Perceived access to general and mental healthcare in primary care in Colombia during COVID-19: A cross-sectional study.

Introduction: The COVID-19 pandemic has had an impact both in general and mental healthcare, challenged the health systems worldwide, and affected their capacity to deliver essential health services. We aimed to describe perceived changes in ease of access to general and mental healthcare among patients with a diagnosis of depression and/or unhealthy alcohol use in Colombia. Methods: This study is embedded in the DIADA project, a multicenter implementation research study aimed at evaluating the integration of mental healthcare in primary care in Colombia. Between November 2020 and August 2021, we conducted a COVID-19 pandemic impact assessment in a cohort of participants with newly diagnosed depression and/or unhealthy alcohol use part of DIADA project. We assessed the ease of access and factors related to perceived ease of access to general or mental healthcare, during the COVID-19 pandemic. Results: 836 participants completed the COVID-19 pandemic impact assessment. About 30% of participants considered their mental health to be worse during the pandemic and 84.3% perceived access to general healthcare to be worse during the pandemic. Most of participants (85.8%) were unable to assess access to mental health services, but a significant proportion considered it to be worse. Experiencing worse ease of access to general healthcare was more frequent among women, patients with diagnosis of depression, and patients with comorbidities. Experiencing worse ease of access to mental healthcare was more frequent among patients aged between 30 and 49.9 years, from socioeconomic status between 4 and 6, affiliated to the contributive social security regime, attending urban study sites, and those who perceived their mental health was worse during the pandemic. Discussion: Despite the overall perception of worse mental health during the pandemic, the use of mental healthcare was low compared to general healthcare. Ease of access was perceived to be worse compared to pre-pandemic. Ease of access and access were affected by geographical study site, socioeconomic status, age and gender. Our findings highlight the need for improved communication between patients and institutions, tailored strategies to adapt the healthcare provision to patients' characteristics, and continued efforts to strengthen the role of mental healthcare provision in primary care.

Scaling Up Science-Based Care for Depression and Unhealthy Alcohol Use in Colombia: An Implementation Science Project.

BACKGROUND: Mental disorders are a major cause of the global burden of disease and significantly contribute to disability and death. This challenge is particularly evident in low- and middle-income countries (LMICs), where >85% of the world's population live. Latin America is one region comprising LMICs where the burden of mental disorders is high and the availability of mental health services is low. This is particularly evident in Colombia, a country with a long-standing history of violence and associated mental health problems. METHODS: This article describes the design of a multisite implementation science project, "Scaling Up Science-Based Mental Health Interventions in Latin America" (also known as the DIADA project), that is being conducted in six primary care systems in Colombia. This project, funded via a cooperative agreement from the National Institute of Mental Health, seeks to implement and assess the impact of a new model for promoting widespread access to mental health care for depression and unhealthy alcohol use within primary care settings and building an infrastructure to support research capacity and sustainability of the new service delivery model in Colombia. This care model centrally harnesses mobile health technology to increase the reach of science-based mental health care for depression and unhealthy alcohol use. RESULTS: This initiative offers great promise to increase capacity for providing and sustaining evidence-based treatment for depression and unhealthy alcohol use in Colombia. NEXT STEPS: This project may inform models of care that can extend to other regions of Latin America or other LMICs.

Patterns of digital information and communication technology use among patients at primary health care centres in Colombia: Phase I of the DIADA project.

OBJECTIVE: Assess the prevalence and types of digital technology use, as well as the extent to which patients use the internet and mobile devises. Evaluate the socioeconomic characteristics of patients and the possible relation to patterns of technology use in Colombia. Understand the nature of patient technology use in primary care for finding medical information. METHODS: A survey was applied to adult patients who attended primary health care centers systems in 6 Colombian cities. The survey inquired about demographic characteristics, insurance, access to services, cell phone use, internet access, and the use of such technology to access health-related services and information. Data was collected and managed using REDCap. Summary statistics on each survey item were calculated and the differences between discrete variables were analyzed using chi-square. Multivariate analyses were performed using logistic regression analysis for binary dependent variables. RESULTS: A total of 1580 patients were surveyed across the six study sites. 93% of the patients reported they have a cell phone. Patients from urban healthcare centers showed a higher use of the Internet on their phone than less urban settings. Around half of the surveyed patients reported Internet use (49.7%). Among Internet users, 65% of participants use the Internet looking for health care information. Around one-third of patients use cellphones to arrange clinic visits. Around 24% of participants answered positively for both Whooley's questions. Of those who screened positive on the Whooley questions, 43% reported being moderately anxious, 47% reported being very anxious. 51% reported having moderate pain; 52% reported having severe pain. CONCLUSIONS: The patterns of technology use identified in this study are essential for developing future health interventions based on ICT. The design of ICT clinical interventions must take into account the cellphone payment plans, availability of internet connection, advantages, and disadvantages of messenger services, including SMS as a possible alternative to people who do not have smartphones.

