Running Head: INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH
PLANNING
Integrating Health Care Providers’ Opinions into Mental Health Service Planning
for Underserved Populations
1Karen
Grace Dyck, Ph.D.*
2Melissa
3Andrea
1 Associate
Tiessen, Ph.D.
M. Lee, Ph.D.
Professor, Director of Rural and Northern Psychology Programme, Dept. of
Clinical Health Psychology, Faculty of Medicine, University of Manitoba, Winnipeg MB.
2 Director,
Education Directorate & Registrar, Accreditation, Canadian Psychological
Association, Ottawa, ON.
3 Reesor
and Associates Psychology Professional Corporation, Ottawa, ON.
Please note that at the time of this research, all authors were affiliated with the Rural
and Northern Psychology Programme, Dept. of Clinical Health Psychology, Faculty of
Medicine, University of Manitoba, Winnipeg, MB.
* CORRESPONDING AUTHOR EMAIL ADDRESS: dyckkg@cc.umanitoba.ca
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Abstract
Psychological interventions are a cost-effective means of treating mental health issues
and the preferred treatment over medication for many patients. Psychological
interventions have also been successfully offered at a distance and have the potential to
address contextual barriers – such as stigma, lack of anonymity, travel costs, limited
local resources – to accessing services for many underserved populations, particularly
rural and northern (R&N) communities. Gaining an accurate understanding of local
providers’ opinions about mental health services (including newer technologicallysupported interventions) appears essential to effective mental health planning. The
current study surveyed local health care providers (physicians, nurses,
paraprofessionals, mental health workers) in two large rural Manitoba health regions
regarding perceived efficacy of various mental health resources, likelihood of
recommending various resources, barriers and facilitators to recommending mental
health resources, and recovery from mental illness. Data are presented within the
context of informing regional mental health policy and planning. The importance of
integrating newer technologically-supported treatments into the more familiar locally
available services is highlighted. The application of stepped-care and collaborative
mental health is also discussed.
KEYWORDS: Mental health planning, underserved, rural, northern, health care
provider opinions
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Introduction
Psychological interventions are a cost-effective means of treating mental health
issues1 and, a preferred treatment over medication for as many as 66% of primary care
patients with depression.2 With the use of technology, psychological interventions have
also been successfully offered at a distance. Computer/internet and telephone-based
treatments are an effective means of delivering cognitive behavioral therapy (CBT) for
the treatment of adult anxiety and depression, pediatric anxiety, oppositional defiant
disorder, and attention deficit/hyperactivity disorder.3-7 Technologically-supported
treatments also have the potential to effectively address contextual barriers for
traditionally underserved populations, such as those in rural and northern (R&N) areas.
Such barriers include resource availability, self-reliance, stigma, anonymity, and travel
costs.8-12 Nonetheless, technology-supported services and programs are not without
limitations.13 Infrastructure and funding issues may limit the application and utilization of
these services in R&N Canada.3,14-16 As well, research has focused primarily on CBT
and includes multiple exclusionary criteria which limit the diversity of participants and
generalizability of these findings.3-5,17 As a result, these approaches may only be
appropriate for a portion of residents in R&N Canada. “In-home” approaches like these
also do little to foster support networks. However, if made available within the context
of a broader mental health service delivery model (e.g., stepped care, collaborative
care) which includes locally available services, these technological advances do have
the potential to address barriers.
Considering the diversity of R&N communities, input from local residents and
service providers appears essential to effective regional mental health planning.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Despite the documented efficacy of psychological interventions, it is important to gain
an accurate understanding of local stakeholders’ perceptions of the efficacy of a range
of mental health services and resources as this can be expected to impact utilization
and referral practices. This appears particularly relevant when considering the
introduction of less familiar technologically-supported treatments as local skepticism
from health care providers and the general public are likely to negatively impact
utilization.9,14,18 For example, adult residents surveyed in two rural health regions in
Manitoba (Interlake and South Eastman) indicated they would be more likely to access
more traditional mental health services (e.g., medication, individual counseling, books)
than newer technologically based treatments (e.g., computer-based treatments, internet
discussion groups, telephone counseling).9 These findings likely reflect, at least in part,
the types of resources that have been most readily available and are most familiar to
residents. These findings suggest successful integration and appropriate utilization of
these latter resources would likely require an initial knowledge translation step.
