Resuming In-person Psychological Treatment in the Era of COVID-19: Barriers & Facilitators

Background: Patient-centered research has emerged as a promising model to adequately address the needs and preferences of patient populations with mental disorders. The Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) Trial aims to increase access to psychological treatment and implements a multi-stakeholder perspective to understand the needs/preferences of perinatal populations with symptoms of depression and anxiety. Specifically, this pragmatic, non-inferiority randomized effectiveness trial examines whether Behavioral Activation (BA) delivered via telemedicine is as effective as in-person treatment. However, due to COVID-19, the study suspended in-person BA sessions and completely shifted to telemedicine. To ensure BA remains widely accessible, the SUMMIT team strives to resume in-person treatment in the near future. Objective: To gain perspectives of key stakeholders on the potential barriers and facilitators for SUMMIT participants to resume in-person BA sessions in a COVID-19 context.   Methods: A focus group discussion (1 hour) was conducted via Zoom with N=9 stakeholders, including patient advocates, nurses, clinicians, and researchers. Qualitative data was coded using NVivo and content analysis was performed to quantify frequently endorsed themes. Results: The majority of stakeholders considered resuming in-person BA sessions to be a challenge amidst COVID-19, with more barriers than facilitators mentioned overall. Most commonly endorsed barriers that participants may face when attending in-person treatment included arranging childcare (n=8; 89%) and discomfort/fear of coming to the hospital (n=6; 67%). The most widely endorsed facilitators for resuming in-person treatment during COVID-19 were clearly communicating hospital and transportation safety precautions to participants (n=7; 78%) and conducting in-person sessions at an off-site location (n=6; 67%). Conclusion: This study identified critical facilitators of resuming in-person BA sessions that can inform: (1) how to resume in-person BA sessions and (2) the development and implementation of strategies to make BA more patient-centered for perinatal populations during COVID-19. Objective: To gain perspectives of key stakeholders on the potential barriers and facilitators for SUMMIT participants to resume in-person BA sessions in a COVID-19 context.    Methods: A focus group discussion (1 hour) was conducted via Zoom with N=9 stakeholders, including patient advocates, nurses, clinicians, and researchers. Qualitative data was coded using NVivo and a content analysis was performed to quantify frequently endorsed themes. Results: The majority of stakeholders considered resuming in-person BA sessions to be a challenge amidst COVID-19, with more barriers than facilitators mentioned overall. Most commonly endorsed barriers that participants may face when attending in-person treatment included arranging childcare (n=8; 89%) and discomfort/fear of coming to the hospital (n=6; 67%). The most widely endorsed facilitators for resuming in-person treatment during COVID-19 were clearly communicating hospital and transportation safety precautions to participants (n=7; 78%) and conducting in-person sessions at an off-site location (n=6; 67%). Conclusion: This study identified critical facilitators of resuming in-person BA sessions that can inform: (1) how to resume in-person BA sessions and (2) the development and implementation of strategies to make BA more patient-centered for perinatal populations during COVID-19

The search for healthy schools: A multilevel latent class analysis of schools and their students

The objective of this study was to establish and investigate a taxonomy of school health among high school students in Ontario, Canada. Data analyzed were based on 3358 9th–12th graders attending 103 high schools who participated in the 2011 Ontario Student Drug Use and Health Survey. Based on 10 health-related indicators, multilevel latent class analysis was used to extract 4 student-level latent classes and 3 school-level latent classes. Unhealthy schools (19% of schools) had the lowest proportion of healthy students (39%) and the highest proportion of substance-using (31%) and unhealthy (18%) students. Healthy schools (66%) contained the highest proportion of healthy students (56%) and smaller proportions of substance-using (22%) and unhealthy students (8%). Distressed schools (15%) were similar to healthy schools in terms of the proportions of healthy and unhealthy students. Distressed schools, however, were characterized by having the largest proportion of distressed students (35%) and the lowest proportion of substance-using students (4%). Meaningful categories of schools with respect to healthy environments can be identified and these categories could be used for focusing interventions and evaluating school health programs. Keywords: Nonparametric multilevel latent class analysis, Healthy schools, High school student

News media and the influence of the alcohol industry: an analysis of media coverage of alcohol warning labels with a cancer message in Canada and Ireland.

