Facilitators of and barriers to County Behavioral Health System Transformation and Innovation: an interview study.

BACKGROUND: Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County's (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes. METHODS: We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research. RESULTS: Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools. CONCLUSIONS: The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.

Variability in the Integration of Peers in a Multi-site Digital Mental Health Innovation Project.

Peer support specialists ("peers") who have the lived experience of, and are in recovery from, mental health challenges are increasingly being integrated into mental health care as a reimbursable service across the US. This study describes the ways peers were integrated into Help@Hand, a multi-site innovation project that engaged peers throughout efforts to develop and offer digital mental health interventions across counties/cities ("sites") in California. Using a mixed methods design, we collected quantitative data via quarterly online surveys, and qualitative data via semi-annual semi-structured phone interviews with key informants from Help@Hand sites. Quantitative data were summarized as descriptive findings and qualitative data from interviews were analyzed using rapid qualitative analysis methods. In the final analytic phase, interview quotes were used to illustrate the complex realities underlying quantitative responses. 117 quarterly surveys and 46 semi-annual interviews were completed by key informants from 14 sites between September 2020 and January 2023. Peers were integrated across diverse activities for support and implementation of digital mental health interventions, including development of training and educational materials (78.6% of sites), community outreach (64.3%), technology testing (85.7%), technology piloting (90.9%), digital literacy training (71.4%), device distribution (63.6%), technical assistance (72.7%), and cross-site collaboration (66.7%). Peer-engaged activities shifted over time, reflecting project phases. Peer-provided digital literacy training and technology-related support were key ingredients for project implementations. This study indicates the wide range of ways peers can be integrated into digital mental health intervention implementations. Considering contextual readiness for peer integration may enhance their engagement into programmatic activities.

Real-World Adoption of Mental Health Support Among Adolescents: Cross-Sectional Analysis of the California Health Interview Survey.

OBJECTIVE: We aim to examine: (a) the extent to which patterns of adoption of counseling services and digital mental health interventions (DMHIs) shifted in recent years (2019-2021); (b) the impact of distress on adoption of mental health support; and (c) reasons related to adolescents' low adoption of DMHIs when experiencing distress. METHODS: Data were from three cohorts of adolescents aged 12-17 years (n = 847 in 2019; n = 1,365 in 2020; n = 1,169 in 2021) recruited as part of the California Health Interview Survey. We estimated logistic regression models to examine the likelihood of using mental health support as a function of psychological distress, sociodemographic characteristics, and cohorts. We also analyzed adolescents' self-reported reasons for not trying DMHIs as a function of distress. RESULTS: The proportion of adolescents reporting elevated psychological distress (∼50%) was higher than those adopting counseling services (<20%) or DMHIs (<10%). A higher level of distress was associated with a greater likelihood of receiving counseling (OR = 1.15), and using DMHIs to connect with a professional (Odds ratio (OR) = 1.11) and for self-help (OR = 1.17). Among those experiencing high distress, adolescents' top reason for not adopting an online tool was a lack of perceived need (19.2%). CONCLUSION: Adolescents' main barriers to DMHI adoption included a lack of perceived need, which may be explained by a lack of mental health literacy. Thoughtful marketing and dissemination efforts are needed to increase mental health awareness and normalize adoption of counseling services and DMHIs.

Facilitators of and Barriers to Integrating Digital Mental Health Into County Mental Health Services: Qualitative Interview Analyses.

BACKGROUND: Digital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts. OBJECTIVE: This paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors. METHODS: This study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework. RESULTS: On the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate. CONCLUSIONS: The successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Understanding the Role of Support in Digital Mental Health Programs With Older Adults: Users' Perspective and Mixed Methods Study.

BACKGROUND: Digital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits. OBJECTIVE: This paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety. METHODS: A total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis. RESULTS: A thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others. CONCLUSIONS: Our findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

Understanding the Potential of Mental Health Apps to Address Mental Health Needs of the Deaf and Hard of Hearing Community: Mixed Methods Study.

BACKGROUND: Mental health concerns are a significant issue among the deaf and hard of hearing (D/HH) community, but community members can face several unique challenges to accessing appropriate resources. OBJECTIVE: The aim of this study was to investigate the mental health needs of the D/HH community and how mental health apps may be able to support these needs. METHODS: A total of 10 members of the D/HH community participated in a focus group and survey to provide their perspectives and experiences. Participants were members of the Center on Deafness Inland Empire team, which comprises people with lived experience as members of and advocates for the D/HH community. RESULTS: Findings identified a spectrum of needs for mental health apps, including offering American Sign Language and English support, increased education of mental health to reduce stigma around mental health, direct communication with a Deaf worker, and apps that are accessible to a range of community members in terms of culture, resources required, and location. CONCLUSIONS: These findings can inform the development of digital mental health resources and outreach strategies that are appropriate for the D/HH community.

