Feasibility and utility of mobile health interventions for depression and anxiety in rural populations: A scoping review.

Despite the potential of mobile health (mHealth) to address high rates of depression and anxiety in underserved rural communities, most mHealth interventions do not explicitly consider the realities of rural life. The aim of this scoping review is to identify and examine the available literature on mHealth interventions that consider the needs of rural populations in order to gauge their feasibility and utility for addressing depression and anxiety. Additionally, we provide an overview of rural users' perceptions about and preferences for mHealth-delivered mental health screening and intervention systems. Out of 169 articles identified, 16 met inclusion criteria. Studies were conducted across a wide range of countries, age groups, and rural subpopulations including individuals with bipolar disorder, anxiety, perinatal depression, PTSD, and chronic pain, as well as refugees, veterans, and transgender and LGBTQ+ individuals. All interventions were in the feasibility/acceptability testing stage for rural users. Identified strengths included their simplicity, accessibility, convenience, availability of support between sessions with providers, and remote access to a care team. Weaknesses included problems with charging phone batteries and exceeding data limits, privacy concerns, and general lack of comfort with app-based support. Based upon this review, we provide recommendations for future mHealth intervention development including the value of developer-user coproduction methods, the need to consider user variation in access to and comfort with smartphones, and potential data or connectivity limitations, mental health stigma, and confidentiality concerns in rural communities.

Diverse rural caregivers for individuals with Alzheimer's disease or related dementias: analysis of health factors at the individual, interpersonal, and community level.

Objectives: Approximately 6.2 million Americans aged 65 or older have Alzheimer's disease or related dementias (ADRD). Unpaid family members and friends provide the bulk of caregiving for these individuals. Caregiving in rural areas adds unique challenges, particularly for ethnically/racially diverse caregivers. This study provides a profile of diverse, rural ADRD caregivers with an emphasis on multi-level factors that influence physical and mental health.Methods: A cross-sectional survey was conducted with 156 diverse rural ADRD caregivers.Results: 65% of participants identified as White/Non-Hispanic (WNH; n = 101) and 35% identified as ethnically/racially diverse (ERD; n = 55). The majority of participants reported economic deprivation. More ERD caregivers were uninsured and had at least one chronic health condition. Higher proportions of ERD caregivers smoked cigarettes, consumed alcohol regularly, and had not seen or talked to a doctor in the previous year. There were no ethnic/racial group differences in stress, anxiety, depressive symptoms, subjective health, or sleep quality.Conclusion: Rural caregivers, regardless of ethnicity/race, may benefit from extra supports in order to maintain optimal health. Further research is needed to disentangle the complex relationship between culture, caregiving, and health.

"We Live on an Island": Perspectives on Rural Family Caregivers for Adults with Alzheimer's Disease and Related Dementias in the United States.

As the United States' aging population grows, there will be increased prevalence of individuals living with Alzheimer's Disease and related dementias (ADRD), who largely rely on the support of their family caregivers. Family caregivers residing in rural areas face additional challenges with managing caregiving responsibilities and navigating support services. The purpose of this multilevel phenomenological qualitative study was to explore the assets, unique needs, and resources of rural-residing ADRD caregivers from the caregiver, provider, and policy influencers' perspectives. The study took place between 2019 through 2021 in northern Arizona, a largely rural and geographically vast area home to caregivers from diverse backgrounds. Twenty-seven caregivers to a loved one with ADRD participated in focus groups. Twelve health and social services providers and twelve policy influencers, those involved in leadership positions for aging programs or advocacy groups, completed individual interviews. Caregivers demonstrate many assets which contribute to their ability to manage and cope with their caregiving role. However, caregivers face a series of issues related to their caregiving role and need early and ongoing education regarding ADRD. There is a lack of resources available in rural areas, in particular providers, making it challenging to obtain needed resources necessary to support their loved one with ADRD. Furthermore, there is a need for more providers trained in working with aging adults and those experiencing ADRD, and a need for more culturally relevant resources.

A multisectoral approach to advance health equity in rural northern Arizona: county-level leaders' perspectives on health equity.