Following from these findings, the current study surveyed local service providers
(physicians, nurses, paraprofessionals, mental health workers) in two large rural
Manitoba health regions, Interlake and South Eastman, regarding perceived efficacy of
various mental health resources, likelihood of recommending various resources, and
barriers and facilitators to recommending mental health resources. The data were
gathered within the context of informing regional mental health policy with respect to
such issues as allocation of mental health funding, adoption of an effective mental
health resource development plan, and adoption of an effective mode of mental health
care. Regional data of this nature had not been gathered prior to this study.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Regional Backdrop
The Interlake region, with a population of 79,527,19 lies north and west of
Winnipeg between Lake Winnipeg and Lake Manitoba. The region is approximately
33,675 square km,20 with a population density of 2.3 people per square km. The South
Eastman region lies south east of Winnipeg, extending to the Ontario border in the east
and the United States border in the south. This region’s population of 70,36221 is
distributed across approximately 9,961 square km,20 resulting in a population density of
7.0 people per square km. Both the Interlake and South Eastman regions include a
number of smaller and larger towns as well as one city with a more substantial
population base (9,814 and 19,728 respectively).19,21 Approximately 22% of Interlake
residents identify themselves as Aboriginal, compared with only 9% in South Eastman.20
Nineteen percent of South Eastman residents report speaking a language other than
English in their home, compared to less than 5% of Interlake residents.20
Residents of both regions have access to free mental health services through
self-help organizations (e.g., Anxiety Disorders Association of Manitoba, Mood
Disorders Association of Manitoba, Manitoba Schizophrenia Society) as well as through
the local health region’s Community Mental Health Program. As such, residents have
access to a variety of services including, but not limited to, individual and group based
paraprofessional services, individual counseling (typically offered by psychiatric nurses,
social workers, and/or occupational therapists), psychosocial rehabilitation,
psychological and psychiatric consultation, drop in support centres and crisis services.
These services are available in various communities throughout the regions and can be
accessed with or without a referral.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Despite these resources, however, access to mental health services remains a
challenge. For example, Community Mental Health caseloads have risen dramatically
over the past several years (e.g., 54% increase in adult caseloads in South Eastman
between 2004/05 and 2008/09)22,23 resulting in caseload-staffing ratios exceeding
provincial recommendations.23 Residents in both regions identify the need for additional
resources and better coordination and communication between providers.23,24 Both
regions recognize the importance of exploring innovative, alternative and collaborative
service delivery models in order to improve the health care system in general.23,25
Method
The Provider Survey (PS) is a paper and pencil questionnaire developed by the
authors in conjunction with input from regional health staff. Based on regional
feedback, two related but region-specific versions of this survey were created and
distributed.
The PS was divided into two parts. Part one included questions about providers’
work experience, and their opinions about the efficacy of various mental health
resources, likelihood of recommending various mental health resources, barriers and
facilitators to recommending various resources, and recovery from mental illness. Part
two questions pertained to the district(s) in which providers worked, age, and gender. In
order to maintain confidentiality, respondents were instructed to forward the two parts of
the survey separately and to refrain from putting identifying information on the survey.
Five hundred and thirty-nine individually addressed surveys were sent out to
various providers (58 physicians, 42 community mental health workers, 34
paraprofessionals, and 405 nurses) in the Interlake region. One hundred and twenty-
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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three surveys were sent out in the South Eastman region (57 physicians, 43 community
mental health workers, 23 paraprofessionals). Nurses were not included in the South
Eastman region due to administrative preferences at the time. The package included a
description of the study (including contact information if anyone should wish additional
information about the study), a reply envelope, and a copy of the PS. Participation in
the study was completely voluntary. Depending upon their location, respondents were
instructed to forward their surveys via the internal courier or by regular mail (business
reply envelope provided).
