiares com o câncer; e (3) estudos de caso de mulheres em diversas fases do câncer cérvico-uterino ou do diagnóstico. São apresentados os achados relativos ao conhecimento e experiência locais quanto ao teste de Papanicolau e câncer cérvico-uterino e sobre a ineficácia de um programa recém-inaugurado para rastreamento do câncer cérvico-uterino. Os achados orientam recomendações para intervenções na região em relação a: (1) mudanças nos programas de educação em saúde; (2) freqüência e idade para rastreamento da doença; (3) locais para rastreamento e tratamento; (4) tipo e disponibilidade de tratamento; (5) formas de pagamento ou reembolso; (6) documentação do atendimento e (7) o potencial terapêutico das ervas medicinais.