Design and Evaluation of Implementation Support Strategies to Increase Preventive Care Delivery for Chronic Disease Risk Factors in Community-Based Mental Health Settings

<p dir="ltr">People with a mental health condition have a reduced life expectancy of up to 30 years compared to that of people without a mental health condition. This gap is contributed to significantly by an inequitable chronic physical disease burden. Four key chronic disease risk factors – tobacco smoking, inadequate nutrition, alcohol overconsumption, and physical inactivity (collectively referred to as snap) – are modifiable behaviours in which people with mental health conditions are more likely to engage in than those without, contributing to their increased chronic disease burden. Preventive care, which refers to the routine support from healthcare providers aimed at improving health behaviours, is one approach to address the elevated prevalence of snap risks amongst people with mental health conditions. One specific model of preventive care is AAR, and includes the care elements of Assessment, brief Advice, and Referral to specialist behaviour change services. Providing preventive care in the form of AAR has been identified as an appropriate intervention to address snap risks for people accessing community-based mental health settings. Community-based mental health settings, including government community mental health care (CMHC) services, and community managed organisations (CMO), have been identified as an important setting for such care delivery. These settings are important due to the large number of people with mental health conditions who access them, the frequency of contact and established rapport between consumers and mental health staff, and their guiding objective of person-centred or holistic care, including both mental and physical health. However, the levels of preventive care receipt by people accessing community-based mental health settings are reported to be low internationally, including in Australia, and limited research has been undertaken to improve our understanding of how to increase the provision of such care. Research is required to increase routine and systematic preventive care delivery to address snap risks in community-based mental health settings, and studies need to involve staff in the design of implementation strategies to ensure they align with the contextual factors associated with preventive care delivery in community-based mental health settings. Further, there are evident gaps in the literature regarding the nature of clustering of multiple snap risks among people with a mental health condition, a key consideration for the design of appropriate care delivery. To address these evidence gaps, this thesis aimed to:</p><p dir="ltr">A. Identify clusters of key chronic disease risks (tobacco smoking, chronic alcohol consumption, acute alcohol consumption, fruit and vegetable intake, physical activity, strength activity, and body mass index (BMI) status) and explore possible associations between identified clusters and demographic characteristics and mental health conditions among a sample of people accessing community mental health services through exploratory analysis (Chapter 2).</p><p dir="ltr">B. Assess the effectiveness of an implementation support package on clinicians’ delivery of preventive care (assessment, advice, referral) for four risk behaviours (tobacco smoking, harmful alcohol consumption, physical inactivity, inadequate fruit and vegetable intake). The participatory approach to developing the support package, and fidelity of the implementation strategies, are also described (Chapter 3).</p><p dir="ltr">C. Describe a co-development workshop involving CMO staff and researchers to identify preferred implementation support strategies to help staff routinely provide preventive care (a); describe the strategies that emerged from the workshop (b); and report staff ratings of the workshop on four co-development principles (c) (Chapter 4).</p><p dir="ltr">D. Evaluate the impact of preventive care implementation support strategies (co-developed in Chapter 4) on CMO staff attitudes and perceptions relating to preventive care for snap behaviours. Additionally, evaluate the impact of the Healthy Conversation Skills (HCS) training on staff perceptions of having behaviour change conversations (Chapter 5).</p><p dir="ltr">These four aims have been addressed through undertaking two controlled trials within two types of community-based mental health settings: a) a government CMHC service and b) a mental health CMO. The sub-studies include: a cross-sectional survey of n=567 clients accessing government CMHC services, which examines risk clustering (Chapter 2); a non-randomised controlled trial of an implementation support intervention designed with staff input involving two government CMHC services (one target and one control service), evaluated using client self-reported preventive care (AAR for snap) collected via telephone surveys at baseline and four month follow-up (Chapter 3); a co-development workshop with n=20 staff of a mental health CMO, which aimed to design implementation support strategies to help staff deliver preventive care (Chapter 4); and a pilot non-randomised controlled trial of a three-month implementation support package involving two branches of a national mental health CMO (one target and one control service), evaluated using staff-reported barriers and facilitators, collected with online surveys at baseline and follow-up, and pre-post surveys of staff attending Health Conversation Skills training (HCS), which was one of the strategies provided in the support package (Chapter 5).