Understanding Mental Health App Use Among Community College Students: Web-Based Survey Study.

BACKGROUND: Mental health concerns are a significant issue among community college students, who often have less access to resources than traditional university college students. Mobile apps have the potential to increase access to mental health care, but there has been little research investigating factors associated with mental health app use within the community college population. OBJECTIVE: This study aimed to understand facilitators of and barriers to mental health app use among community college students. METHODS: A web-based survey was administered to a randomly selected sample of 500 community college students from April 16 to June 30, 2020. Structural equation modeling was used to test the relationships between the use of mental health apps, perceived stress, perceived need to seek help for mental health concerns, perceived stigma, past use of professional mental health services, privacy concerns, and social influence of other people in using mental health apps. RESULTS: Of the 500 participants, 106 (21.2%) reported use of mental health apps. Perceived stress, perceived need to seek help, past use of professional services, and social influence were positively associated with mental health app use. Furthermore, the effect of stress was mediated by a perceived need to seek help. Privacy concerns were negatively associated with mental health app use. Stigma, age, and gender did not have a statistically significant effect. CONCLUSIONS: These findings can inform development of new digital interventions and appropriate outreach strategies to engage community college students in using mental health apps.

Curating the Digital Mental Health Landscape With a Guide to Behavioral Health Apps: A County-Driven Resource.

With more than 10,000 mental health apps available, consumers and clinicians who want to adopt such tools can be overwhelmed by the multitude of options and lack of clear evaluative standards. Despite the increasing prevalence of curated lists, or app guides, challenges remain. Organizations providing mental health services to consumers have an opportunity to address these challenges by producing guides that meet relevant standards of quality and are tailored to local needs. This column summarizes an example of the collaborative process of app guide development in a publicly funded mental health service context and highlights opportunities and barriers identified through the process.

Rise in Use of Digital Mental Health Tools and Technologies in the United States During the COVID-19 Pandemic: Survey Study.

BACKGROUND: Accompanying the rising rates of reported mental distress during the COVID-19 pandemic has been a reported increase in the use of digital technologies to manage health generally, and mental health more specifically. OBJECTIVE: The objective of this study was to systematically examine whether there was a COVID-19 pandemic-related increase in the self-reported use of digital mental health tools and other technologies to manage mental health. METHODS: We analyzed results from a survey of 5907 individuals in the United States using Amazon Mechanical Turk (MTurk); the survey was administered during 4 week-long periods in 2020 and survey respondents were from all 50 states and Washington DC. The first set of analyses employed two different logistic regression models to estimate the likelihood of having symptoms indicative of clinical depression and anxiety, respectively, as a function of the rate of COVID-19 cases per 10 people and survey time point. The second set employed seven different logistic regression models to estimate the likelihood of using seven different types of digital mental health tools and other technologies to manage one's mental health, as a function of symptoms indicative of clinical depression and anxiety, rate of COVID-19 cases per 10 people, and survey time point. These models also examined potential interactions between symptoms of clinical depression and anxiety, respectively, and rate of COVID-19 cases. All models controlled for respondent sociodemographic characteristics and state fixed effects. RESULTS: Higher COVID-19 case rates were associated with a significantly greater likelihood of reporting symptoms of depression (odds ratio [OR] 2.06, 95% CI 1.27-3.35), but not anxiety (OR 1.21, 95% CI 0.77-1.88). Survey time point, a proxy for time, was associated with a greater likelihood of reporting clinically meaningful symptoms of depression and anxiety (OR 1.19, 95% CI 1.12-1.27 and OR 1.12, 95% CI 1.05-1.19, respectively). Reported symptoms of depression and anxiety were associated with a greater likelihood of using each type of technology. Higher COVID-19 case rates were associated with a significantly greater likelihood of using mental health forums, websites, or apps (OR 2.70, 95% CI 1.49-4.88), and other health forums, websites, or apps (OR 2.60, 95% CI 1.55-4.34). Time was associated with increased odds of reported use of mental health forums, websites, or apps (OR 1.20, 95% CI 1.11-1.30), phone-based or text-based crisis lines (OR 1.20, 95% CI 1.10-1.31), and online, computer, or console gaming/video gaming (OR 1.12, 95% CI 1.05-1.19). Interactions between COVID-19 case rate and mental health symptoms were not significantly associated with any of the technology types. CONCLUSIONS: Findings suggested increased use of digital mental health tools and other technologies over time during the early stages of the COVID-19 pandemic. As such, additional effort is urgently needed to consider the quality of these products, either by ensuring users have access to evidence-based and evidence-informed technologies and/or by providing them with the skills to make informed decisions around their potential efficacy.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review.