BACKGROUND: Multisectoral and public-private partnerships are critical in building the necessary infrastructure, policy, and political will to ameliorate health inequity. A focus on health equity by researchers, practitioners, and decision-makers prioritizes action to address the systematic, avoidable, and unjust differences in health status across population groups sustained over time and generations that are beyond the control of individuals. Health equity requires a collective process in shaping the health and wellbeing of the communities in which we live, learn, work, play, and grow. This paper explores multisectoral leaders' understanding of the social, environmental, and economic conditions that produce and sustain health inequity in northern Arizona, a geographically expansive, largely rural, and culturally diverse region. METHODS: Data are drawn from the Southwest Health Equity Research Collaborative's Regional Health Equity Survey (RHES). The RHES is a community-engaged, cross-sectional online survey comprised of 31 close-ended and 17 open-ended questions. Created to assess cross-sectoral regional and collective capacity to address health inequity and inform multisectoral action for improving community health, the RHES targeted leaders representing five rural northern Arizona counties and 13 sectors. Select open-ended questions were analyzed using an a priori coding scheme and emergent coding with thematic analysis. RESULTS: Although leaders were provided the definition and asked to describe the root causes of inequities, the majority of leaders described social determinants of health (SDoH). When leaders described root causes of health inequity, they articulated systemic factors affecting their communities, describing discrimination and unequal allocation of power and resources. Most leaders described the SDoH by discussing compounding factors of poverty, transportation, housing, and rurality among others, that together exacerbate inequity. Leaders also identified specific strategies to address SDoH and advance health equity in their communities, ranging from providing direct services to activating partnerships across organizations and sectors in advocacy for policy change. CONCLUSION: Our findings indicate that community leaders in the northern Arizona region acknowledge the importance of multisectoral collaborations in improving health equity for the populations that they serve. However, a common understanding of health equity remains to be widely established, which is essential for conducting effective multisectoral work to advance health equity.

Homeless Opioid Treatment Clients Transitioning to Dependent and Independent Housing: Differential Outcomes by Race/Ethnicity.

Purpose: Homeless opioid treatment clients who transition into housing generally demonstrate better outcomes, but housing environments vary widely and may not benefit racial/ethnic minority populations equally. We sought to identify how race/ethnicity moderates the association between positive opioid treatment response and moving into dependent or independent living environments. Methods: We used the Treatment Episode Dataset-Discharges (2018-2019) to identify outpatient treatment clients who were homeless at admission and indicated heroin or other opioids as their primary drug of choice (n = 20,021). We defined positive treatment response as a reduction in opioid use between admission and discharge. We used multivariable logistic regression to model treatment response. We included an interaction between housing at discharge (remained homeless [reference], dependent living, or independent living) and race/ethnicity, and adjusted for relevant confounders. Results: Transitioning from homeless to dependent living was positively associated with treatment response among White (aOR = 3.57, 95% CI = 3.15-4.06), Hispanic (aOR = 2.11, 95% CI = 1.55-2.86), and Black clients (aOR = 1.79, 95% CI = 1.41-2.27), but no association was observed for homeless American Indian/Alaska Native clients. Transitioning from homeless to independent living was strongly associated with treatment response among all groups with the strongest association observed among White clients (aOR = 4.70, 95% CI = 4.26-5.19). Conclusions: Interventions aimed at improving OUD treatment outcomes among homeless clients should identify individual and structural factors that support moving into fully housed and independent living environments. Dependent living offers needed support during crises, but should be temporary and priority should be placed on independent, permanent, and autonomous living environments.

Health Impacts of Perchlorate and Pesticide Exposure: Protocol for Community-Engaged Research to Evaluate Environmental Toxicants in a US Border Community.