Results
Descriptive statistics were calculated in order to enable exploration of region
specific patterns and trends relative to providers’ responses to survey questions.
Descriptive statistics are reported for the overall sample rather than by provider
subgroup, as opinions regarding mental health services showed consistent trends
across subgroups. Percentages were rounded to the nearest whole number.
Respondents
As shown in Table 1, overall response rates for the surveys were higher in the
South Eastman region, however similar absolute numbers of physicians and
proctors/self-help organization staff were represented in both regions. Community
Mental Health Workers (CMHW) were represented to a greater extent in South
Eastman, while nurses comprised the group with the lowest response rate, and were
only surveyed in the Interlake. In both regions, the distribution of respondents indicates
representation similar to the geographical areas in which the surveyed providers work
(i.e., more respondents are located in the larger divisions of each region). Interestingly,
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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while a majority of respondents in the Interlake indicated that they have worked in their
field for over 25 years, and conversely a majority of respondents in South Eastman
indicated being in their field for less than 5 years, there was a similar overall age
distribution of respondents in both regions. It is also important to note that the
overwhelming majority of health care providers in both regions indicated that their work
touches on mental health related issues somewhat often to very often. Only 1% of
respondents indicated never dealing with mental health topics. Finally, despite frequent
work in the area, only about half of the respondents felt that they are knowledgeable
about mental health treatment
Table 1
Demographics of Respondents
Interlake
South Eastman
Total n = 115
Total n = 66
(21% of 539 sent)
(54% of 123 sent)
Gender
Female
Male
86%
14%
63%
36%
Age
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
Over 65
1%
10%
27%
40%
18%
3%
4%
17%
24%
32%
20%
3%
Professional group
Physicians
CMHWs
Proctors/Self-help
Nurses
15%
14%
8%
63%
30%
52%
18%
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
Education
Some high school
High school or equivalent
Technical
diploma/certificate
College diploma/certificate
Bachelor’s degree
Master’s degree
Medical/doctoral degree
9
1%
7%
7%
47%
32%
3%
16%
3%
9%
3%
11%
29%
15%
30%
Years in field
0 to 5 years
6 to 10
11 to 15
16 to 20
21 to 25
Over 25
9%
14%
11%
15%
17%
34%
33%
12%
17%
14%
12%
12%
District work in
South East / Central
South West / Northern
North East / Western
North West / Southern
All 4 districts
50%
27%
21%
17%
--
59%
21%
8%
3%
9%
Frequency of MH work
Very often
Often
Somewhat
Not very often
Never
43%
25%
23%
7%
1%
82%
Knowledge re MH treatment
Very knowledgeable
Knowledgeable
Somewhat
Not very knowledgeable
None
17%
26%
39%
13%
1%
52%
17%
1%
45%
3%
Note. Due to rounding and missing data, percentages may not equal 100%.
Likelihood of recommending various mental health resources
As shown in Table 2, providers in the Interlake indicated that they would be most
likely to recommend one-on-one counseling, followed by medications prescribed by a
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
10
psychiatrist or family doctor. Providers in South Eastman indicated that they would be
most likely to recommend medications prescribed by a psychiatrist, followed by one-onone counseling, and medications prescribed by a physician. Providers in South
Eastman also indicated a significant likelihood of recommending a series of small group
sessions. In both regions providers indicated they would be very unlikely to recommend
computer-based treatment programs or internet discussion groups.