BACKGROUND: Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user's uptake and sustained interactions with these interventions. OBJECTIVE: This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs. METHODS: A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included. RESULTS: A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one's own health. CONCLUSIONS: Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

A scoping review of qualitative research in JAMIA: past contributions and opportunities for future work.

OBJECTIVE: Qualitative methods are particularly well-suited to studying the complexities and contingencies that emerge in the development, preparation, and implementation of technological interventions in real-world clinical practice, and much remains to be done to use these methods to their full advantage. We aimed to analyze how qualitative methods have been used in health informatics research, focusing on objectives, populations studied, data collection, analysis methods, and fields of analytical origin. METHODS: We conducted a scoping review of original, qualitative empirical research in JAMIA from its inception in 1994 to 2019. We queried PubMed to identify relevant articles, ultimately including and extracting data from 158 articles. RESULTS: The proportion of qualitative studies increased over time, constituting 4.2% of articles published in JAMIA overall. Studies overwhelmingly used interviews, observations, grounded theory, and thematic analysis. These articles used qualitative methods to analyze health informatics systems before, after, and separate from deployment. Providers have typically been the main focus of studies, but there has been an upward trend of articles focusing on healthcare consumers. DISCUSSION: While there has been a rich tradition of qualitative inquiry in JAMIA, its scope has been limited when compared with the range of qualitative methods used in other technology-oriented fields, such as human-computer interaction, computer-supported cooperative work, and science and technology studies. CONCLUSION: We recommend increased public funding for and adoption of a broader variety of qualitative methods by scholars, practitioners, and policy makers and an expansion of the variety of participants studied. This should lead to systems that are more responsive to practical needs, improving usability, safety, and outcomes.

Characterizing Frequent Flyers of an Emergency Department Using Cluster Analysis.

Emergency department (ED) overcrowding has been a pain point in hospitals across the globe. "Frequent flyers," who visited the ED at a much higher rate than average, account for almost one third of ED visits even though they represent only a small proportion of all ED patients. In this study, we used data-mining methods to cluster ED frequent flyers at a large academic medical center in the US. The objective was to identify distinct types of frequent flyers, and the common characteristics associated with each type. The results show that the frequent flyers at the ED have three subgroups each exhibiting distinct characteristics: (1) the elderly with chronic health conditions, (2) middle-aged males with unhealthy behavior, and (3) adult females who are generally healthy. These findings may inform targeted interventional strategies for patients of each subgroup, who likely have distinct reasons for visiting the ED frequently, to reduce ED overcrowding.

The Use of General Health Apps Among Users with Specific Conditions: Why College Women with Disordered Eating Adopt Food Diary Apps.

There is a myriad of mobile health applications designed to address a variety of health conditions. While these apps hold significant promise for the management of these conditions, users sometimes turn to general health apps, rather than those designed with their specific condition in mind, which can lead to unmet needs and worsened conditions. We outline one example by focusing on college women with disordered eating behaviors and their use of general food diary apps, rather than eating disorder-specific apps. We investigate the types of health apps they use and how they choose them, focusing on the role of motivations and search behavior. We found their initial motivation informs their search process, which results in their selection of general food diary apps. Researchers should consider app adoption as influenced by user motivations and navigation behavior, particularly when determining how and why general apps are used and how clinicians can help.

Desire to Be Underweight: Exploratory Study on a Weight Loss App Community and User Perceptions of the Impact on Disordered Eating Behaviors.

BACKGROUND: Mobile health (mHealth) apps for weight loss (weight loss apps) can be useful diet and exercise tools for individuals in need of losing weight. Most studies view weight loss app users as these types of individuals, but not all users have the same needs. In fact, users with disordered eating behaviors who desire to be underweight are also utilizing weight loss apps; however, few studies give a sense of the prevalence of these users in weight loss app communities and their perceptions of weight loss apps in relation to disordered eating behaviors. OBJECTIVE: The aim of this study was to provide an analysis of users' body mass indices (BMIs) in a weight loss app community and examples of how users with underweight BMI goals perceive the impact of the app on disordered eating behaviors. METHODS: We focused on two aspects of a weight loss app (DropPounds): profile data and forum posts, and we moved from a broader picture of the community to a narrower focus on users' perceptions. We analyzed profile data to better understand the goal BMIs of all users, highlighting the prevalence of users with underweight BMI goals. Then we explored how users with a desire to be underweight discussed the weight loss app's impact on disordered eating behaviors. RESULTS: We found three main results: (1) no user (regardless of start BMI) starts with a weight gain goal, and most users want to lose weight; (2) 6.78% (1261/18,601) of the community want to be underweight, and most identify as female; (3) users with underweight BMI goals tend to view the app as positive, especially for reducing bingeing; however, some acknowledge its role in exacerbating disordered eating behaviors. CONCLUSIONS: These findings are important for our understanding of the different types of users who utilize weight loss apps, the perceptions of weight loss apps related to disordered eating, and how weight loss apps may impact users with a desire to be underweight. Whereas these users had underweight goals, they often view the app as helpful in reducing disordered eating behaviors, which led to additional questions. Therefore, future research is needed.

