Methods of training lay individuals in the use of evidence-based services for the management of mental and behavioral health disorders: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to describe how lay individuals have been trained in evidence-based therapies to manage mental and behavioral health disorders as defined by the International Classification of Diseases, version 11. INTRODUCTION: Health service delivery by lay individuals is common in under-resourced areas. Prior systematic reviews have examined the characteristics of lay workers, the types of services they provide, and the efficacy of their services. Our goal is to focus on the methods of training. INCLUSION CRITERIA: Participants will include lay individuals who provide services to community residents; we will exclude individuals with formal training in health service delivery. We will consider for inclusion studies that include training programs for evidence-based therapies delivered to individuals with mental and behavioral health disorders, and will exclude those involving pharmacology or focusing on cognitive defects. METHODS: We conducted a preliminary search of the literature on PubMed and CINAHL for articles related to the inclusion criteria and published in the past 10  years. Scanning the title, abstract, keywords, and MeSH terms, we generated comprehensive lists of terms and added search terms from 6 recent systematic reviews. Our search strategy will include MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, and gray literature. We will also consult with experts and review the reference lists of articles selected for final inclusion. Articles published in English or Spanish between 1960 and the present will be considered for inclusion. Data analysis will use a mix of descriptive and qualitative approaches, with data presented graphically or in diagrammatic or tabular format.

Comfort With Telehealth Among Residents of an Underserved Urban Area.

BACKGROUND: Deployment of telehealth has been touted as a means of reducing health disparities in underserved groups. However, efforts to reduce regulatory barriers have not been associated with greater telehealth uptake. The goal of this study was to examine engagement with technology among low-income people of color living in Newark, New Jersey. METHODS: Using surveys and focus groups, we examined study participants' daily use of technology (eg, Internet) and comfort with telehealth services (eg, use of teleconferencing for medication refills) before and after COVID-related social distancing mandates went into effect. RESULTS: Use of technology was significantly lower in the pre-COVID period. However, prior months' use of technology had a weak but significant correlation with comfort with telehealth (r = .243, P = .005) in bivariate analyses and was the only significant predictor in multivariate analyses. Analyses of focus group discussions confirmed that lack of experience with technology and distrust of the security and privacy of digital systems were the most important barriers to comfort with telehealth in our sample. CONCLUSION: Our study found that approximately 20% of people in this under-resourced community lacked access to basic technologies necessary for successful deployment of telehealth services. The study's timing provided an unexpected opportunity to compare experiences and attitudes relating to telehealth in 2 regulatory environments. Although uptake of telehealth services increased with the Federal governments' relaxation of regulatory barriers, there was not a similar increase in comfort with telehealth use. Investments in broadband access and equipment should be accompanied by educational programs to increase day-to-day use of and comfort with associated technologies which would improve consumer confidence in telehealth.

A Systematic Review of the Effectiveness of Telemedicine in Reproductive and Neonatal Health in Rural and Low-Income Areas in India.

A systematic review of four relevant databases for articles about the use of telemedicine to expand access to neonatal and reproductive health in rural India was conducted. The objective of this review was to identify initiatives with evidence for potential public health benefits through large-scale implementation. Of 3,098 records from the initial search, 1,415 records were selected for further review after removing duplicates. Eight reports that met the eligibility and inclusion criteria were included in the final review. Selected studies included two types of interventions, direct telemedicine interventions with patients and indirect telemedicine interventions through frontline health care workers. Among studies involving direct telemedicine interventions, 22.4% of the collective health and knowledge outcomes (n = 49) showed statistically significant improvement in the intervention group, whereas 38.0% of the collective health and knowledge outcomes (n = 50) in the studies involving indirect telemedicine intervention showed statistically significant improvement. This systematic review suggested that the use of telemedicine interventions may have a statistically significant effect through educational impacts. There were certain limitations around the use of technology and training that may have undermined the effects of some of the outcomes. This systematic review did not receive any funding.

Clinician Barriers and Facilitators to Routine HIV Testing: A Systematic Review of the Literature.