BACKGROUND: The Northern Arizona University (NAU) Center for Health Equity Research (CHER) is conducting community-engaged health research involving "environmental scans" in Yuma County in collaboration with community health stakeholders, including the Yuma Regional Medical Center (YRMC), Regional Center for Border Health, Inc. (RCBH), Campesinos Sin Fronteras (CSF), Yuma County Public Health District, and government agencies and nongovernmental organizations (NGOs) working on border health issues. The purpose of these efforts is to address community-generated environmental health hazards identified through ongoing coalitions among NAU, and local health care and research institutions. OBJECTIVE: We are undertaking joint community/university efforts to examine human exposures to perchlorate and agricultural pesticides. This project also includes the parallel development of a new animal model for investigating the mechanisms of toxicity following a "one health" approach. The ultimate goal of this community-engaged effort is to develop interventions to reduce exposures and health impacts of contaminants in Yuma populations. METHODS: All participants completed the informed consent process, which included information on the purpose of the study, a request for access to health histories and medical records, and interviews. The interview included questions related to (1) demographics, (2) social determinants of health, (3) health screening, (4) occupational and environmental exposures to perchlorate and pesticides, and (5) access to health services. Each participant provided a hair sample for quantifying the metals used in pesticides, urine sample for perchlorate quantification, and blood sample for endocrine assays. Modeling will examine the relationships between the concentrations of contaminants and hormones, demographics and social determinants of health, and health status of the study population, including health markers known to be impacted by perchlorate and pesticides. RESULTS: We recruited 323 adults residing in Yuma County during a 1-year pilot/feasibility study. Among these, 147 residents were patients from either YRMC or RCBH with a primary diagnosis of thyroid disease, including hyperthyroidism, hypothyroidism, thyroid cancer, or goiter. The remaining 176 participants were from the general population but with no history of thyroid disorder. The pilot study confirmed the feasibility of using the identified community-engaged protocol to recruit, consent, and collect data from a difficult-to-access, vulnerable population. The demographics of the pilot study population and positive feedback on the success of the community-engaged approach indicate that the project can be scaled up to a broader study with replicable population health findings. CONCLUSIONS: Using a community-engaged approach, the research protocol provided substantial evidence regarding the effectiveness of designing and implementing culturally relevant recruitment and dissemination processes that combine laboratory findings and public health information. Future findings will elucidate the mechanisms of toxicity and the population health effects of the contaminants of concern, as well as provide a new animal model to develop precision medicine capabilities for the population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15864.

Using a Multisectoral Approach to Advance Health Equity in Rural Arizona: Community-Engaged Survey Development and Implementation Study.

BACKGROUND: Over the past decade, public health research and practice sectors have shifted their focus away from identifying health disparities and toward addressing the social, environmental, and economic determinants of health equity. Given the complex and interrelated nature of these determinants, developing policies that will advance health equity requires collaboration across sectors outside of health. However, engaging various stakeholder groups, tapping into their unique knowledge systems, and identifying common objectives across sectors is difficult and time consuming and can impede collaborative efforts. OBJECTIVE: The Southwest Health Equity Research Collaborative at Northern Arizona University, in partnership with an 11-member community advisory council, is addressing this need with a joint community-campus effort to develop and implement a Regional Health Equity Survey (RHES) designed to generate an interdisciplinary body of knowledge, which will be used to guide future multisectoral action for improving community health and well-being. METHODS: Researchers and community partners used facilitated discussions and free listing techniques to generate survey items. The community partners pilot tested the survey instrument to evaluate its feasibility and duration before survey administration. Respondent-driven sampling was used to ensure that participants included leadership from across all sectors and regions of northern Arizona. RESULTS: Over the course of 6 months, 206 participants representing 13 sectors across the 5 counties of northern Arizona were recruited to participate in an RHES. Survey response rates, completion percentage, and sector representation were used to assess the effectiveness and feasibility of using a community-engaged apporach for survey development and participant recruitment. The findings describe the current capacity to impact health equity by using a multisectoral approach in northern Arizona. CONCLUSIONS: The Southwest Health Equity Research Collaborative effectively engaged community members to assist with the development and implementation of an RHES aimed at understanding and promoting multisectoral action on the root causes of health inequity. The results will help to build research and evaluation capacity to address the social, economic, and environmental conditions of health inequity in the region.

A Community-Engaged Approach to Environmental Health Research: Process and Lessons Learned.

BACKGROUND: This study used a community-engaged approach to examine associations between environmental contaminants and health outcomes among residents of Yuma, Arizona. Our team conducted a process evaluation to assess scientific rigor and adherence to community engagement principles. OBJECTIVE: Our evaluation focused on four dimensions of community-based participatory research: 1) context, 2) group dynamics, 3) intervention and research, and 4) outcomes. METHODS: Interviews were conducted with key informants from community partner organizations. Thematic analysis was used to evaluate community partners' experiences with our collaborative process. LESSONS LEARNED: Community partners reported collaborating to establish research goals, recruit participants, collect data, plan analyses, and formulate dissemination strategies. Training needs, roles, and expectations of community partners varied based on available resources, prior research experience, and perceived research challenges. CONCLUSIONS: Leveraging community-engaged principles for studies of environmental contamination can expedite recruitment efforts and stimulate action to improve health outcomes.

Voices of Community Partners: Perspectives Gained from Conversations of Community-Based Participatory Research Experiences.

