Reimagining Rural Health Equity: Understanding Disparities And Orienting Policy, Practice, And Research In Rural America.

A narrative has taken hold that public health has failed the US. We argue instead that the US has chronically failed public health, and nowhere have these failures been more apparent than in rural regions. Decades of underinvestment in rural communities, health care, and public health institutions left rural America uniquely vulnerable to the COVID-19 pandemic. Rural communities outpaced urban ones in deaths, and many rural institutions and communities sustained significant impacts. At the same time, the pandemic prompted creative actions to meet urgent health and social needs, and it illuminated opportunities to address long-standing rural challenges. This article draws on our cross-disciplinary expertise in public health and medical anthropology, as well as our research on COVID-19 and rural health equity in northern New England. In this Commentary, we articulate five principles to inform research, practice, and policy efforts in rural America. We contend that advancing rural health equity beyond the pandemic requires understanding the forces that generate rural disparities and designing policies and practices that account for rural disadvantage.

Adapting natural language processing and sentiment analysis methods for an intervention in older adults: Positive perceptions of health and technology.

Background: Older adults frequently participate in behavior change studies, yet it is not clear how to quantify a potential relationship between their perception of the intervention and its efficacy. Research Aim: We assessed the relationship between participant sentiment toward the intervention from follow-up interviews with physical activity and questionnaires for the perception of health. Methods: Sentiment was calculated using the transcripts of exit interviews through a bag of words approach defined as the sum of positive and negative words in 28 older adults with obesity (body mass index ≥30kg/m2). Results: Mean age was 73 years (82% female), and 54% lost ≥5% weight loss. Through linear regression we describe a significant association between positive sentiment about the intervention and weight loss; positive sentiment on technology and change in PROMIS-10 physical health and reduced physical activity time, while controlling for sex and age. Conclusions: This analysis demonstrates that sentiment analysis and natural language processing in program review identified an association between perception and topics with clinical outcomes.

Coproduction of Low-Barrier Hepatitis C Virus and HIV Care for People Who Use Drugs in a Rural Community: Brief Qualitative Report.

BACKGROUND: People who inject drugs are experiencing syndemic conditions with increasing risk of infection with hepatitis C (HCV) and HIV. However, rates of accessing HCV and HIV testing and treatment among people who inject drugs are low for various reasons, including the criminalization of drug use, which leads to a focus on treating drug use rather than caring for drug users. For many people who inject drugs, health care becomes a form of structural violence, resulting in traumatic experiences, fear of police violence, unmet needs, and avoidance of medical care. There is a clear need for novel approaches to health care delivery for people who inject drugs. OBJECTIVE: This study aimed to analyze the process of a multidisciplinary team-encompassing health care professionals, community representatives, researchers, and people with lived experience using drugs-that was formed to develop a deep understanding of the experiences of people who inject drugs and local ecosystem opportunities and constraints to inform the cocreation of low-barrier, innovative HCV or HIV care in a rural community. Given the need for innovative approaches to redesigning health care, we sought to identify challenges and tensions encountered in this process and strategies for overcoming these challenges. METHODS: Analysis was based on an in-depth review of meeting notes from the project year, followed by member-checking with the project team to revise and expand upon the challenges encountered and strategies identified to navigate these challenges. RESULTS: Challenges and tensions included: scoping the project, setting the pace and urgency of the work, adapting to web-based work, navigating ethics and practice of payment, defining success, and situating the project for sustainability. Strategies to navigate these challenges included: dedicated effort to building personal and meaningful connections, fostering mutual respect, identifying common ground to make shared decisions, and redefining successes. CONCLUSIONS: While cocreated care presents challenges, the resulting program is strengthened by challenging assumptions and carefully considering various perspectives to think creatively and productively about solutions.

A Mixed-Methods Evaluation of Patient Education Materials for Colorectal Cancer.