</p><p dir="ltr">The findings presented in each chapter of the thesis have contributed several new insights. Firstly, Chapter 2 identified three distinct clusters of chronic disease risks: Cluster 1 (19.05%) had < 0.5 probabilities for most risks, Cluster 2 (34.04%) had high probabilities for all risks, especially tobacco smoking and harmful alcohol consumption, and Cluster 3 (46.91%) had high probabilities for inadequate physical activity, inadequate fruit and vegetable intake, and high BMI. These findings emphasise the need to address multiple chronic disease risks in individuals with mental health conditions. Secondly, the implementation support package in Chapter 3 to assist clinicians to provide preventive care for snap behaviours was ineffective at increasing preventive care receipt. Analyses revealed no significant differential changes in AAR receipt between the target and control sites from baseline to follow-up, across any of the primary or secondary outcomes. The fidelity of implementation strategies in this study was limited. Of the four strategies included within the implementation support package, one was delivered as intended (clinician training and educational resources), two were delivered but not as originally intended (enabling resources and prompts for clinicians, and client activation materials), and one was not delivered (audit and feedback). Specifically, components of enabling resources and prompts as well as client activation material were not delivered as intended, and although education and training were delivered as intended, some components were offered late in the implementation period. The limited fidelity of implementation strategies was contributed to by abrupt and considerable disruptions related to the COVID-19 pandemic impacting the service. The COVID-19 lockdowns aligned with the implementation and follow-up periods of this trial, which occurred following the participatory design process and baseline data collection phases. As a result, it is not possible to ascertain whether the implementation package was not effective, or whether it’s limited fidelity due to the disruptions related to the COVID-19 pandemic contributed to the lack of effect. Additional research is needed to identify feasible but effective participatory design methods for developing implementation strategies to support preventive care delivery in government CMHC services. Thirdly, the co-development workshop in Chapter 4 that was undertaken with CMO staff using a structured Nominal Group Technique process identified preferred implementation strategies to fit within five categories: training, point of care prompts, guidelines, continuous quality improvement and consumer activation. Training for staff to have difficult conversations about behaviour change was ranked highest in both workshops, and participants rated the workshops positively across four co-development principles. The implementation strategies that were selected during the workshops informed the development of the pilot implementation support trial to assist CMO staff to provide preventive care to people with mental health conditions in Chapter 5. Lastly, findings from Chapter 5 demonstrated the feasibility and potential effectiveness of the co-developed implementation support package, with improvements in most barrier and facilitator outcomes, and almost all perceived individual and organisation ability outcomes for the target group. Evaluation of the HCS training component demonstrated immediate post-training improvements in outcomes including skills, beliefs about capabilities, intentions, participant confidence, perceived usefulness, and competence in using open discovery questions (a key healthy conversations skill).</p><p dir="ltr">The work presented in this thesis contributes to advancing the research field in a number of ways. Firstly, these findings emphasise the importance of addressing multiple chronic disease risks in individuals with mental health conditions and highlight the need for effective preventive care delivery in community-based mental health settings. Secondly, they demonstrate the value of involving staff in the design of implementation strategies to align with contextual factors associated with preventive care delivery in these settings. Thirdly, the findings highlight implications in the context of external public health or environmental challenges to mental health care service provision, such was the case with COVID-19. Future research should focus on integrating preventive care delivery into mental health service policy and key performance indicators. Additionally, future research should dedicate efforts to leverage telehealth as a tool to support preventive care, establishing it as a fundamental component of mental health care delivery. Lastly, future research should be directed towards the development of responsive and flexible preventive care interventions by assessing the suitability of alternative models across and within diverse community-based mental health settings. These research actions will require a collaborative effort that engages policymakers, healthcare providers, researchers, technology developers, and consumers as active co-designers to ensure feasibility and effectiveness of any preventive care approach or intervention, ultimately leading to better health outcomes for individuals with a mental health condition.</p>