OBJECTIVE: Media coverage of alcohol-related policy measures can influence public debate and is often more aligned with interests of the alcohol industry than public health. The purpose of this study was to examine the framing of news coverage of alcohol warning label (AWL) initiatives that included a cancer message on alcohol containers in two different countries. Policy contexts and industry perspectives were also evaluated. METHOD: We identified and systematically reviewed news articles published between 2017-2019 covering an AWL academic study in Yukon, Canada, and labeling provisions in a Public Health (Alcohol) Bill in Ireland. Both included a cancer message. News stories were coded for media type and topic slant; inclusion of alcohol industry perspectives was examined using content analysis. RESULTS: Overall, 68.4% of media articles covering the Yukon Study (n = 38) and 18.9% covering the Ireland Bill (n = 37) were supportive of AWLs with a cancer message. The majority of articles in both sites presented alcohol industry perspectives (Yukon, 65.8%; Ireland, 86.5%), and industry arguments opposing AWLs were similar across both contexts. In articles with statements from industry representatives, the label message was frequently disputed by distorting or denying the evidence that alcohol causes cancer (n = 33/43). CONCLUSIONS: News coverage of AWLs with a cancer message was more supportive in Canada than Ireland, where alcohol industry perspectives were consistently foregrounded. Industry arguments opposing the cancer label bore similarities across contexts, often distorting or denying the evidence. Increasing awareness of industry messaging strategies may generate more critical coverage of industry lobbying activities and increase public support for alcohol policies

Improving Knowledge that Alcohol Can Cause Cancer is Associated with Consumer Support for Alcohol Policies: Findings from a Real-World Alcohol Labelling Study

Knowledge that alcohol can cause cancer is low in Canada. Alcohol labels are one strategy for communicating alcohol-related harms, including cancer. Extending existing research observing an association between knowledge of the alcohol–cancer link and support for alcohol policies, this study examined whether increases in individual-level knowledge that alcohol is a carcinogen following an alcohol labelling intervention are associated with support for alcohol polices. Cancer warning labels were applied to alcohol containers at the intervention site, and the comparison site did not apply cancer labels. Pre-post surveys were conducted among liquor store patrons at both sites before and two-and six-months after the intervention was stopped due to alcohol industry interference. Limiting the data to participants that completed surveys both before and two-months after the cancer label stopped, logistic regression was used to examine the association between increases in knowledge and support for policies. Support for pricing and availability policies was low overall; however, increases in individual-level knowledge of the alcohol-cancer link was associated with higher levels of support for pricing policies, specifically, setting a minimum unit price per standard drink of alcohol (OR = 1.86, 95% CI: 1.11–3.12). Improving knowledge that alcohol can cause cancer using labels may increase support for alcohol policies. International Registered Report Identifier (IRRID): RR2-10.2196/1632

Evaluation of Daily Physical Activity (DPA) policy implementation in Ontario: surveys of elementary school administrators and teachers

Abstract Background School-based structured opportunities for physical activity can provide health-related benefits to children and youth, and contribute to international guidelines recommending 60 min of moderate-to-vigorous physical activity (MVPA) per day. In 2005, the Ministry of Education in Ontario, Canada, released the Daily Physical Activity (DPA) policy requiring school boards to “ensure that all elementary students, including students with special needs, have a minimum of twenty minutes of sustained MVPA each school day during instructional time”. This paper reports on the first provincial study evaluating implementation fidelity to the DPA policy in Ontario elementary schools and classrooms. Using an adapted conceptual framework, the study also examined associations between implementation of DPA and a number of predictors in each of these respective settings. Methods Separate cross-sectional online surveys were conducted in 2014 with Ontario elementary school administrators and classroom teachers, based on a representative random sample of schools and classrooms. An implementation fidelity score was developed based on six required components of the DPA policy. Other survey items measured potential predictors of implementation at the school and classroom levels. Descriptive analyses included frequency distributions of implementation fidelity and predictor variables. Bivariate analyses examining associations between implementation and predictors included binary logistic regression for school level data and generalized linear mixed models for classroom level data, in order to adjust for school-level clustering effects. Results Among administrators, 61.4 % reported implementation fidelity to the policy at the school level, while 50.0 % of teachers reported fidelity at the classroom level. Several factors were found to be significantly associated with implementation fidelity in both school and classroom settings including: awareness of policy requirements; scheduling; monitoring; use of resources and supports; perception that the policy is realistic and achievable; and specific barriers to implementation. Conclusions Findings from the surveys indicate incomplete policy implementation and a number of factors significantly associated with implementation fidelity. The results indicate a number of important implications for policy, practice and further research, including the need for additional research to monitor implementation and its predictors, and assess the impacts of study recommendations and subsequent outcomes of a reinvigorated DPA moving forward

Barriers and Facilitators to Resuming In-Person Psychotherapy with Perinatal Patients amid the COVID-19 Pandemic: A Multistakeholder Perspective