BACKGROUND: Patient education materials are created by professional organizations to inform patients about their disease and its treatment. However, it remains unclear if these materials are appropriate for patients. OBJECTIVE: This study aims to broadly evaluate the education materials for patients with colorectal cancer. DESIGN: Patient education materials from the National Comprehensive Cancer Network, the National Cancer Institute, and the American Society of Colon and Rectal Surgeons were assessed quantitatively by using 1) the Flesch-Kincaid readability formula and 2) the Patient Education Material Assessment Tool. The Patient Education Material Assessment Tool scores materials in 2 domains: understandability and actionability. These materials were further evaluated qualitatively via an exploratory focus group with patients and their caregivers (n = 5) and semi-structured interviews with board-certified/eligible colorectal surgeons (n = 10). SETTING: This study was conducted at academic centers and a regional professional society meeting. PARTICIPANTS: The mean patient age was 63. Most surgeons (8/10) practiced in an academic setting, and 4/10 were female. MAIN OUTCOME MEASURES: The primary outcomes measured were reading grade level and domain scores for the Patient Education Material Assessment Tool. Qualitative data were recorded, transcribed, and coded. Themes were generated through data interpretation and data reduction. RESULTS: Materials ranged from 7th to 11th grade reading level. National Comprehensive Cancer Network materials scored highest for understandability (92.2% ± 6.1%, mean ± SD), followed by National Cancer Institute (84.0% ± 6.6%) and American Society of Colon and Rectal Surgeons (82.2% ± 6.3%) materials. Actionability scores varied; the National Comprehensive Cancer Network materials scored 82.5% ± 1.7%, whereas the National Cancer Institute and American Society of Colon and Rectal Surgeons materials scored 23.3% ± 6.7% and 50.0% ± 8.2%. Critical gaps were identified in the content of these materials. Patients wanted more information about self-care, both emotional and physical. Specifically, patients sought details about postoperative bowel function. Whereas surgeons wanted information about the typical hospital course and recovery, all wanted materials to be customizable. LIMITATIONS: A limited number of materials were reviewed, and patient focus groups were exploratory. CONCLUSIONS: Commonly available printed education materials for colorectal cancer are written at a high reading grade level, vary in their usability, and neglect important details about postoperative recovery. See Video Abstract at http://links.lww.com/DCR/B535. EVALUACIN DE MTODOS MIXTOS DE MATERIALES EDUCATIVOS PARA PACIENTES SOBRE CNCER COLORECTAL: ANTECEDENTES:Los materiales educativos para pacientes son creados por organizaciones profesionales para informar a los pacientes sobre su enfermedad y su tratamiento. Sin embargo, no está claro si estos materiales son apropiados para los pacientes.OBJETIVO:Evaluar ampliamente los materiales para el cáncer colorrectal.DISEÑO:Los materiales educativos para pacientes de la Red Nacional Integral del Cáncer (NCCN), el Instituto Nacional del Cáncer (NCI) y la Sociedad Americana de Cirujanos de Colon y Recto (ASCRS) se evaluaron cuantitativamente utilizando (1) la fórmula de legibilidad de Flesch-Kincaid y (2) la herramienta de evaluación de material educativo para pacientes. La Herramienta de evaluación de materiales educativos para pacientes califica los materiales en dos dominios: comprensibilidad y viabilidad. Estos materiales fueron evaluados cualitativamente a través de un grupo de enfoque exploratorio con pacientes y sus cuidadores (n = 5) y entrevistas semiestructuradas con cirujanos colorrectales certificados o elegibles para certificación por el consejo (n = 10).ESCENARIO:Centros académicos y un encuentro regional de una sociedad profesional.PACIENTES:La edad media de los pacientes fue de 63 años. La mayoría de los cirujanos (8/10) practicaban en un entorno académico, y 4/10 eran mujeres.PRINCIPALES MEDIDAS DE RESULTADO:Nivel de grado de lectura y puntajes de dominios para la Herramienta de evaluación de materiales educativos para pacientes. Los datos cualitativos se registraron, transcribieron y codificaron. Los temas se generaron mediante la interpretación y la reducción de datos.RESULTADOS:Los materiales variaron desde el nivel de lectura del 7° al 11° grado. Los materiales de la NCCN obtuvieron la puntuación más alta en comprensibilidad (92.2 ± 6.1%, media ± DE), seguidos por los materiales de NCI (84.0 ± 6.6%) y ASCRS (82.2 ± 6.3%). Los puntajes de viabilidad variaron; Los materiales de NCCN obtuvieron una puntuación de 82.5 ± 1.7%, mientras que los materiales de NCI y ASCRS obtuvieron una puntuación de 23.3 ± 6.7% y 50.0 ± 8.2%, respectivamente. Se identificaron lagunas críticas en el contenido de estos materiales. Los pacientes querían más información sobre el autocuidado, tanto emocional como físico. Específicamente, los pacientes buscaron detalles sobre la función intestinal posoperatoria. Mientras que los cirujanos querían información sobre el curso hospitalario típico y la recuperación, y todos querían que los materiales fueran personalizables.LIMITACIONES:Se revisó una cantidad limitada de materiales y los grupos de enfoque de pacientes fueron exploratorios.CONCLUSIONES:Los materiales educativos impresos comúnmente disponibles para el cáncer colorrectal están escritos a un alto nivel de grado de lectura, varían en su usabilidad y omiten detalles importantes sobre la recuperación postoperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B535.