BACKGROUND: Routine HIV screening rates are suboptimal. OBJECTIVES: This systematic review identified barriers to/facilitators of routine HIV testing, categorized them using the socioecological model (SEM), and provided recommendations for interventions to increase screening. DATA SOURCES: Included articles were indexed in PubMed, EBSCO CINAHL, Scopus, Web of Science, and the Cochrane Library between 2006 and October 2018. ELIGIBILITY CRITERIA: Included studies were published in English or Spanish and directly assessed providers' barriers/facilitators to routine screening. DATA EXTRACTION: We used a standardized Excel template to extract barriers/facilitators and identify levels in the SEM. DATA SYNTHESIS: Intrapersonal factors predominated as barriers, while facilitators were directed at the institutional level. LIMITATIONS: Policy barriers are not universal across countries. Meta-analysis was not possible. We could not quantify frequency of any given barrier/facilitator. CONCLUSIONS: Increasing reimbursement and adding screening as a quality measure may incentivize HIV testing; however, many interventions would require little resource investment.

A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic.

The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the inter-relations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.

Predictors of enacted, internal, and anticipated stigma among PLHIV in New Jersey.

This article describes findings from the first statewide implementation of the People Living with HIV (PLHIV) Stigma Index in the United States. The goals of the study were to identify sources of stigma and contributing factors as a means of developing stigma-reduction interventions in New Jersey. Based on a sample of 371 PLHIV, the study found high levels of internal and anticipated stigma, particularly feelings of self-blame, anger, low self-esteem, fear of gossip, and fear of lack of sexual intimacy. Forty-nine percent of participants stated that they had experienced gossip in the past year, which was the most common type of enacted stigma. Current use of antiretroviral medications was the factor most strongly associated with enacted stigma, while self-rated health had the strongest association with internal and anticipated stigma. These findings were consistent with studies implementing the Stigma Index in other countries and locations within the United States. In New Jersey, people who were unemployed or homeless and those who identified as someone diagnosed with a mental illness or as a sex worker, most frequently reported experiencing all three types of stigma. The study's findings suggest the need to invest in interventions to address needs for job training, mental health services, and housing supports for PLHIV. One result of the study was the formation of a new advocacy group, the Coalition to End Discrimination, which seeks to develop new policies and interventions to reduce HIV-related stigma in New Jersey.

Enhancing Routine HIV Testing in Primary Care With a Continuing Education Intervention.

Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine HIV screening in primary care settings for people ages 13 to 64, regardless of individual risk factors. However, an extensive body of research has identified several barriers to primary care providers' (PCPs) adherence to the CDC recommendations. Employing a pre-postintervention design, this study provided an assessment of barriers among 11 PCPs and implemented an evidence-based continuing education program adapted to the specific individual barriers they identified. The study found that PCPs were initially providing HIV testing using risk-based criteria but that the continuing education program increased intentions to perform routine HIV testing (e.g., during annual wellness examinations and new patient visits). Results of the study inform individual quality improvement projects and legislative or policy actions to increase HIV screening in sites providing primary care. [J Contin Educ Nurs. 2018;49(12):563-574.].

Support for PrEP Among New Jersey Health Care Workers.

We used an online survey of health care workers in New Jersey to assess awareness, perceptions, and support of preexposure prophylaxis (PrEP). We sampled respondents from diverse health care worker occupations, in HIV and non-HIV care settings. Of 174 participants, awareness of PrEP was high at 91% (n = 122), as was support for its use by members of at-risk groups (74%). Occupation was the only independent variable with significant variation in support of PrEP, with 41% of disease intervention specialists/health educators supporting PrEP completely, compared with 93% of nurses. Concerns that poor adherence could lead to resistant strains of HIV and that use could lead to "irresponsible sexual activity" were the most commonly endorsed barriers to PrEP support. The study suggests that, despite high levels of PrEP awareness, targeted education activities are needed to support New Jersey's efforts to expand PrEP availability and use.

Changes in research on language barriers in health care since 2003: A cross-sectional review study.

