Zaslavsky, OlegChu, Frances2023-08-142023-08-142023Chu_washington_0250E_25505.pdfhttp://hdl.handle.net/1773/50156Thesis (Ph.D.)--University of Washington, 2023Background: Mental disorders ranging from mild anxiety and depression to severe psychiatric illnesses are a worldwide concern that can lead to disability, high morbidity and mortality, and economic burden. In the United States of America (US), primary care has increasingly taken on the care of patients with mental health concerns. As the world population ages, mental health concerns in older adults can impede quality of life, increase resource usage, and impact healthcare spending. To aid in addressing mental health problems worldwide, tele-mental health (TMH) interventions are becoming increasingly used as an alternative to the traditional methods of mental health care delivery. However, implementation of these interventions has met with uneven success with many barriers that will need to be addressed to ensure that TMH interventions have the structures in place to ensure implementation success in existing health systems. Task sharing is a care model that trains less specialized health care workers to perform tasks typically done by specialized health care workers. Task sharing has been shown to be effective, acceptable, and feasible in Low- and Middle-Income Countries (LMIC) with various evidence-based mental health interventions in various mental health conditions and patient populations. In the context of TMH interventions, few studies have examined the combination of task sharing and TMH intervention for the management of mental conditions in High-Income Countries (HIC). Method: This dissertation project utilized implementation science methodology for formative assessment of task sharing of TMH interventions. The dissertation studies were embedded in two parent studies. The first parent study was aiming to assess the modifiable components of a TMH intervention and identify barriers to implementation in primary care used a multi-method design of interviews and surveys. However, due to the COVID-19 pandemic, the researchers pivoted to examining perceptions of TMH interventions in general among healthcare professionals in the primary care setting using an explanatory sequential mixed-methods design. The goals of the three dissertation studies were to examine the organizational readiness, acceptability, appropriateness, and feasibility for the implementation strategy of task sharing of tele-mental health interventions (the innovation, the “thing”) in primary care clinic. In Aim 1, a case study was based on the first parent study. The case study describes the formative, exploratory process of using Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC) to formulate the study, to identify barriers and facilitators to the innovation, to analyze the results, and then using the CFIR-ERIC Mapping Tool identify strategies to overcome barriers. Aims 2 and 3 were embedding in the pivoted research. For Aim 2, the project presents the health professionals’ perception of their organizational readiness to implement task sharing of TMH interventions. The study examines differences between health professionals’ roles and level of behavioral health integration in their clinics. Lastly, Aim 3 studies the health professionals’ perception of the acceptability, appropriateness, and feasibility of task sharing of TMH interventions for their clinics. The study examines differences between health professionals’ roles and their comfort with task sharing to the implementation outcomes of acceptability, appropriateness, and feasibility. Results: All the studies demonstrate a formative research process. In Aim 1, the intrinsic case study approach exemplified the process of using Consolidate Framework for Implementation Research (CFIR), Expert Recommendations for Implementing Change (ERIC), and especially the CFIR-ERIC Mapping Tool to identify methods to aid implementation of a complex innovation. The case study identified many issues with using the CFIR-Mapping Tool and speculated on possible changes to this tool given the updated CFIR determinant framework. Aim 2 found that the health care providers from clinics that had behavioral and mental health services integrated with primary care perceived their organization as ready to implement change and had an implementation climate more supportive for evidence-based practice. This can be reflected in the qualitative data where those in BHI clinics were positive about implementation. Additionally, the survey showed that there were no differences between the three healthcare professionals (Primary Care Provider (PCP), Behavioral/Mental Health specialist (BMH), and Nurses, who can be considered Frontline Staff (FLS), for organizational readiness for change or implementation climate. The qualitative results reflect this lack of difference as the three healthcare professional roles of PCPs, BMH specialists, and FLS were all positive about the innovation. In Aim 3, the BMH specialists, PCPs, and Nurses show differences in scores for acceptability, appropriateness, and feasibility of implementing task sharing of TMH interventions in primary care. The BMH specialists and PCPs had lower scores in comparison to Nurses. The qualitative data showed that the BMH specialists and PCPs expressed the concerns most often coded with CFIR constructs of Available Resources, Knowledge & Beliefs of the Innovation, Self-Efficacy, Needs & Resources of Those Served by the Organization, External Policies & Incentives, and Complexity for implementing task sharing of TMH interventions in primary care. Conclusion: These three studies add to the research on task sharing of TMH interventions in primary care in HICs, and help researchers and clinicians use implementation methods to investigate implementation strategies and the interventions in real-world setting. The three studies describe one aspect of implementation science, the formative, exploratory phase of implementation. After formative assessment, the next steps would have been to plan, implement, and sustain the innovation in the primary care clinics.application/pdfen-USCC BY-NC-SAGerontechnologyImplementation ScienceMental HealthTele-Mental Health (TMH)NursingInformation technologyCounseling psychologyThesis