Life with FOCUS: A qualitative evaluation of the impact of a smartphone intervention on people with serious mental illness.

OBJECTIVE: A growing body of literature indicates that mobile health (mHealth) interventions that utilize smartphones for illness management are feasible, acceptable, and clinically promising. In this study, we examine how individuals with serious mental illness use a mHealth intervention-FOCUS-to self-manage their illnesses. Additionally, we explored participant perceptions of the intervention's impact on their subjective illness experience. METHOD: We analyzed qualitative data from 30 individuals with serious mental illness who participated in 1 of 2 community-based, 3-month trials of FOCUS. In Study 1, weekly calls were conducted by a mHealth specialist to facilitate and enhance intervention use. In Study 2, researchers conducted qualitative interviews to gather detailed perspectives of intervention use. Data were sampled from the weekly call notes and qualitative interviews and analyzed using a thematic and collaborative approach. RESULTS: Thematic analyses revealed 6 recurring themes. Three themes emerged in regard to participants' ongoing daily use of FOCUS: "back-up" support, symptom management, and self-awareness. Another 3 themes emerged related to the intervention's impact on participants' recovery processes: acceptance of symptoms, motivation and supporting positive outlook. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This qualitative study offers insight into how individuals with serious mental illness made use of a mHealth intervention designed to support illness self-management. Our findings suggest that individuals may benefit differently from mHealth interventions depending on where they are in the recovery process. As mHealth interventions become increasingly popular in clinical settings, it is important to understand consumers' short-term and long-term benefits from these interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Usability Evaluation for the Amulet Wearable Device in Rural Older Adults with Obesity.

Mobile health (mHealth) interventions hold the promise of augmenting existing health promotion interventions. Older adults present unique challenges in advancing new models of health promotion using technology including sensory limitations and less experience with mHealth, underscoring the need for specialized usability testing. We use an open-source mHealth device as a case example for its integration in a newly designed health services intervention. We performed a convergent, parallel mixed-methods study including semi-structured interviews, focus groups, and questionnaires, using purposive sampling of 29 older adults, 4 community leaders and 7 clinicians in a rural setting We transcribed the data, developed codes informed by thematic analysis using inductive and deductive methods, and assessed the quantitative data using descriptive statistics. Our results suggest the importance of end-users in user-centered design of mHealth devices and that aesthetics are critically important. The prototype could potentially be feasibly integrated within health behavior interventions. Centralized dashboards were desired by all participants and ecological momentary assessment could be an important part of monitoring. Concerns of mHealth, including the prototype device, include the device's accuracy, its intrusiveness in daily life and privacy. Formative evaluations are critically important prior to deploying large-scale interventions.

Beyond "Med Management".

Today, outpatient psychiatric care is commonly referred to as "medication management" and is often delivered in 15- to 20-minute visits by psychiatric care providers who receive little workflow support from technology or medical assistants. This Open Forum argues that this current state of psychiatric care delivery is a problem, comments on how psychiatry got here, and suggests that, through reframing and redesign, psychiatric professionals can improve care for those delivering and for those receiving this needed service.

Developing the WorkingWell mobile app to promote job tenure for individuals with serious mental illnesses.

