Anxiety management interventions research articles
The protocol included a mixture of "grand-tour" type questions that are common opening questions for inductive analyses e. With conventional content analyses, investigators focus on descriptions of phenomena to identify themes and concepts that emerge from reading the interview transcript text without being constricted to a specific theory or conceptual model of behavior i.
With directed content analysis, investigators are guided by existing theory or research findings and explore predetermined themes or concepts in their coding. We employed both types of content analysis, with an emphasis on the former. When two coders were involved, they independently coded identical sections of text and compared coding and interpretations. Each subsample of participants' transcripts was coded as a group, in this sequence: ACSs, physicians, nurses, administrators, and staff.
This method allowed the coders to focus on that data and emergent themes of one group at a time as opposed to coding random transcripts , and the sequence allowed the coders to investigate the stakeholders most involved with the CALM intervention first ACSs , then in descending order of overall stakeholder involvement in implementation. Further subcoding of categories within each top-level code came next.
The final list of codes consisted of behaviors, attitudes, personal characteristics, contexts, processes, and policies the informants believed to be associated with the implementation and sustainability of the CALM intervention. While numerous barriers and facilitators were recognized and reported by the informants, we chose to highlight here those reported most often and those referred to by the participants as the most salient from their perspective. Additional information about the full range of barriers and facilitators is available from the authors.
Exemplar quotations are contained in Additional file 1. The most often cited barrier to implementation across stakeholders was uneven physician "buy-in" or support for the CALM intervention within clinics.
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A common pattern emerged: some physicians were highly motivated to participate in the intervention, some were marginally so, and some were not at all motivated to participate. The highly motivated physicians were usually less than half of the total number of physicians in a clinic. Further, participants across stakeholder groups recognized that it was challenging to increase physician interest.
Many participants speculated that the less enthusiastic physicians were not comfortable with treating mental health. Others noted that low enthusiasm could also be linked to providers both physicians and nurses feeling that the prevalence of anxiety was low in their clinic. Also, many physicians reported that enthusiasm for the intervention could wane without supportive attention from "champions" or "opinion leaders. Two very commonly noted barriers to implementation across stakeholder group and clinic types were high prevalence of part-time primary care providers and space concerns for the ACS.
The ACS and physician stakeholder groups especially reported concerns about part-time physicians including residents being harder to reach with information about CALM than full-time providers, and thus it was harder to engage with them and facilitate their involvement. University-affiliated clinics with large numbers of residents seemed most impacted by the barrier. Informants from all stakeholder groups and clinic types noted barriers associated with finding adequate space for the ACSs to do their work.
If an ACS's work space was not proximal to the providers, their relationships with them suffered. Further, if an ACS had no permanent or reliable place to work, a common issue in many clinics, this also hindered communication with providers and negatively impacted referrals. An often cited barrier to implementation within this category was ACSs who worked part-time in a clinic. Referrals are hindered when an ACS is on-site only certain days per week to receive them.
Also, less "face time" in the clinic means less communication and fewer opportunities for building rapport with clinic providers and staff. Some physicians discussed communication with ACSs being unsatisfactory. Interestingly, the nature of the dissatisfaction was not uniform.
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In fact, some physicians wanted more frequent and extensive communication with the ACS, while others felt there was too much. In addition, some nurses reported feeling "out of the loop" between their PCPs, the ACSs, and the off-site psychiatrist, and they felt that they could not act as "champions" for the intervention when they were out of the loop.
This barrier could also fall under the category of clinic structure if its genesis had more to do with pre-existing clinic culture. Some nurses also reported only hearing about the intervention from their PCP, indicating that in some clinics the nurses were not consistent targets for education and marketing about the intervention. Some physicians noted that when patients drop out or "no show" for their ACS appointments, this can weaken their enthusiasm for the intervention.
Perhaps related to this, a patient-related barrier noted among ACSs working in clinics with high numbers of uninsured was that the high overall disease burden and social stressors among lower socioeconomic status SES patients seemed to make it harder for those patients to engage in the intervention.
The pressures of unstable employment, housing, and transportation appeared to negatively affect how some patients prioritized their anxiety treatment. They speculated that culturally bound beliefs about mental illness were contributing to males being resistant to admitting a problem and females not getting necessary support from their families to participate in the sessions. Implementation seemed to go smoothly and referrals to the ACS were most plentiful when physicians especially and nurses had enthusiastically "bought in" to the intervention.
The factor most linked to strong buy-in was a belief that mental health concerns should be a priority. This is the inverse of the buy-in barrier noted above. It is unclear to what extent education and outreach efforts of the study investigators and the ACSs influenced this priority setting. When the ACSs were asked to speculate on this point, they reported that most of the enthusiastic providers were that way "from the get go," indicating that many providers were positively predisposed to a mental health intervention.
