Acceptability and suitability of tele-mental health

Although the suitability of tele-mental health for many groups is well documented [12–15], there has been a continued reluctance to engage in telehealth modalities, with face-to-face modalities considered by some to be superior to virtual [12–15]. Rural and remote youth, adults, and the mental health workforce acknowledge tele-mental health is an important complement to face-to-face services [16–18], and many young people with a mental illness living in rural and remote areas report that tele-mental health is acceptable and equivalent to in-person support [19]. Nevertheless, some still prefer to engage with face-to-face services, and these findings are consistent internationally [16–18, 20, 21]. Benefits of tele-mental health include reducing costs and travel times [16, 17, 19], convenience, shorter wait times [22], and anonymity, particularly for young people identifying as lesbian, gay, bisexual, transgender, queer, intersex, aromantic, asexual and other diverse genders and sexualities (LGBTQIA+) [16]. The perceived impersonal nature of tele-mental health, privacy concerns, and poor audio quality and internet connectivity are concerns for young people, adults, and clinicians delivering tele-mental health services alike [16, 17, 19, 22–25]. A recent systematic review of preferences of rural and remote youth for mental health service access was only able to identify four papers, two Australian, two Canadian, meeting search criteria. The review concluded “Whilst rural and remote youth may prefer to access mental health services in person rather than via telehealth, further well-designed research is needed to better understand under what circumstances this preference holds true and why” [21].

While telehealth has potential to reduce barriers and improve access to healthcare for vulnerable populations, there still remains inequity in telehealth accessibility, for example, those living in rural and remote areas generally have reduced access to reliable technological infrastructure and internet [7, 26, 27]. Some people may lack the requisite skills or equipment [28, 29], and tele-health may be less suitable for some groups. Some people with physical or cognitive disabilities may struggle to operate digital devices, and those with vision or hearing impairments or sensory sensitivities may struggle with digital communication [27, 29, 30], or need to rely on caregiver facilitation within sessions. Evidence on suitability of telehealth for people with autism spectrum disorder is mixed. While some people with autism spectrum disorder may experience challenges building rapport and understanding, and an exacerbation of traits and behaviours during tele-mental health sessions [23, 29], overall, research has demonstrated equal or better outcomes using telehealth compared with face-to-face care for this group [31]. Challenges such as distraction or disengagement have been found with children with disabilities or children who have experienced significant trauma [29,32], and some studies, such as those as outlined in Martiniuk, Toepfer and Lane-Brown’s review paper on risks and mitigation strategies for tele-mental health, have reported difficulties assessing and treating people experiencing a mental health crisis such as acute suicidality [33]. Without finding solutions to address these barriers, the Inverse Care Law–where vulnerable and disadvantaged populations require greater access to healthcare, but receive less–will be amplified [34]. More research is needed to determine whether strategies can be developed to improve the suitability of telehealth for these groups.

Mental health care navigation

Mental health care navigation models have been developed and trialled internationally [35–37]. Early findings are promising, however further research is needed to determine the effectiveness of these models and their various components [37]. Given the known barriers, described above, to accessing face-to-face mental health care for people living in rural and remote areas, an important gap in the existing mental health care navigation literature is whether care navigation can improve the perceived acceptability and suitability of telehealth for help-seekers. This research aims to address this critical gap in knowledge.

The Navicare model

In 2020 Wesley Research Institute engaged Queensland University of Technology’s Australian Centre for Health Services Innovation (AusHSI) to conduct a co-design process to develop a model of mental health care for the Bowen Basin region of rural and remote Queensland, Australia [4, 5]. Through a series of interviews with service providers and community representatives, and town hall-style workshops open to all interested parties including health consumers, Council, and service providers, the Isaac Navicare model was developed. Care navigation was supported by stakeholders from all groups, however the problem of “navigation to nowhere” was raised because there were insufficient local services to address the needs of the population. A strong theme in the context assessment was the need for the intervention to be local, and therefore stakeholders felt telehealth alone was not the answer. A layered care navigation model was developed, including a supported telehealth site and locally based care navigator. The supported telehealth facility includes a private consultation room with a computer and video camera that clients may use for their telehealth psychology appointments. A care navigator assists clients to access their sessions and can conduct a brief intervention with clients following their appointments if needed. Isaac Navicare commenced a 12-month pilot in November 2021 with a care navigator based at a youth and community centre located in Moranbah. The possibility of stigma related to a person’s attendance at a mental health service is minimised by co-locating Navicare with several other community support services and community programs such as a youth group, seniors’ activities, and neighbourhood centre program.

Setting

The Isaac region in Queensland’s Bowen Basin consists of predominantly rural, remote, and very remote communities and is characterised by a large mining and agricultural workforce, comprised of both resident and non-resident workers. Although widely-distanced, the many small communities across this region are close-knit. By necessity, the few existing local mental health services work collaboratively across the region to ensure continuity of care for help-seekers. Typically, drive-in-drive-out and fly-in-fly-out workforces are not included in government resource allocations and increase the population of these small local communities by up to 20%, leaving health services under-resourced [38].

Displacement from family and social networks due to workforce requirements and geographic isolation often results in a decline in mental health. Unique risk factors associated with the mining and agricultural industries compound mental health issues, increasing the risk of suicide [39–42]. Compared with other sectors in Queensland, mining and construction employees are 1.72 times more likely to die by suicide [43] and agricultural employees are 2.3 times more likely to die by suicide [40]. Limited access to mental health support services in rural and remote areas likely contributes to the increase in deliberate self-harm and suicides. Notwithstanding these challenges, Isaac locals value the strong community spirit and sense of connectedness within towns and across the broader community.