Designing for privacy management in hospitals: Understanding the gap between user activities and IT staff's understandings.

PURPOSE: We examined the role of privacy in collaborative clinical work and how it is understood by hospital IT staff. The purpose of our study was to identify the gaps between hospital IT staff members' perceptions of how electronic health record (EHR) users' protect the privacy of patient information and how users actually protect patients' private information in their daily collaborative activities. Since the IT staff play an important role in implementing and maintaining the EHR, any gaps that exist between the IT staff's perceptions of user work practices and the users' actual work practices can result in a number of problems in the configuration, implementation, or customization of the EHR, which can lead to collaboration challenges, interrupted workflow, and privacy breaches. METHODS: We used qualitative data collection methods for this study. We conducted semi-structured interviews with 20 hospital IT staff members. We also conducted observations of EHR users in the in-patient units of the same hospital. RESULTS: We identified gaps in IT staff's understandings of users' work activities, especially in regards to privacy-compromising workarounds that are used by users and why they are used. DISCUSSION: We discuss the reasons why this gap may exist between IT staff and users and ways to improve IT staff's understanding of why users perform certain privacy-compromising workarounds. CONCLUSION: A hospital's IT staff face a daunting task in ensuring users' collaborative work practices are supported by the system while providing effective privacy mechanisms. In order to achieve both goals, the IT staff must have a clear understanding of their users' practices. However, as this study highlights, there may be a mismatch between the IT staff's understandings of how users protect patient privacy and how users actually protect privacy.

Examining the role of collaboration in studies of health information technologies in biomedical informatics: A systematic review of 25 years of research.

PURPOSE: Our objective was to identify and examine studies of collaboration in relation to the use of health information technologies (HIT) in the biomedical informatics field. METHODS: We conducted a systematic literature review of articles through PubMed searches as well as reviewing a variety of individual journals and proceedings. Our search period was from 1990-2015. We identified 98 articles that met our inclusion criteria. We excluded articles that were not published in English, did not deal with technology, and did not focus primarily on individuals collaborating. RESULTS: We categorized the studies by technology type, user groups, study location, methodology, processes related to collaboration, and desired outcomes. We identified three major processes: workflow, communication, and information exchange and two outcomes: maintaining awareness and establishing common ground. Researchers most frequently studied collaboration within hospitals using qualitative methods. DISCUSSION: Based on our findings, we present the "collaboration space model", which is a model to help researchers study collaboration and technology in healthcare. We also discuss issues related to collaboration and future research directions. CONCLUSION: While collaboration is being increasingly recognized in the biomedical informatics community as essential to healthcare delivery, collaboration is often implicitly discussed or intertwined with other similar concepts. In order to evaluate how HIT affects collaboration and how we can build HIT to effectively support collaboration, we need more studies that explicitly focus on collaborative issues.

Exploring the relationship between changes in weight and utterances in an online weight loss forum: a content and correlational analysis study.

BACKGROUND: There is increasing interest in the use of online forums as a component of eHealth weight loss interventions. Although the research is mixed on the utility of online forums in general, results suggest that there is promise to this, particularly if the systems can be designed well to support healthful interactions that foster weight loss and continued engagement. OBJECTIVE: The purpose of this study was to examine the relationship between the styles of utterances individuals make on an online weight loss forum and week-to-week fluctuations in weight. This analysis was conducted to generate hypotheses on possible strategies that could be used to improve the overall design of online support groups to facilitate more healthful interactions. METHODS: A convenience sample of individuals using an online weight loss forum (N=4132) included data both on online forum use and weight check-in data. All interactions were coded utilizing the Linguistic Inquiry and Word Count (LIWC) system. Mixed model analyses were conducted to examine the relationship between these LIWC variables and weight over time. RESULTS: Results suggested that increased use of past-tense verbs (P=.05) and motion (P=.02) were associated with lower weekly weights whereas increased use of conjunctions (eg, and, but, whereas; P=.001) and exclusion words (eg, but, without, exclude; P=.07) were both associated with higher weight during the weeks when these utterances were used more. CONCLUSIONS: These results provide some insights on the styles of interactions that appear to be associated with weight fluctuations. Future work should explore the stability of these findings and also explore possibilities for fostering these types of interactions more explicitly within online weight loss forums.