Community-based participatory research (CBPR) has been documented as an effective approach to research with underserved communities, particularly with racial and ethnic minority groups. However, much of the literature promoting the use of CBPR with underserved communities is written from the perspective of the researchers and not from the perspective of the community partner. The purpose of this article is to capture lessons learned from the community partners' insight gained through their experiences with CBPR. A multi-investigator consensus method was used to qualitatively code the transcripts of a CBPR story-telling video series. Seven major themes were identified: (1) expectations for engaging in research, (2) cultural humility, (3) respecting the partnership, (4) open communication, (5) genuine commitment, (6) valuing strengths and recognizing capacities, and (7) collaborating to yield meaningful results. The themes drawn from the community partner's voice align with the tenets of CBPR advanced in the academic literature. More opportunities to include the community voice when promoting CBPR should be undertaken to help introduce the concepts to potential community partners who may be research cautious.

Building Behavioral Health Homes: Clinician and Staff Perspectives on Creating Integrated Care Teams.

Adults with serious mental illness and substance use disorders have elevated risk of mortality and higher healthcare costs compared to the general population. As these disparities have been linked to poor management of co-occurring chronic conditions in primary care, the behavioral health setting may be a preferred setting for routine medical screening and treatment. This qualitative study describes early stages of integrating care teams in emerging medical homes based in mental health and addiction treatment settings. Clinicians and staff from ten agencies engaged in the Behavioral Health Home Learning Collaborative participated in qualitative interviews exploring local definitions of "behavioral health home" and initial barriers and facilitators to integration. Facilitators included clear staff roles, flexible scheduling, and interdisciplinary huddles and staff trainings. Challenges included workforce, limited use of electronic health records, and differing professional cultures. Participants advocated for new workflows and payment structures to accommodate scheduling demands and holistic case management.

Correction to: Building Behavioral Health Homes: Clinician and Staff Perspectives on Creating Integrated Care Teams.

The Publisher regrets that due to a malfunction in production, there are duplications and errors and rogue addresses in the author affiliations of the published article. The correct author affiliations are listed below.

Mammography Decision Aid Reduces Decisional Conflict for Women in Their Forties Considering Screening.

BACKGROUND: Clinical guidelines recommend a personalized approach to mammography screening for women in their forties; however, methods to do so are lacking. An evidence-based mammography screening decision aid was developed as an electronic mobile application and evaluated in a before-after study. METHODS: The decision aid (Mammopad) included modules on breast cancer, mammography, risk assessment, and priority setting about screening. Women aged 40-49 years who were patients of rural primary care clinics, had no major risk factors for breast cancer, and no mammography during the previous year were invited to use the decision aid. Twenty women participated in pretesting of the decision aid and 75 additional women completed the before-after study. The primary outcome was decisional conflict measured before and after using Mammopad. Secondary outcomes included decision self-efficacy and intention to begin or continue mammography screening. Differences comparing measures before versus after use were determined using Wilcoxon signed rank tests. RESULTS: After using Mammopad, women reported reduced decisional conflict based on mean Decisional Conflict Scale scores overall (46.33 versus 8.33; Z = -7.225; p < 0.001) and on all subscales (p < 0.001). Women also reported increased mean Decision Self-Efficacy Scale scores (79.67 versus 95.73; Z = 6.816, p < 0.001). Although 19% of women changed their screening intentions, this was not statistically significant. CONCLUSIONS: Women reported less conflict about their decisions for mammography screening, and felt more confident to make decisions after using Mammopad. This approach may help guide women through the decision making process to determine personalized screening choices that are appropriate for them.

Cooperative behaviour and prosocial reputation dynamics in a Dominican village.

Prosocial reputations play an important role, from the evolution of language to Internet transactions; however, questions remain about their behavioural correlates and dynamics. Formal models assume prosocial reputations correlate with the number of cooperative acts one performs; however, if reputations flow through information networks, then the number of individuals one assists may be a better proxy. Formal models demonstrate indirect experience must track behaviour with the same fidelity as direct experience for reputations to become viable; however, research on corporate reputations suggests performance change does not always affect reputation change. Debate exists over the cognitive mechanisms employed for assessing reputation dynamics. Image scoring suggests reputations fluctuate relative to the number of times one fails to assist others in need, while standing strategy claims reputations fluctuate relative to the number of times one fails to assist others in good standing. This study examines the behavioural correlates of prosocial reputations and their dynamics over a 20-month period in an Afro-Caribbean village. Analyses suggest prosocial reputations: (i) are correlated with the number of individuals one assists in economic production, not the number of cooperative acts; (ii) track cooperative behaviour, but are anchored across time; and (iii) are captured neither by image scoring nor standing strategy-type mechanisms.