During the COVID-19 pandemic, outpatient psychotherapy transitioned to telemedicine. This study aimed to examine barriers and facilitators to resuming in-person psychotherapy with perinatal patients as the pandemic abates. We conducted focus group and individual interviews with a sample of perinatal participants (n = 23), psychotherapy providers (n = 28), and stakeholders (n = 18) from Canada and the U.S. involved in the SUMMIT trial, which is aimed at improving access to mental healthcare for perinatal patients with depression and anxiety. Content analysis was used to examine perceived barriers and facilitators. Reported barriers included concerns about virus exposure in a hospital setting (77.8% stakeholders, 73.9% perinatal participants, 71.4% providers) or on public transportation (50.0% stakeholders, 26.1% perinatal participants, 25.0% providers), wearing a mask during sessions (50.0% stakeholders, 25.0% providers, 13.0% participants), lack of childcare (66.7% stakeholders, 46.4% providers, 43.5% perinatal participants), general transportation barriers (50.0% stakeholders, 47.8% perinatal participants, 25.0% providers), and the burden of planning and making time for in-person sessions (35.7% providers, 34.8% perinatal participants, 27.8% stakeholders). Reported facilitators included implementing and communicating safety protocols (72.2% stakeholders, 47.8% perinatal participants, 39.3% providers), conducting sessions at alternative or larger locations (44.4% stakeholders, 32.1% providers, 17.4% perinatal participants), providing incentives (34.8% perinatal participants, 21.4% providers, 11.1% stakeholders), and childcare and flexible scheduling options (31.1% perinatal participants, 16.7% stakeholders). This study identified a number of potential barriers and illustrated that COVID-19 has fostered and amplified barriers. Future interventions to facilitate resuming in-person sessions should focus on patient-centered strategies based on empathy regarding ongoing risk-aversion among perinatal patients despite existing safety protocols, and holistic thinking to make access to in-person psychotherapy easier and more accessible for perinatal patients

Protocol for an economic evaluation of scalable strategies to improve mental health among perinatal women: Non-specialist care delivered via telemedicine vs. specialist care delivered in-person

Background: Perinatal depression affects an estimated 1 in 5 women in North America during the perinatal period, with annualized lifetime costs estimated at 20.6 billion dollars CAD in Canada and over 45.9 billion dollars USD in the US. Access to psychological treatments remains limited for most perinatal women suffering from depression and anxiety. Some barriers to effective care can be addressed through task-sharing to non-specialist providers and through telemedicine platforms. The cost-effectiveness of these strategies compared to traditional specialist and in-person models remains unknown. This protocol describes an economic evaluation of non-specialist providers and telemedicine, in comparison to specialist providers and in-person sessions within the ongoing Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial. Methods: The economic evaluation will be undertaken alongside the SUMMIT trial. SUMMIT is a pragmatic, randomized, non-inferiority trial across five North American study sites (N = 1,226) of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a behavioural activation treatment for perinatal depressive and anxiety symptoms. The primary economic evaluation will be a cost-utility analysis. The outcome will be the incremental cost-effectiveness ratio, which will be expressed as the additional cost required to achieve an additional quality-adjusted life-year, as assessed by the EuroQol 5-Dimension 5-Level instrument. A secondary cost-effectiveness analysis will use participants' depressive symptom scores. A micro-costing analysis will be conducted to estimate the resources/costs required to implement and sustain the interventions; healthcare resource utilization will be captured via self-report. Data will be pooled and analysed using uniform price and utility weights to determine cost-utility across all trial sites. Secondary country-specific cost-utility and cost-effectiveness analyses will also be completed. Sensitivity analyses will be conducted, and cost-effectiveness acceptability-curves will be generated, in all instances. Discussion: Results of this study are expected to inform key decisions related to dissemination and scale up of evidence-based psychological interventions in Canada, the US, and possibly worldwide. There is potential impact on real-world practice by informing decision makers of the long-term savings to the larger healthcare setting in services to support perinatal women with common mental health conditions.</p

Scaling up quality-assured psychotherapy : The role of therapist competence on perinatal depression and anxiety outcomes

Objectives: To examine: (1) the psychometric properties of two therapist competence measures-multiple choice questionnaire (MCQ) and standardized role-plays; (2) whether therapist competence differed between non-specialist (NSPs) and specialist (SPs) providers; and (3) the relations between therapist competence and pa-tient outcomes among perinatal patients receiving brief psychotherapy.Methods: This study is embedded within the SUMMIT Trial-a large, ongoing psychotherapy trial for perinatal women with depressive and anxiety symptoms. We assessed the: (1) psychometric properties of therapist competence measures using Cronbach's alpha and inter-class correlation; (2) differences in therapist competence scores between n = 23 NSPs and n = 22 SPs using a two-sample t-test; and (3) relations between therapist competence measures and perinatal patient outcomes through a linear regression model.Results: Internal consistency for role-play was acceptable (alpha = 0.71), whereas MCQ was excellent (alpha = 0.97). Role-play showed good inter-rater reliability (ICC = 0.80) and scores were higher for SPs compared with NSPs (t (2,38) =-2.86, p = 0.0069) and associated with outcomes of anxiety (B = 1.52, SE = 0.60, p = 0.01) and depressive (B = 0.96, SE = 0.55, p = 0.08) symptom scores.Conclusions: Our study highlights the importance of demonstrating psychological treatment skills through standardized role-plays over knowledge-based competence to predict perinatal patient outcomes. Using well-defined evidence-based tools is critical for deploying NSPs to provide high-quality psychotherapy and increase accessibility to psychological treatments for perinatal populations worldwide.Peer reviewe