Approximately half of the providers interviewed self-identified as champions of the intervention. Informants from all of the stakeholder groups noted that when positive outcomes of patients were communicated, this increased provider enthusiasm and referral activity. Additionally, when reduced somatic complaints were observed in some patients, provider enthusiasm increased.
In addition, among those with a favorable view of CALM, providers did not need to see dramatic improvements in their patients to maintain a positive attitude towards the intervention. As well, most provider informants said they appreciated the additional referral source. Two related facilitators in this category were pre-existing presence of a mental health provider and pre-existing presence of collaborative-care services for another disorder. If the providers were in the habit of referring patients to another mental health specialist within their clinic, or were in the habit of using a collaborative-care coordinator of some kind, those factors facilitated the use of the ACS.
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The large HMO clinics were the most likely to be already employing a collaborative-care coordinator for another disorder e. As noted above, the in-house mental health professionals were usually master's-level clinicians. The interviews with the ACSs did not uncover much information about their relationship with these providers, though some found them to be "good referrers. Perhaps the most universal facilitator across clinic stakeholders was that the CALM intervention was not overly burdensome.
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The physicians and nurses reported little to no increased burden in their workload, and many noted reductions in their workload as a result of reduced somatic complaints. The vast majority found the referral processes very easy and that referrals worked best when the ACSs were in the clinic full time. While it was usual for providers to leave a paper-and-pencil or electronic referral note for the ACSs to follow up on, some providers liked to have the ACS join their encounter with the patient for a face-to-face "hand-off.
Further, the ACSs found that the more they had "face time" with providers to discuss CALM and establish rapport, the better the implementation went. Face time could occur in the hallways, at lunchtime, or during staff meetings. From the clinic stakeholder point of view, when ACSs were seen as warm, engaging, and visible , they received high marks.
And most of the informants who commented specifically about their ACS did so very positively. The main patient-level facilitator seemed to be that many expressed their preference to these informants especially the nurses that they prefer coming to primary care for their mental health issues.
This preference seemed to be rooted in both the ease of coming there "one-stop shopping" and that stigma was reduced by coming to primary care and seeing a mental health provider there. The two main barriers expressed by the vast majority of stakeholders were paying for the ACS services and space for the ACS. Most, but not all, of the stakeholders expressed doubt that the intervention would be maintained and that the main "culprit" would be the difficulty in paying for the ACS.
A payor or payors would have to decide to reimburse for the services, an external source would have to provide the service for free e. In the latter case, the informants indicated that a strong "business case" would have to be made in favor of it and that this seemed unlikely at the present time. Further, many participants noted their difficulty in finding appropriate space for the ACS during the intervention, and they suspected that this would continue if they tried to sustain the intervention.
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Numerous providers and administrators reported a positive opinion about the CALM intervention and expressed that they would like to see CALM continue in their clinic. Many informants reported that, overall, the intervention increased their clinic's awareness of anxiety and that increased their desire to continue treating anxiety.
The clinics that already have a mental health provider or a collaborative-care program for another disorder felt more confident that sustaining CALM was possible or even probable in a minority of cases. This qualitative process evaluation found, in general, that the CALM collaborative-care intervention for multiple anxiety disorders was not overly burdensome to providers and staff, and it was relatively easy to incorporate into the clinics' routine.
Satisfaction with the intervention among these respondents was generally high. Primary care providers appreciated the additional referral source and the feedback they received from the ACS and psychiatrist. The majority of informants reported seeing moderate improvements in enough patients for them to find value in the intervention.
A majority of informants stated, without being prompted, they would like to see the intervention continue after the clinical effectiveness study was over. There were many important facilitators to implementation, perhaps the most important being positive attitudes about the intervention among providers buy-in. Providers who held a pre-existing belief in the importance of recognizing and treating mental health problems in primary care, who found the intervention nonburdensome, who perceived the ACS as visible and well-liked, who valued the feedback from the clinical team, and who observed positive patient outcomes especially reduced somatic complaints were those who most enthusiastically supported the intervention.
Other facilitators were a reliable and proximate location of the ACS's workspace, having the ACS work full-time in the clinic, "face time" for ACSs to interact frequently with providers, and the perception of a relatively high prevalence of anxiety among clinic patients. It is also possible that clinics with pre-existing mental health providers attracted a greater number of patients with anxiety disorders, and therefore, those clinics might have recognized a greater benefit of the intervention.
Numerous barriers to implementation were also found. First and foremost, it was clear that not all providers bought in to the intervention. Some were infrequent users of the intervention, and some never used it at all.