Table 2
Likelihood of Recommending Various Mental Health Resources
Interlake
Resource
Medication
Psychiatrist
Family Doctor
Counseling
One-on-one
Telephone
One-on-one religious
Group Education Meeting
One-time, large group
Series, group size
unspecified
Series, large group
Series, small group
Not at
all
1
Somewhat
2
3
4
South Eastman
Very
5
Not
at all
1
2
Very
3
1%
0%
0%
5%
22% 37% 41%
21% 38% 35%
1% 18% 79%
1% 29% 67%
2%
17%
17%
2%
28%
33%
17% 36% 44%
33% 17% 4%
32% 13% 2%
3% 20% 77%
32% 36% 32%
18% 67% 14%
55%
15%
---
16%
24%
---
13% 4%
24% 29%
-----
27% 41% 32%
---15% 50% 33%
6% 33% 59%
3%
8%
---
Other
Book
20% 25% 34% 14% 5%
14% 50% 36%
Website
27% 24% 26% 16% 8%
15% 50% 35%
Computer-based treatment
44% 40% 11% 3%
0%
55% 35% 4%
Internet discussion group
45% 37% 16% 1%
1%
73% 20% 5%
Note. Due to missing data, percentages may not equal 100%. – is used to indicate
instances where data were not obtained in that particular region.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Provider opinions about effectiveness of various mental health resources
Table 3 demonstrates that, similar to preferred resource recommendations,
providers in both regions rated one-on-one counseling as the most effective resource.
In the Interlake, providers rated medication prescribed by a psychiatrist as next most
effective, followed by a series of education group meetings, and medication prescribed
by a physician. In South Eastman, providers rated a series of small group meetings as
next most effective, followed by medication prescribed by a psychiatrist and physician,
respectively. Providers in both regions rated computer-based treatment programs as
least effective.
Table 3
Perceived Effectiveness of Various Mental Health Resources
Interlake
Resource
Medication
Psychiatrist
Family Doctor
Counseling
One-on-one
Telephone
One-on-one religious
Group Education Meeting
One-time, large group
Series, group size
unspecified
Series, large group
Series, small group
Not at
all
1
2
Somewhat
3
4
South Eastman
Very
5
Not
at all
1
2
Very
3
0%
0%
1%
3%
31% 45% 19%
40% 41% 12%
2% 41% 55%
2% 52% 44%
0%
7%
4%
1%
16%
17%
16% 42% 37%
49% 22% 4%
45% 24% 4%
3% 26% 68%
9% 64% 24%
9% 65% 23%
7%
2%
---
20%
6%
---
52% 14% 3%
28% 46% 15%
-------
18% 68% 9%
---5% 67% 24%
2% 33% 62%
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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Other
Book
8% 24% 52% 9%
4%
1% 70% 26%
Website
6% 22% 53% 12% 2%
5% 71% 18%
Computer-based treatment
11% 42% 32% 6%
1%
32% 49% 9%
Internet discussion group
8% 13% 36% 36% 8%
27% 52% 9%
Note. Due to missing data, percentages may not equal 100%. – is used to indicate
instances where data were not obtained in that particular region.
Barriers and facilitators to recommending mental health resources
Providers were asked about the reasons they might not recommend a mental
health resource other than medication. As shown in Table 4, in the Interlake, providers
particularly noted not knowing what to recommend and not being aware of the
resources available. In South Eastman, providers most frequently endorsed not being
aware of the resources available, followed by not thinking the resource would help, and
not knowing what to recommend. Interestingly, in both regions, less than 5% of
providers indicated that they think medications are the best line of treatment, or that
they feel their client would only want medications.
Providers were also asked about the factors that might make it more or less likely
for them to recommend a mental health resource other than medication. As noted in
Table 5, in both regions the top three most frequently endorsed (although in slightly
different orders) facilitating factors were having previous positive contact with someone
working with the resource, knowledge of other providers’ positive ratings of a resource,
and favourable ratings from other clients/patients.