BACKGROUND: Understanding how to mitigate language barriers is becoming increasingly important for health care providers around the world. Language barriers adversely affect patients in their access to health services; comprehension and adherence; quality of care; and patient and provider satisfaction. In 2003, the United States (US) government made a major change in national policy guidance that significantly affected limited English proficient patients' ability to access language services. OBJECTIVE: The objectives of this paper are to describe the state of the language barriers literature inside and outside the US since 2003 and to compare the research that was conducted before and after a national policy change occurred in the US. We hypothesize that language barrier research would increase inside and outside the US but that the increase in research would be larger inside the US in response to this national policy change. METHODS: We reviewed the research literature on language barriers in health care and conducted a cross sectional analysis by tabulating frequencies for geographic location, language group, methodology, research focus and specialty and compared the literature before and after 2003. RESULTS: Our sample included 136 studies prior to 2003 and 426 studies from 2003 to 2010. In the 2003-2010 time period there was a new interest in studying the providers' perspective instead of or in addition to the patients' perspective. The methods remained similar between periods with greater than 60% of studies being descriptive and 12% being interventions. CONCLUSIONS: There was an increase in research on language barriers inside and outside the US and we believe this was larger due to the change in the national policy. We suggest that researchers worldwide should move away from simply documenting the existence of language barriers and should begin to focus their research on documenting how language concordant care influences patient outcomes, providing evidence for interventions that mitigate language barriers, and evaluating the cost effectiveness of providing language concordant care to patients with language barriers. We think this is possible if funding agencies around the world begin to request proposals for these types of research studies. Together, we can begin document meaningful ways to provide high quality health care to patients with language barriers.

Assessing cultural perspectives on healthcare quality.

This study explores cultural differences in perceptions of quality of care and examines whether existing surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS(®)) questionnaires, adequately capture conceptions of healthcare quality among members of racial/ethnic minority groups. Eight focus groups with African Americans, Asian Indians, Latinos, and whites were organized into two 45-minute segments. In one segment, participants rated the quality of care depicted in a video; in the other they discussed the concept of "healthcare quality." We found that members of racial/ethnic minority groups are more likely than whites to identify cultural competency and providing a holistic approach to care as important to healthcare quality. Neither of these concepts is currently included in the core CAHPS(®) questionnaire. The CAHPS(®) and other quality surveys may not accurately capture concepts of healthcare quality that members of racial/ethnic minority groups deem most important.

Treatment and outcomes for congestive heart failure by race/ethnicity in TRICARE.

BACKGROUND: Equitable access to health insurance coverage may improve outcomes of care for chronic health conditions and mitigate racial/ethnic health disparities. This study examines racial/ethnic disparities in the treatment and outcomes of care for TRICARE beneficiaries with congestive heart failure (CHF). METHODS: Using a retrospective cohort analysis, we examined demographic characteristics, sources of care, and comorbid conditions for 2183 beneficiaries of the Military Health System's TRICARE program (representing 115,584 beneficiaries after adjusting for survey weights) with CHF. Treatments included use of CHF-related medications, while the outcome of interest was any CHF-related potentially avoidable hospitalizations (PAHs). RESULTS: While African Americans were less likely than whites to have received beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers following a CHF diagnosis (P<0.0001). Hispanics were, in some cases, equally likely as whites to receive pharmacological treatments for CHF. In multivariate models, there were no significant racial/ethnic differences in the odds of a PAH; age greater than 65 was the most significant predictor of a PAH. CONCLUSIONS: This study suggests that although there are some racial and ethnic disparities in the receipt of pharmacological therapy for CHF among TRICARE beneficiaries, these differences do not translate into disparities in the likelihood of a PAH. The findings support previous research suggesting that equal access to care may mitigate racial/ethnic health disparities.

Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: results of a randomized controlled trial.

STUDY OBJECTIVES: This study examines whether availability of in-person professional interpreter services during emergency department (ED) visits affects satisfaction of limited English proficient patients and their health providers, using a randomized controlled trial. METHODS: We randomized time blocks during which in-person professional interpreters were available to Spanish-speaking patients in the EDs of 2 central New Jersey hospitals. We assessed the intervention's effects on patient and provider satisfaction through a multilevel regression model that accounted for the nesting of patients within time blocks and controlled for the patient's age and sex, hospital, and when the visit occurred (weekday or weekend). RESULTS: During the 7-month intake period, 242 patients were enrolled during 101 treatment time blocks and 205 patients were enrolled during 100 control time blocks. Regression-adjusted results indicate that 96% of treatment group patients were "very satisfied" (on a 5-point Likert scale) with their ability to communicate during the visit compared with 24% of control group patients (odds ratio=72; 95% confidence interval 31 to 167). (Among control group members who were not very satisfied, responses ranged from "very dissatisfied" to "somewhat satisfied.") Similarly, physicians, triage nurses, and discharge nurses were more likely to be very satisfied with communication during treatment time blocks than during control time blocks. We did not assess acuity of illness or global measures of satisfaction. CONCLUSION: Use of in-person, professionally trained medical interpreters significantly increases Spanish-speaking limited English proficient patients' and their health providers' satisfaction with communication during ED visits.