OBJECTIVE: Individuals living with serious mental illnesses are key stakeholders in user experience design and the development of the WorkingWell mobile app to enhance on-the-job follow-along support. In this study, Individual Placement and Support (IPS) consumers identify challenges in sustaining employment, provide data regarding their use of technology, and suggest technology-based solutions for coping on the job to inform app development. METHOD: Focus groups were conducted in 3 agencies providing IPS services to examine consumers' perspectives on supported employment, work, and their preferences for technology-based supports. Qualitative data were coded thematically in a multistep, collaborate approach to ensure trustworthiness. Survey data were collected to describe participants and their current technology use; these data were analyzed descriptively. RESULTS: A total of 25 IPS consumers reported work challenges related to interpersonal relationships and social situations; job characteristics, tasks, and expectations; illness- and treatment-related issues; lifestyle/wellness and conditions apart from work; and motivation. The majority owned mobile phones, felt comfortable using technology, and could see how technology-based tools could help sustain employment. Participants highlighted the potential benefits of technology-based supports for work challenges, and underscored the potential for independence and empowerment as a consequence. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Study findings suggest the value of a WorkingWell mobile app that is innovative, easy to access, self-directed, and individually tailored to enhance IPS follow-along support. The WorkingWell app, if proven effective, will provide an empowering set of tools designed with input from individuals with serious mental illnesses, and integrated into a single, accessible interface. (PsycINFO Database Record

Long-term sobriety strategies for men with co-occurring disorders.

OBJECTIVE: Roughly half of people with severe mental disorders also experience a co-occurring substance use disorder, and recovery from both is a critical objective for health care services. While understanding of abstinence initiation has grown, the strategies people with co-occurring disorders use to maintain sobriety are largely unknown. This article reports strategies for relapse prevention as described by men with co-occurring disorders who achieved one or more years of sobriety. METHODS: We analyzed semi-structured interviews conducted with a sample of 12 men with co-occurring psychosis and substance use disorder who achieved and maintained sobriety for at least one year, supplemented with demographic and diagnostic clinical record data. These men were participating in residential or outpatient treatment at a private, nonprofit integrated treatment clinic. RESULTS: The 12 men were primarily Caucasian (91.7%) and unmarried (100%), and their ages ranged from 23 to 42 years. The two most common psychiatric disorders were schizoaffective disorder (n = 4, 33.3%) and bipolar disorder (n = 4, 33.3%), while the two most commonly misused substances were alcohol and cannabis. Qualitative analyses showed that participants maintained sobriety for at least one year by building a supportive community, engaging in productive activities, and carefully monitoring their own attitudes toward substances, mental health, and responsibility. Alcoholics Anonymous might act as a catalyst for building skills. CONCLUSIONS: People with co-occurring disorders who achieve sobriety use a variety of self-management strategies to prevent relapse-seeking support, activities, and a healthy mindset. The findings suggest a relapse prevention model that focuses on social networks, role functioning, and self-monitoring and conceptualizes self-care as critical to extending periods of wellness.

A qualitative study of career exploration among young adult men with psychosis and co-occurring substance use disorder.

OBJECTIVE: This article explores the meaning and importance of career exploration and career development in the context of integrated treatment for young adults with early psychosis and substance use disorders (i.e., co-occurring disorders). METHODS: Twelve young adult men (aged 18 to 35 years) with co-occurring disorders recruited from an integrated treatment center completed a series of three semi-structured in-depth qualitative interviews. Data were transcribed verbatim and analyzed using thematic analysis. Purposive sampling ensured participants represented a range of substance abuse treatment stages. RESULTS: Participants had a mean age of 26 (SD = 3) and identified as White. Two-thirds of participants (n = 8, 67%) had diagnosed schizophrenia-spectrum disorders, three (25%) had bipolar disorder, and one (8%) had major depression; four (33%) also had a co-occurring anxiety disorder. The most common substance use disorders involved cannabis (n = 8, 67%), cocaine (n = 5, 42%), and alcohol (n = 5, 42%). These young adult men with co-occurring disorders described past jobs that did not align with future goals as frustrating and disempowering, rather than confidence-building. Most young adult participants began actively developing their careers in treatment through future-oriented work or school placements. They pursued ambitious career goals despite sporadic employment and education histories. Treatment engagement and satisfaction appeared to be linked with career advancement prospects. CONCLUSIONS: Integrating career planning into psychosocial treatment is a critical task for providers who serve young adults with co-occurring disorders. Whether integrating career planning within early intervention treatment planning will improve clinical, functional, or economic outcomes is a promising area of inquiry for rehabilitation researchers and clinicians.