Health-related quality of life and health literacy among adult primary care patients with subsidized or contributive health insurance in Colombia.

CONTEXT: Colombia passed Law 100 in 1993 with the goal of providing universal health care coverage, and by 2013, over 96% of the Colombian population had health insurance coverage. However, little is known about how health-related quality of life (HRQoL) and health literacy are related among those with the two most common types of health insurance coverage: subsidized (those with lower incomes) and contributory (those with higher incomes) coverage. OBJECTIVES AND METHODS: In the current exploratory investigation, data from adults visiting six primary care clinics in Colombia were analysed to examine the relationship between HRQoL (assessed as problems with mobility, self-care, completing usual activities, pain/discomfort, and anxiety/depression), demographics, the two health insurance types, and health literacy. Analyses also assessed whether, within insurance types, health literacy was related to HRQoL. RESULTS: Results showed that those with contributory health insurance coverage had greater health literacy than those with subsidized coverage, and this was accounted for by differences in education and socioeconomic status. HRQoL did not differ by insurance type. Although lower health literacy was related to worse HRQoL in the overall sample, in subgroup analyses lower health literacy significantly related to worse HRQoL only among those with subsidized health insurance coverage. CONCLUSION: Targeting skills which contribute to health literacy, such as interpreting medical information or filling out forms, may improve HRQoL, particularly in those with subsidized insurance coverage.

Addressing harmful alcohol use in primary care in Colombia: Understanding the sociocultural context.

Harmful alcohol use is a public health problem worldwide, contributing to an estimated 5.1% of the global burden of illness. Screening and addressing at-risk drinking in primary care settings is an empirically supported health care intervention strategy to help reduce the burden of alcohol-use problems. In preparation for introducing screening and treatment for at-risk drinking in primary care clinics in Colombia, we conducted interviews with clinicians, clinic administrators, patients, and participants in Alcoholics Anonymous. Interviews were conducted within the framework of the Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (DIADA, [Detection and Integrated Care for Depression and Alcohol Use in Primary Care] www.project-diada.org) research project, and its qualitative phase that consisted of the collection of data from 15 focus groups, 6 interviews and field observations in 5 regional settings. All participants provided informed consent to participate in this research. Findings revealed the association of harmful alcohol use with a culture of consumption, within which it is learned and socially accepted practice. Recognition of harmful alcohol consumption includes a social context that influences its screening, diagnosis and prevention. The discussion highlights how, despite the existence of institutional strategies in healthcare settings and the awareness of the importance of at-risk drinking among health personnel, the recognition of the harmful use of alcohol as a pathology should be embedded in an understanding of historical, social and cultural dimensions that may affect different identification and care scenarios.

A characterisation of social media users within the primary care system in Colombia and predictors of their social media use to understand their health.

INTRODUCTION: Social media use is growing in Latin America and is increasingly being used in innovative ways. This study sought to characterise the profile of social media users, among primary care patients in Colombia, and to assess predictors of their use of social media to search for health and mental health information (searching behaviour). METHODS: As part of a larger scale-up study, we surveyed 1580 patients across six primary care sites in Colombia about their social media use. We used chi-square and Student's t-tests to assess associations between demographic variables, social media use and searching behaviour, and a Chi-square Automatic Interaction Detector (CHAID) analysis to determine predictors of searching behaviour. RESULTS: In total, 44.4% of respondents reported that they were social media users. Of these, 35.7% used social media to search for health-related information and 6.6% used it to search for mental health-related information. While the profile of individuals who used social media to search for health-related information was similar to that of general social media users (the highest use was among women living in urban areas), the presence of mental health symptoms was a more important predictor of using social media to search for mental health-related information than demographic variables. Individuals with moderate-severe symptoms of anxiety reported a significantly higher percentage of searching than individuals without symptoms (12.5% vs. 5.2%). CONCLUSIONS: Given that some individuals with mental health disorders turn to social media to understand their illness, social media could be a successful medium for delivering mental health interventions in Colombia.

Network of actors involved in the identification, care, and follow-up of unhealthy alcohol use in primary care in Colombia.

This article explores the structure of the network of actors involved in the care of individuals with unhealthy alcohol use (UAU) at the primary care level in five primary care centers in Colombia between 2017 and 2018. We use the Actor-Network Theory Framework (ANT) which posits that health outcomes are a product of a multitude of relationships between different stakeholders. The article focuses on the network configuration that develops between the actors and its effects on the processes of identification, care, and follow-up of people with UAU. The data come from five care centers that participated in the pilot phase of an implementation research project that seeks to apply evidence-based interventions for the detection and treatment of depression and unhealthy alcohol use. Semi-structured interviews and focus groups (FG) were conducted with patients, health and administrative staff, and users from Alcoholics Anonymous. The interviews were transcribed and coded using N-Vivo. The analysis identified the ways in which actors are linked by the community to UAU. The results of this qualitative approach based on ANT present the actors identified in a non-linear network with different dimensions.