How many nursing home residents live with a mental illness?

OBJECTIVE: A number of data sets can be used to estimate the size of the nursing home population that has mental illness; however, estimates vary because of differences in methods of data collection. This study sought to compare estimates from three nationally representative data sets of the number of nursing home residents who have a mental illness, determine which data set provides the best national-level estimate, and identify the types of policy and monitoring questions that can best be answered with each. METHODS: The study compared estimates of the number of nursing home residents who had either a primary or any diagnosed mental illness from the National Nursing Home Survey (NNHS), the Minimum Data Set (MDS), and the Medicaid Analytic eXtract (MAX) files. RESULTS: The NNHS produced the most valid national-level estimates of residents with a mental illness--nearly 102,000 with a primary diagnosis in 2004 (6.8% of residents), of which about 23,000 were under age 65 and 79,000 were aged 65 and older. However, data from the NNHS cannot be broken down to the state level; therefore, state- and facility-level estimates would have to be generated with the MDS or MAX data sets. CONCLUSIONS: Policy makers and program managers need to be aware of the strengths and limitations of the data they use in order to make informed decisions. Users of the NNHS, MDS, and MAX data sets should be aware of the differences in recorded diagnoses among the three, especially the relatively limited diagnoses in the MAX and imprecise diagnoses in the MDS.

Racial and ethnic health disparities in TRICARE.

BACKGROUND: As a major provider of health care for racial and ethnic minority groups, the federal government has affirmed its commitment to the elimination of health disparities. Although numerous studies have examined health care disparities in various federal systems of care, few have examined these issues within TRICARE, the Department of Defense (DoDJ's program for providing health care coverage to members of the uniformed services and their dependents. METHODS: This study provides an exploratory analysis examining apparent disparities in health status, access to and satisfaction with care, and use of preventive care using the 2007 Health Care Survey of DoD Beneficiaries. Analyses compare outcomes by race/ethnicity and between TRICARE beneficiaries and national norms derived from the National Consumer Assessment of Health Plans Study Benchmarking Database and the National Healthcare Disparities Report, and are stratified by duty status. RESULTS: Compared to black non-Hispanics, a higher proportion of white non-Hispanic active-duty and retiree TRICARE beneficiaries reported good to excellent health status. However, on most measures, we found no differences between white non-Hispanic beneficiaries and members of racial/ethnic groups. When differences did exist, minority populations were likely to report better access to and use of services than whites. CONCLUSIONS: Although health disparities exist in health status and some measures of preventive care, black non-Hispanics and Hispanics often receive more equitable care under TRICARE than in the nation as a whole. These findings suggest the need to explore the characteristics of TRICARE that may be associated with more-favorable outcomes for racial and ethnic minority groups.

Medicaid beneficiaries with congestive heart failure: association of medication adherence with healthcare use and costs.

OBJECTIVES: To examine the association of medication adherence with healthcare use and costs among Medicaid beneficiaries with congestive heart failure (CHF), to investigate whether the association was a graded one, and to estimate the potential savings due to improved adherence. STUDY DESIGN: Using Medicare and Medicaid data for 4 states, adherence was estimated using the medication possession ratio (MPR). METHODS: Multivariate logistic and 2-part general linear models were estimated to study the primary objectives. The MPR was specified in multiple ways to examine its association with healthcare use and costs. RESULTS: Adherent beneficiaries were less likely to have a hospitalization (0.4 percentage points), had fewer hospitalizations (13%), had in excess of 2 fewer inpatient days (25%), were less likely to have an emergency department (ED) visit (3%), and had fewer ED visits (10%) than nonadherent beneficiaries. Total healthcare costs were $5910 (23%) less per year for adherent beneficiaries compared with nonadherent beneficiaries. The relationship between medication adherence and healthcare costs was graded. For example, beneficiaries with adherence rates of 95% or higher had about 15% lower healthcare costs than those with adherence rates between 80% and less than 95% ($17,665 vs $20,747, P <.01). The relationship between adherence and total healthcare costs was even more stark when the most adherent beneficiaries were segmented into finer subgroups. CONCLUSIONS: Healthcare costs among Medicaid beneficiaries with CHF would be lower if more patients were adherent to prescribed medication regimens. Researchers should reconsider whether a binary threshold for adherence is sufficient to examine the association of adherence with outcomes and healthcare costs.

