Virginia Rovnyak

Barriers to Help Seeking for Mental Disorders in a Rural Impoverished Population

This study examined barriers to seeking mental health care reported by individuals in a rural impoverished population, by screening 646 randomly selected adults for depression, anxiety, and alcohol abuse. Respondents who screened positive were randomly assigned to one of three groups: (1) no intervention, (2) an educational intervention alone, or (3) the educational intervention in the presence of a significant other. Those who screened positive for disorders cited barriers to care at significantly higher rates than respondents who screened negative. Respondents who received the educational intervention endorsed several barriers at significantly lower rates in the follow-up telephone call (subsequent to the intervention) than in the original interview (prior to the intervention). Virtually all respondents in a subsample of 142 subjects (99.3%) said they would seek mental health care if they thought mental health services would help them.

Rurality, Gender, and Mental Health Treatment

Mental health problems are common and costly, yet many individuals with these problems either do not receive care or receive care that is inadequate. Gender and place of residence contribute to disparities in the use of mental health services. The objective of this study was to identify the influence of gender and rurality on mental health services utilization by using more sensitive indices of rurality. Pooled data from 4 panels of the Medical Expenditure Panel Survey (1996–2000) yielded a sample of 32,219 respondents aged 18 through 64. Variables were stratified by residence using rural–urban continuum codes. We used logistic and linear regression to model effects of gender and rurality on treatment rates. We found that rural women are less likely to receive mental health treatment either through the general healthcare system or through specialty mental health systems when compared to women in metropolitan statistical areas (MSA) or urbanized non-MSA areas. Rural men receive less mental health treatment than do rural women and less specialty mental health treatment than do men in MSAs or least rural non-MSA areas. Reported mental health deteriorates as the level of rurality increases. There is a considerable unmet need for mental health services in most rural areas. The general health sector does not seem to contribute remarkably to mental health services for women in these areas.

Rurality and Mental Health Treatment

Diversity within rural areas renders rural–urban comparisons difficult. The association of mental health treatment rates with levels of rurality is investigated here using Rural–Urban Continuum Codes. Data from the 1996–1999 panels of the Medical Expenditure Panel Survey are aggregated to provide annual treatment rates for respondents reporting mental health problems. Data show that residents of the most rural areas receive less mental health treatment than those residing in metropolitan areas. The adjusted odds of receiving any mental health treatment are 47% higher for metropolitan residents than for those living in the most rural settings, and the adjusted odds for receiving specialized mental health treatment are 72% higher. Findings suggest rural community size and adjacency to metropolitan areas influence treatment rates.

Mental disorders and help seeking in a rural impoverished population.

Objective: This study examined the impact of an in-home screening and educational intervention on help seeking among rural impoverished individuals with untreated mental disorders. The effect of including a significant other in the intervention and reasons for not seeking help were explored. Method: The sample was randomly selected from households in nine rural counties in Virginia. The short form of the CIDI was used to screen 646 adult residents. Respondents who screened positive were randomly assigned to one of three groups: 1) no intervention, 2) an educational intervention, or 3) the educational intervention with a significant other. A list of local sources of health and mental health care was distributed. At one-month post interview, respondents were telephoned to inquire about help seeking. Results: Almost one-third (32.4%) of these respondents screened positive for at least one disorder. Five hundred and sixty-six (87.6%) were successfully followed up, and thirty-three of the 566 (5.8%) reported that they had sought professional help since the interview. Eighty-four subjects who screened positive and received the educational intervention reported in follow up that they had discussed the interview with a friend or family member, but only eleven (13.1%) received encouragement to seek treatment. The predominant reason endorsed for not seeking help was “felt there was no need,” even among respondents who were informed that they had a disorder. Conclusions: A significant proportion of this rural impoverished sample screened positive for a mental disorder. Few individuals sought professional help and significant others did not encourage them to seek treatment. The implication of these results for investigators and service providers is that motivating individuals to seek mental health services is a complex process; more attention must be devoted to the development of culturally relevant methods for facilitating help seeking.

Effect of Geographic Migration on SMI Prevalence Estimates

The prevalence of serious mental illness (SMI) varies by the socioeconomic characteristics of communities. This variation is presumed to be due to the differential incidence of disorders caused by adverse social factors (social causation) and differential geographic migration (social selection and drift). The objective of this study was to measure the geographic migration patterns of adults treated for SMI. A sample of 11,725 adults with three or more psychiatric hospital admissions between July 1978 and November 1992 was drawn from inpatient records. At least one third migrated to different counties between first and last admission. Migration rates were higher for Whites than for African Americans and higher for unmarried than for married patients. There were no significant differences in migration rates by gender or mental disorder. Patient migration did not parallel shifts in the general population. Patient migration was generally toward medium-size, low-income urban counties with relatively declining general populations, and movement was away from both the most rural and the largest urban counties. Public needs assessments and resource allocation policies may understate the need in communities with net SMI out-migration and overstate endemic need where there is net in-migration. In the long term, these same policies may induce migration through resource allocation decisions.