The potential of technology for enhancing individual placement and support supported employment.

TOPIC: The potential of technology to enhance delivery and outcomes of Individual Placement and Support (IPS) supported employment. PURPOSE: IPS supported employment has demonstrated robust success for improving rates of competitive employment among individuals with psychiatric disabilities. Still, a majority of those with serious mental illnesses are not employed (Bond, Drake, & Becker, 2012). The need to promote awareness of IPS and expand services is urgent. In this study, we describe ways that technologies may enhance delivery of IPS supported employment across the care continuum and stakeholder groups. Directions for research are highlighted. SOURCES USED: published literature, clinical observations, IPS learning collaborative. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Technology has the potential to enhance direct service as well as workflow in the IPS supported employment process, which may lead to improved fidelity and client outcomes. Mobile and cloud technologies open opportunities for collaboration, self-directed care, and ongoing support to help clients obtain and maintain meaningful employment. Research is needed to evaluate efficacy of technology-based approaches for promoting client employment outcomes, to identify provider and organization barriers to using technology for IPS delivery, and to determine effective strategies for implementing technology with IPS in different settings and with diverse client audiences.

Recovery in a family context: experiences of mothers with serious mental illnesses.

OBJECTIVE: Adults with mental illness are as likely as those without mental illness to be parents. Yet parenting and family life have received considerably less attention than employment, housing, and community integration in psychiatric rehabilitation and mental health services research. This ethnographic pilot study aimed to understand the lived experiences of urban low-income African American mothers diagnosed with serious mental illnesses. METHOD: Ethnographic observations and informal interviews were conducted over 12 months with three mothers diagnosed with serious mental illnesses and their children. Data were analyzed using a case study approach to distill prominent themes, perspectives, and experiences within and across participating families. RESULTS: Five themes emerged to characterize the lived experiences of African American mothers with serious mental illnesses: (a) mental illness and mental health services are not a prominent focus in everyday life; (b) families live in a context of ubiquitous violence, loss, and everyday stress; (c) family life is the main focus for mothers as they strive for a better life; (d) mothers have limited social support; and (e) religion is a source of meaning and a resource for the everyday work of recovery. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings from this exploratory pilot study suggest that rehabilitative efforts tailored for this population should not focus on, or reside in, professional mental health services. Meaningful rehabilitative strategies for families might include supported employment, social support, youth mentoring, faith-based supports, and community-based antiviolence efforts. Peer-based approaches may be a promising way to provide supports within this population.

Principles for enhancing the role of state vocational rehabilitation in IPS-supported employment.

OBJECTIVE: Research has established the Individual Placement and Support (IPS) model of supported employment as an effective approach for persons with severe mental illnesses. This article examines strategies for Vocational Rehabilitation (VR) to enhance employment outcomes through better collaboration with IPS programs. METHODS: Twenty-one focus groups were conducted in rural and urban locations in Illinois with mental health consumers, VR counselors, IPS specialists, and mental health professionals. Thematic analysis was conducted to identify features of strong collaborations between VR and IPS programs. RESULTS: Features of strong collaborations between VR and IPS programs included the following: (a) expertise, (b) consistency, (c) accessibility, and (d) integration. Five recommendations were developed from themes expressed in focus groups: (a) enhance mutual knowledge and understanding between VR and IPS practitioners, (b) examine and modify VR regulations and guidelines that conflict with IPS principles, (c) create clear guidelines for VR participation on IPS teams, (d) create guidelines for good relationships between VR and community mental health centers, and (e) develop tools to promote accountability in VR staff and systems to improve employment outcomes for people with mental illness. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Modest changes in the federal/state VR program could enhance that system's capability to foster employment outcomes for persons with severe mental illness.