Alternatively, providers in South Eastman noted that negative evaluations of the
resource by a client or other health care providers, along with previous negative contact
with a worker of the resource, were the top factors making it less likely for them to
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
13
recommend a resource. In the Interlake, respondents were more split in their opinions,
with smaller proportions of providers endorsing these same variables, but also
indicating that the location of the service and a service providers’ personal background
may influence the likelihood of recommending a resource.
Table 4
Barriers to Recommending Mental Health Resources (Non-Medication)
Interlake
South
Eastman
Not aware of the resources available
27%
49%
Do not think the resource would help
17%
38%
Do not know what to recommend
44%
36%
Do not think client would want the
recommendation
5%
Only give MH recommendation if requested
16%
8%
Think meds are the best line of treatment
4%
5%
Think client would only want meds
3%
1%
Barrier
17%
Table 5
Factors Influencing the Likelihood of Recommending Resources (Non-Medication)
Factor
Previous positive contact with
resource
Favourable rating from another service
Interlake
South Eastman
Less Neither More
likely
likely
Less Neither More
likely
likely
10%
2%
84%
3%
6%
88%
5%
5%
84%
5%
6%
86%
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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provider
Favourable rating from another client
4%
2%
89%
9%
2%
86%
Having a handout about resource to
give out
9%
7%
78%
6%
23%
65%
Service provider has a relevant degree
30%
2%
63%
6%
32%
59%
Service provider has personal
experience
34%
8%
54%
9%
42%
46%
Resource located in a general health
clinic
32%
8%
56%
15%
49%
32%
Resource located in a mental health
clinic
33%
6%
56%
11%
47%
38%
Unfavourable rating from another
service provider
24%
65%
4%
59%
30%
6%
Unfavourable rating from another
client
23%
68%
4%
73%
17%
6%
Previous negative contact with
resource
24%
63%
4%
76%
15%
6%
Factors contributing to recovery
Finally, providers were asked whether they believe that recovery from mental
health difficulties is possible, and what they believe best supports recovery, or what
must happen for recovery to be possible. Recovery was defined as: “a way of living a
satisfying, hopeful and contributing life even with the limitations caused by mental
illness. Recovery involves the development of new meaning and purpose in one’s life
as one grows beyond the … effects of mental illness” (p. 19).26 The overwhelming
majority of respondents in both regions indicated that they feel recovery is possible. In
South Eastman, only one provider indicated that they do not think recovery is possible
(two did not respond), and in the Interlake, seven providers said they do not think
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
15
recovery is possible, while two said yes and no (four did not respond). Of the
respondents who indicated that they do not think recovery is possible, they cited
reasons such as relapse or less than full recovery being possible. Among the providers
who indicated that they believe recovery is possible, 54% of respondents in the
Interlake and 43% in South Eastman commented on the importance of various
supports, especially family, which was the most frequently noted example, cited by 32%
of providers in the Interlake, and 28% in South Eastman.
Discussion
Psychological interventions are a cost-effective means of treating mental health
issues1 and a preferred treatment over medication for as many as 66% of primary care
patients with depression.2 Access to such services is a frequent challenge, however,
particularly for underserved populations, such as R&N communities. There is a need to
make psychological interventions available within the context of a broader mental health
service delivery model (e.g., stepped care, collaborative mental health care) which
includes locally available services. Given the diversity that exists across R&N
communities, the present study sought to obtain the input of local service providers in
order to best inform effective mental health planning.
Health care service providers from Manitoba’s Interlake and South Eastman rural
health regions identified medication, one-on-one counseling, and educational group
meetings as effective mental health resources and ones they would be likely to
recommend. In contrast, computer-based treatment was viewed by respondents as
least effective and a resource they would be very unlikely to recommend. Overall, these
opinions are consistent with those obtained from adult residents in these same regions9
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
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and likely reflect, at least in part, the resources that are most familiar to providers.