Race and Ethnicity and Rural Mental Health Treatment

Objective. Research has shown that there is less use of mental health services in rural areas even when availability, accessibility, demographic, and need factors are controlled. This study examined mental health treatment disparities by determining treatment rates across different racial/ethnic groups. Methods. Data from the first four panels of the Medical Expenditure Panel Survey (MEPS) were used for these analyses. The sample consisted of 36,288 respondents yielding 75,347 person-year observations. The Economic Research Service’s Rural-Urban Continuum was used as a measure of rurality. Results. Findings show that rural residence does little to contribute to existing treatment disparities for racial/ethnic minorities living in these areas. Conclusions. Findings suggest that characteristics of the rural environment may disadvantage all residents with respect to mental health treatment. In more populated areas where mental health services are more plentiful, complex racial and service system factors may play a greater role in evident ethnic/racial treatment disparities.

Preprocedural Distress in Children With Cancer: An Intervention Using Biofeedback and Relaxation

Children diagnosed with cancer experience many invasive procedures throughout diagnosis and treatment of their disease. These procedures, oftentimes a source of distress in children, can elicit a variety of anticipatory symptoms prior to the actual procedure. Although there have been efforts to develop approaches to alleviate this distress through use of distraction, relaxation, sedation, guided imagery, and hypnosis, there has not been a combination treatment that merged relaxation techniques and biofeedback within a pediatric framework. A group of 12 children diagnosed with cancer participated in a 4-session intervention combining relaxation and biofeedback. This feasibility study suggests that the combination intervention offered in a clinical setting may be beneficial to children experiencing procedural distress as a novel coping strategy.

Shared medical appointments: facilitating care for children with asthma and their caregivers.

As important members of the health care team, patients and caregivers must be empowered to recognize their asthma status and to act accordingly. Education about asthma, complications, and successful management of asthma provide the best way to empower children and their caregivers. A Shared Medical Appointment (SMA) is a unique health care delivery approach that integrates disease management and patient education. The SMA described here is a 90-minute group appointment for four to nine patients who share a diagnosis of asthma, bronchospasm, or wheeze and their caregivers. The appointment includes a brief individual examination, health education delivered to the group, and the opportunity for interaction between group members. Because a supporting theoretic framework is not identified in the original design proposals for the SMA model or in the literature on its use, for the purposes of this project, Social Cognitive Theory is identified as the theoretical framework that best explains and reinforces the benefits of the SMA. The theoretic framework is important to direct the development and continued success of this treatment model. This project report describes the first nurse practitioner-led SMA as a tool for improving quality of care and service for children with asthma and their caregivers.

Evaluation of an Office Protocol to Increase Exclusivity of Breastfeeding

OBJECTIVE: The purpose of this study was to determine whether implementing a program based on a clinical protocol affects breastfeeding rates within a pediatric primary care setting. Increasing breastfeeding rates is an important public health initiative identified by multiple agencies. METHODS: The Academy of Breastfeeding Medicine (ABM) clinical protocol (“The Breastfeeding-Friendly Physician’s Office, Part 1: Optimizing Care for Infants and Children”) was used as a template for the provision of breastfeeding services within a pediatric primary care clinic. There were 757 mother–infant pairs included in the study. A retrospective before-and-after study design was used. Data collection points included the hospital stay, the newborn visit, and the 2-, 4-, and 6-month health maintenance visits. The 2 groups were compared to estimate the protocol’s effectiveness as a method of increasing breastfeeding rates. RESULTS: The results of this evaluation were positive for exclusive breastfeeding, with group comparisons showing a statistically significant increase in exclusive breastfeeding rates at all 5 time points. CONCLUSIONS: Our diverse patient population within a pediatric practice had increased initiation rates and exclusive breastfeeding rates after implementation of the ABM’s breastfeeding-friendly protocol. Families who receive care in a pediatric primary care setting that has implemented the ABM clinical protocol may have increased rates of exclusive breastfeeding.

The Relationship Between Diabetes Mellitus, Depression, and Missed Appointments in a Low-Income Uninsured Population

Purpose The purpose of this project is to identify rates of depression and document mental health needs of adults with diabetes who obtained care in free clinics. Data were collected to determine if there is a relationship between diabetes and depression and missed appointments in a sample of patients who were low-income, uninsured, and represented a variety of racial groups. Methods A sample of 183 adults with diabetes participated by completing paper and computerized questionnaires. Instruments included the Patient Health Questionnaire 9 (to measure prevalence of depression), the RAND 36 Health Survey (to measure quality of health), the Audit of Diabetes Dependent Quality of Life (to measure diabetes-dependent quality of life), and the Diabetes Empowerment Scale (to measure self-efficacy). Results The prevalence of depression at a moderate or greater level in the sample was found to be 30.1%. Levels of quality of health and self-efficacy were found to be reduced among those with the presence of depression. A significant increase in the rate of depression was found among those who had attended the free clinic for a longer period. No significant differences were found in diabetes-dependent quality of life and missed appointments among those with depression compared with those without. Conclusions Rates of depression among adults with diabetes in a free clinic setting were found to be comparable with the highest rates reported by other studies of insured populations. Results of this study support the need to develop mental health treatment programs for free clinic settings.