Awareness of stigma among persons with schizophrenia: marking the contexts of lived experience.

This article investigates the subjective experience of stigma attached to schizophrenia-related disorders. We examine data from anthropological interviews from a community sample of 90 out-patients residing in a metropolitan area of the United States. Patients were under treatment with atypical antipsychotic medication, and their symptoms were for the most part relatively well controlled. Overall, 96% of participants reported an awareness of stigma that permeated their daily life. Based on an understanding of stigma as a product of interpersonal, reciprocal social processes, we identify 6 types of social relations and 5 identity domains in which social stigma is routinely encountered by participants. We describe the experience of stigma in each of these 11 subcategories, and suggest that taken together they constitute a framework of social and personal factors involved in the struggle to recover from psychotic illness. Among types of social relations, anonymous social interactions most commonly generated an awareness of stigma. Among identity domains, being a person who regularly takes medication was most commonly associated with an awareness of stigma. The finding that multiple forms of stigma are encountered irrespective of substantial symptomatic, functional, and subjectively perceived improvement creates a complex situation of stigma despite recovery.

Stigma despite recovery: strategies for living in the aftermath of psychosis.

In this article, we identify an array of creative strategies used by persons diagnosed with schizophrenia-related illness to deflect and resist social stigma, and address the lived experience of deploying these strategies in the intersubjective context of everyday life. The data are derived from anthropological interviews and ethnographic observations of ninety persons who received treatment at community mental health facilities in an urban North American locale. Nearly all were keenly aware of stigma that permeated their lives. Their predicament is contradictory: on the one hand, they have recovered relative to previous states of psychosis; on the other hand, their subjectivity is saturated by intense awareness of social stigma that seems intractable in relation to temporal or functional criteria. Ironically, these lives can be characterized as fraught with stigma despite recovery. The strategies generated to resist the impact of stigma highlight the fact that persons with these illnesses are often not only exceedingly socially aware but also strategically skilled in response to social assaults on their personhood and survival. We examine these strategies in terms of (1) the social characteristics of each afflicted person, (2) the situational characteristics of managing stigma, (3) the cultural context of recovery, and (4) the illness-specific characteristics of schizophrenia.

Ethnocultural variations in mental illness discourse: some implications for building therapeutic alliances.

OBJECTIVE: In the delivery of mental health services over the past decade, the field has attempted to shift from paternalism to client-centered care, in which treatment and recovery are based on client-practitioner collaboration. Such a shift requires that providers elicit and work with clients' discursive accounts of their illness experiences and understand these accounts in the context of clients' ethnocultural backgrounds. The purpose of this ethnography was to elucidate ethnocultural aspects of illness accounts and interactions with the mental health system. METHODS: Over 18 months, 25 ethnically diverse, unemployed, inner-city residents with severe and long-term mental disorders participated in an ethnographic (participant observation) study of illness accounts and their relationship to sociocultural background. Field ethnographers shared in activities with participants at many of their regular haunts, engaging in observation, conversation, and informal interviewing in many real-world contexts and settings. RESULTS: The study revealed significant differences between the ways that European Americans, African Americans, and Puerto Rican Americans discursively constructed their illness experiences and their interactions with the mental health system. The clients' narratives of their illness experiences provided valuable information, which clinicians could use to open up topics for discussion, insert themselves into an engaging relationship with clients, and link clinical advice or guidance with the clients' own conceptions of how mental illness fits into their larger lived world. CONCLUSIONS: To develop a working therapeutic partnership with clients, mental health service providers must become aware through context-sensitive, context-informed dialog of the differences in how individual clients "en-story," communicate, and experience their illnesses.

Cultural competence reexamined: critique and directions for the future.

This Open Forum aims to stimulate productive dialogue about cultural competence in providing mental health care. The authors examine recent calls for culturally competent care in mental health practice and give a brief overview of the context in which demands for such care have arisen. Using select examples from anthropology, the authors provide evidence of the importance of culture in the production, presentation, and experience of psychic distress. Acknowledging the value of culturally appropriate care, the authors synthesize anthropological critiques of cultural competence models. The essay concludes with suggestions for future directions in cultural competence research and implementation.