Barriers and facilitators to the diagnosis and treatment of depression in primary care in Colombia: Perspectives of providers, healthcare administrators, patients and community representatives.

INTRODUCTION: Depression represents a major disease burden in Colombia. To better understand opportunities to improve access to mental healthcare in Colombia, a research team at Javeriana University conducted formative qualitative research to explore stakeholders' experiences with the integration of mental healthcare into the primary care system. METHODS: The research team conducted 16 focus groups and 4 in-depth interviews with patients, providers, health administrators and representatives of community organisations at five primary care clinics in Colombia, and used thematic analysis to study the data. RESULTS: Themes were organised into barriers and facilitators at the level of patients, providers, organisations and facilities. Barriers to the treatment of depression included stigma, lack of mental health literacy at the patient and provider level, weak links between care levels, and continued need for mental health prioritization at the national level. Facilitators to the management of depression in primary care included patient support systems, strong patient-provider relationships, the targeting of depression interventions and national depression guidelines. DISCUSSION: This study elucidates the barriers to depression care in Colombia, and highlights action items for further integrating depression care into the primary care setting.

Implementing Technology-Supported Care for Depression and Alcohol Use Disorder in Primary Care in Colombia: Preliminary Findings.

OBJECTIVE: Depression and alcohol use disorder are among the most common causes of disability and death worldwide. Health care systems are seeking ways to leverage technology to screen, evaluate, and treat these conditions, because workforce interventions alone, particularly in low- and middle-income countries, are insufficient. This article reports data from the first year of implementation of a technology-supported, systematic approach to identify and care for persons with these disorders in primary care in Colombia. METHODS: A care process that includes waiting room kiosks to screen primary care patients, decision support tablets to guide doctors in diagnosis and treatment, and access to digital therapeutics as a treatment option was implemented in two primary care clinics, one urban and one in a small town. The project collected data on the number of people screened, diagnosed, and engaged in the research and their demographic characteristics. RESULTS: In the first year, 2,656 individuals were screened for depression and unhealthy alcohol use in the two clinics. Primary care doctors increased the percentage of patients diagnosed as having depression and alcohol use disorder from next to 0% to 17% and 2%, respectively. CONCLUSIONS: Early experience with implementing technology-supported screening and decision support for depression and alcohol use disorder into the workflow of busy primary care clinics in Colombia indicates that this care model is feasible and leads to dramatically higher rates of diagnoses of these conditions. Diagnosis in these settings appeared to be easier for depression than for alcohol use disorder.

Perspectives, Experiences, and Practices in the Use of Digital Information Technologies in the Management of Depression and Alcohol Use Disorder in Health Care Systems in Colombia.

Digital information technologies are increasingly used in the treatment of mental health disorders. Through this qualitative study, researchers illuminated perspectives, experiences, and practices among diverse stakeholders in the use of digital information technologies in the management of depression and alcohol use disorders in Colombia. In-depth interviews and focus groups were conducted in five primary care institutions across Colombia. Thematic analysis was used to analyze the data. The use of technology in the treatment of mental health disorders can facilitate the evaluation and diagnosis, treatment, and promotion and prevention of mental health disorders, as well as multiple nonmental health applications in the primary care setting. Potential barriers to the use of technology in this setting include challenges of digital literacy, access to technology, confidentiality, and financing. This study can inform the implementation of digital information technologies in the care of depression and problematic alcohol use within health care systems in Colombia.

Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru.

Many Latin American countries face the challenge of caring for a growing number of people with severe mental illnesses while promoting deinstitutionalization and community-based care. This article presents an overview of current policies that aim to reform the mental health care system and advance the employment of people with disabilities in Colombia, Costa Rica, and Peru. The authors conducted a thematic analysis by using public records and semistructured interviews with stakeholders. The authors found evidence of supported employment programs for vulnerable populations, including people with disabilities, but found that the programs did not include people with severe mental illnesses. Five relevant themes were found to hamper progress in psychiatric vocational rehabilitation services: rigid labor markets, insufficient advocacy, public subsidies that create conflicting incentives, lack of deinstitutionalized models, and lack of reimbursement for evidence-based psychiatric rehabilitation interventions. Policy reforms in these countries have promoted the use of medical interventions to treat people with severe mental illnesses but not the use of evidence-based rehabilitation programs to facilitate community integration and functional recovery. Because these countries have other supported employment programs for people with nonpsychiatric disabilities, they are well positioned to pilot individual placement and support to accelerate full community integration among individuals with severe mental illnesses.

Assessing the Integration of Behavioral Health Services in Primary Care in Colombia.

Integration of behavioral health care into primary care can improve health and economic outcomes. This study adapted the Behavioral Health Integration in Medical Care (BHIMC) index to the Colombian context and assessed the baseline level of behavioral health integration in a sample of primary care organizations. The BHIMC was able to detect the capacity to provide integrated behavioral care in Colombian settings. Results indicate a minimal to partial integration level across all sites, and that it is possible to measure the degree of integrated care capacity and identify improvement areas for better behavioral health care provision.