Primary care (PC) providers' stigmatizing attitudes and behaviors towards persons with serious mental illness (SMI) have been implicated as factors contributing to disparities in healthcare for these patients, including VA patients. Contact and educational interventions provide evidence-based approaches to reduce provider stigma and potentially reduce disparities in receipt of medical services. We conducted a hybrid type 2 effectiveness-implementation study to test implementation of a contact stigma reduction intervention (Serving All Veterans Equally (SAVE)) to reduce stigma of mental illness in PC providers.
This study examined feasibility of utilizing an external facilitation strategy (EFS) for implementing the SAVE intervention for PC providers. We also examined impact of the contact and an education intervention on reducing mental illness stigma among PC providers.
We used EFS to implement the contact and education interventions at the PC services at Central Arkansas Veterans Healthcare System (CAVHS), Little Rock, AR and Veterans Health Care System of the Ozarks (VHCSO), Fayetteville, AR and recruited PC providers (MD, APN, RN, and LPN) from an available pool of 62 (CAVHS) and 42 (VHCSO) providers. Participants were randomly assigned to the contact or education intervention. Participants in the contact intervention received a narrative of personal experience of mental illness delivered by a physician. Education intervention participants received a PowerPoint presentation contrasting myths vs. facts about mental illness. All participants completed a set of instruments to measure attitudes and behavioral intentions at baseline, post-intervention, at completion of the 1-month booster session and at the 3- month follow-up assessment. A process evaluation gathered qualitative data on stakeholder perspectives and experiences with the EFS and the contact intervention. Feasibility of the EFS to implement the contact intervention was assessed by determining 'Reach' (proportion of eligible PC providers receiving the intervention) and 'Adoption' (number and proportion of eligible PC providers receiving BOTH baseline and booster intervention sessions). Fidelity of the EFS intervention was assessed by documenting the initial local implementation plan and changes to the local plan undertaken to support implementation of contact intervention. To assess impact of SAVE on provider attitudes, we measured social distance, attribution of mental illness, and provider stigma using a vignette-based survey. To assess intervention impact on provider behavior, we compared the status of completed consults ordered by providers in each of the intervention groups and examined differences in rates of consult completions for patients with SMI compared to those without SMI.
Aim 1: Feasibility and impact of using an external facilitation strategy to support implementation
There was strong support for the study from PC services at both sites but "reach" and "adoption" by PC providers were low. At CAVHS, 18/62 (29%) PC providers participated in the study and at VHCSO, 21/42 (50%) participated. At CAVHS, 7/18 (39%) of participants attended both the initial and booster intervention sessions whereas at VHSO, 12/21 (57%) attended both sessions. The main barrier to implementation of the SAVE intervention at both sites was provider clinic schedule and logistics of arranging group provider sessions. All participants at both sites (100%) completed the 3-month final assessment, largely because providers were allowed to complete assessments at their convenience.
Main EFS activities included local marketing, implementation planning, stakeholder engagement and assessment of logistical issues for recruitment and scheduling intervention sessions. Given the low complexity of EFS needed, our study suggests that such tasks could effectively be assumed by an experienced program coordinator with no prior research background.
Aim 2: Impact of the SAVE and Education interventions on PC providers' attitudes
A total of 39 providers participated in the study with 19 randomized to contact and 20 to the education intervention. Demographics were similar across both groups with the majority of the participants identifying as white females of the nursing profession who were >50 years in age.
Repeated measures ANOVAs were used to model the effectiveness outcomes for three measures of provider attitudes. Although there was no significant treatment-by-time interaction for any stigma measure, it approached significance for the provider stigma measure (p=0.07). For social distance, the time effect was significant with mean scores declining 12.5% from baseline to 1-month booster session but the decline from baseline to 3 months (7.2%) was not statistically significant. For attribution, there was a statistical difference in mean scores across treatment groups with mean values of 17.5 for the contact and 15.0 for the education groups, respectively. Overall, there were no significant differences between the changes in the means for the two intervention groups over time
Descriptive consult data analyses revealed that rates of completion of consults for persons with SMI were lower than for those without SMI. Although these results are in the expected direction, the small number of providers and lack of patient level data prevents meaningful conclusions.
Aim 3: Stakeholder perceptions of the SAVE intervention
Qualitative data on the intervention process revealed that most providers favored blocking clinic time to participate in the study, preferred more than one booster session and liked the format of in-person presentation followed by discussion. Some desired more time for discussion. Regarding the experience with the contact intervention, most providers liked the content and found the physician's narrative credible and compelling. Most found contact intervention to be much needed because it increased awareness of biases towards persons with mental illness and disparities in physical health care.
Overall, the SAVE intervention was well liked and targeted the intended provider attitudes. However, quantitative analyses did not demonstrate a significant impact on provider attitudes.
Interventions to reduce provider stigma can be implemented in PC settings. Both education and contact interventions show promise in this regard based on quantitative and qualitative data respectively. A larger study is needed to further establish the impact of both contact and educational interventions in reducing providers stigmatizing attitudes towards persons with SMI. Future studies will need to overcome implementation barriers that exist for PC providers to participate in such quality improvement efforts.
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Grant Number: I21HX001671-01
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