Utilization of, and adherence to, drug therapy among medicaid beneficiaries with congestive heart failure.

BACKGROUND: Congestive heart failure (CHF) affects 4.8 million adult Americans, particularly those aged >65 years, and has been described as a "new epidemic" due to the high annual incidence of the disease (an estimated 550,000 new cases per year). OBJECTIVES: The goal of this research was to determine the number of Medicaid beneficiaries with CHF, identify the rate of CHF drug use, estimate adherence rates, examine factors associated with CHF drug use and adherence, and explore policy implications of the research findings. METHODS: Methods used included identifying noninstitutionalized beneficiaries with >or=1 inpatient claim or >or=2 ambulatory claims with a CHF diagnosis and claims for CHF drugs using 1998 State Medicaid Research Files and 1999 Medicaid Analytic eXtract data for Arkansas, California, Indiana, and New Jersey. Patient adherence was estimated using the medication possession ratio (MPR) and days of medication persistence. Multivariate regression models were used to identify factors associated with CHF drug use and adherence. RESULTS: Overall, 84.8% of beneficiaries had claims for at least 1 CHF medication; 15.2% of beneficiaries were not using any CHF medications. Among those with a claim, the mean number of claims per month was 1.4, and 25.8% had >or=4 claims per month. Mean MPR was 71.9% and mean days of medication persistence were 24.8 per month. Persons aged <65 years, men, ethnic minorities, patients with hospital admissions for conditions other than CHF, and beneficiaries with high Chronic Illness and Disability Payment System scores were less likely to have a CHF drug claim and had lower adherence rates. CONCLUSIONS: State Medicaid agencies and Medicare prescription drug plans should consider designing targeted interventions that encourage better adherence among Medicaid beneficiaries with CHF, particularly men, those aged <65 years, ethnic minorities, and patients with poor overall health status.

Prescription drug use and expenditures among dually eligible beneficiaries.

Using Medicaid Analytic eXtract (MAX) claims files for 1999 and 2001, the authors describe patterns of prescription drug use and expenditures among dually eligible Medicare and Medicaid beneficiaries for all Medicaid full dually eligible beneficiaries and three important subgroups: (1) aged, (2) disabled, and (3) full-year nursing home residents. The analyses indicate great variation in use and expenditures across States that cannot be explained through differences in use of cost containment strategies. Further, the findings suggest that Medicare Part D plans may achieve significant savings by providing incentives for greater use of generic drugs.

Use of antipsychotic medications among HIV-infected individuals with schizophrenia.

Persons with schizophrenia face elevated risk of infection with HIV. While HIV therapy is demanding, patients diagnosed with both conditions also require appropriate and consistent management of their psychiatric illness, for the same reasons that generally apply to persons with schizophrenia and because untreated psychiatric illness can interfere with full participation in HIV care. This study examines the correlates of use of and persistence on antipsychotic medications among HIV-infected individuals with schizophrenia, using merged New Jersey HIV/AIDS surveillance data and paid Medicaid claims. Persistence was defined as at least 2 months of medication use in a quarter. We identified 350 individuals who were dually diagnosed with HIV and schizophrenia. Overall, 81% of these beneficiaries had at least one claim for an antipsychotic medication at some point between 1992 and 1998. Multivariate techniques were used, including simple logistic regressions on use and robust longitudinal regressions that controlled for repeated observations on the same individual and treatment gaps. Among users of antipsychotic medications, persistence was very low at 37%. Racial/ethnic minorities were less likely to receive atypical antipsychotic medications. Use of atypical antipsychotics was associated with higher persistence. Our study confirmed past findings of racial disparities in the receipt of atypical antipsychotic medications. Findings suggest that use of atypical medications may benefit individuals dually diagnosed with HIV and serious mental illness.