These findings emphasize the importance of developing and implementing effective
knowledge translation strategies in order to successfully incorporate newer, less familiar
mental health services such as technologically-supported treatments (e.g., computerbased treatments). For example, this could include information regarding documented
efficacy, advantages and disadvantages, etc., as well as opportunities for a
demonstration of technologically-supported treatments.
Findings from the current study further highlight the importance of understanding
the factors impacting the likelihood of local providers recommending various mental
health resources. Providers in the current studied identified lack of awareness of local
services, not knowing what to recommend, and thinking a resource would not be helpful
as barriers to recommending non-pharmacological mental health resources. These
findings also emphasize the need to develop knowledge translation strategies that
ensure providers have accurate information about the effectiveness of all available
treatments, not only new or less familiar treatments. Furthermore, these findings
emphasize the need to identify effective information dissemination strategies to ensure
providers have accurate up-to-date knowledge of locally available mental health
resources. Providing information about reputable books and websites regarding mental
health issues and evidence based treatments – both to recommend to patients and for
providers’ own professional development – may also prove beneficial. There is
particular value in family doctors being well informed about local mental health
resources, given that adult residents in Dyck, Tiessen, and Lee’s9 community survey
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
17
indicated that, second only to a spouse or partner, they would be next most likely to
speak to their family doctor regarding a mental health concern.
Health care providers also identified positive contacts with and/or positive ratings
of a particular mental health resource as important for facilitating a recommendation of a
resource. As such, disseminating evaluations/ratings from stakeholders who have
accessed various mental health resources appears important in these particular regions
and could easily be incorporated into local knowledge translation strategies (e.g.,
provide research data reflecting stakeholder evaluations/ratings). With appropriate
planning and implementation, collaborative mental health care may also address these
issues as it offers a framework for enhancing opportunities for positive contact between
providers. However, collaborative mental health care alone may be unlikely to alter
practice patterns or predict clinical outcome.2 Inclusion of treatment protocols/
guidelines, consideration of consumer treatment preference, and systematic follow-up
with opportunities to adjust treatment for non-responders, such as in a stepped-care
model, appear to positively influence treatment engagement and clinical outcome2 and
appear essential components to effective mental health planning.
Considering both treatment research and survey data from adult residents in the
Interlake and South Eastman regions9 it would appear important to ensure direct
access to a range of treatments (e.g., one-on-one counseling, technologically-supported
and self-directed treatments) with multiple access points (e.g., in-person services at a
community health centre, technologically-supported treatments that can be accessed at
home or at a local community health centre) that could be accessed directly (i.e.,
without a professional referral). A collaborate stepped-care mental health model with
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
18
these components has the potential to address contextual barriers, increase
accessibility, decrease caseloads, and allow a better client-service fit.
Finally, a significant proportion of health care providers in the present surveys
indicated that supportive family members are key to recovery from mental health
difficulties. This finding parallels data from Dyck, Tiessen, and Lee’s9 community
survey, wherein adult residents noted the importance of family members, especially
spouses/partners, as the individuals they would be most likely to seek out for support
and assistance with a mental health difficulty. Currently the majority of supports for
family members exist outside of the formal health care system, such as within self-help
organizations. Consequently, there is a valuable opportunity for the health care system
to better support the ways in which family members can facilitate health and recovery of
their loved ones, and be supported themselves as the primary natural caregivers.
The current study offers the largest provider input, to date, regarding mental
health planning in these rural health regions. However, the low response rate
(particularly in the Interlake region) is a limitation of this study. As such, caution must
be used when generalizing these findings. Future efforts should focus on identifying
strategies for accessing additional input from local providers.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
19
Acknowledgements
The authors wish to acknowledge the Interlake Regional Health Authority, South
Eastman Health, and the University of Manitoba for their financial and collaborative
support of this project. The authors also wish to thank the health care providers of both
regions for taking the time to complete this survey.
INTEGRATING PROVIDERS’ OPINIONS MENTAL HEALTH PLANNING
20
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