Isaac Navicare pilot

Isaac Navicare aims to improve access to timely and clinically appropriate mental health services for people living in the Isaac region who require mental health supports by: (1) Supporting service users to navigate the mental health system by identifying an appropriate and affordable mental health service to meet the user’s clinical needs and individual preferences; (2) Reducing waiting time for access to mental health care; (3) Providing a supportive entry point to the mental health system. Engagement with local stakeholders commenced from September 2021. Although the official opening date was November 9, referrals commenced as soon as local providers were aware of the service. Within six months, the high volume of referrals had the service operating at capacity. A second care navigator commenced in December 2022, shortly after the one-year evaluation period ended. Local mental health options are extremely limited, thus it was necessary for the care navigator to find alternative options to avoid “navigation to nowhere.”

Relationships were developed with several telehealth and drive-in-drive-out mental health services to enable care navigators to complete referrals directly to their services on behalf of GPs, circumventing the need to send clients back to their doctor to complete the necessary referral paperwork. Furthermore, due to the large client cohort who were unemployed or on a pension or concession of some kind, it was necessary to identify low gap fee and bulk billed counselling and psychology options.

Aims

This research aimed to: (1) Determine the reach and effectiveness of the Isaac Navicare service in supporting people with mental health concerns to access appropriate mental health services; (2) Identify the model’s strengths and limitations; (3) identify adaptations that would improve the acceptability, fit and sustainability of the model.

Design

Ethical approval was granted by UnitingCare Queensland Human Research Ethics Committee (Fisher_20220926), which included the database review, survey and interview. The research design was based on the RE-AIM Framework [44, 45], an implementation science framework focusing on Reach, Effectiveness, Adoption, Implementation and Maintenance. The RE-AIM framework is well suited to the present research as it is a widely used and understood conceptualisation which allows the identification of components of a care delivery model that are effective and those which require adaptation. A strength is a focus on generalisability to other settings and populations [44].

Data were gathered by: (1) Database review; (2) A survey of service users; (3) Interviews with service users. This research related to the pilot phase of the Isaac Navicare service from 9 November 2021 to 8 November 2022, and focuses on the service only, not individual mental health outcomes. Database records for all clients who contacted the service during the pilot phase were included in the study. The service user survey included a modified version of the Navigation Satisfaction Tool (NAVSAT) [46]. To our knowledge, the NAVSAT is the only known validated tool for evaluating service user’s satisfaction with care navigation.

The primary outcomes of interest were the reach (number of users, clinical and demographic characteristics) and effectiveness of the service (whether the service user was able to access an appropriate and timely mental health service). Secondary outcomes were adoption, implementation, and adaptations needed to improve sustainability. Queensland University of Technology is conducting a separate study known as The Bridging Study to expand and evaluate Navicare in additional areas of Queensland. This pilot evaluation, led by Wesley Research Institute, was conducted prior to data collection commencing for The Bridging Study and is separate to The Bridging Study led by Queensland University of Technology.

Participants and recruitment

Isaac Navicare is available to all Isaac area residents and people who work in the Isaac area who are seeking mental health support for themselves or someone else, therefore there were no restrictions on eligibility for the service. Eligible participants were people over the age of 18 who engaged with the Isaac Navicare service during the pilot period to obtain support for themselves or for a child or family member. Survey and interview data collection was conducted between December 2022 and March 2023. Potential participants were contacted by email in December 2022 and invited to participate in a 15-minute online survey canvassing levels of satisfaction, helpfulness, and effectiveness as well as waiting times. At the completion of the survey, participants were invited to enter contact details for participation in a follow-up interview (S1 File A–Interview Guide). Clients who received a routine check-in call from care navigators were also informed about the study. Interviews were conducted by OF via phone or online meeting according to participant preference. Participants were invited to share further reflections within two weeks of the interview via phone, video conference or email. Exclusion criteria were service users who: were not able to participate in an interview, for example due to health reasons or intellectual impairment; were under 18 years of age; or had previously stated that they did not wish to be contacted. Interviews were conducted between December 2022 and March 2023.

Analyses

Demographic data were analysed descriptively. Interview transcripts were double coded to the RE-AIM Framework by OF and CG and were analysed using a combined deductive-inductive framework analysis approach [47]. Initial codes were derived from the RE-AIM framework and the research questions, and additional codes were derived inductively. This approach is commonly used in qualitative implementation science research as it allows for a rapid but robust coding process [48]. Trustworthiness was maintained through regular discussion between coders to ensure consistency. Additionally, CL-C acted an external researcher and reliability checker experienced in qualitative analysis, with no role in the development or delivery of the program. CL-C reviewed a sample of four transcripts and the aggregated quantitative data, and in discussion with OF, KM and CG confirmed the overall results. To further guard against researcher bias, qualitative data were triangulated with quantitative data.

Participants and recruitment

Of the 197 people who engaged with Isaac Navicare during the pilot, 23 people were not sent the survey due to: age (minor, n = 8); non-consent to be contacted (n = 4); missing contact details (n = 1); intellectual impairment (n = 3); and people who were referred to the service but did not respond to attempts to contact (n = 7). Duplicate emails (n = 11) were removed, e.g., one parent was the contact person for multiple children. In total, 155 emails and 8 text messages were sent in December 2022, with a reminder email/text in January 2023. Eight emails were “undeliverable” so where possible these participants were sent an SMS (n = 7), resulting in 162 invitations. In total, 11 survey responses were received, a response rate of 6.8%. Six survey participants also participated in an interview, with a further five interview participants recruited through routine follow-up by the care navigator. Given the low survey response rate, survey results are not presented, and the findings were only used to confirm and provide context to the database records and interview data. Service user interviews (n = 11) were conducted by phone (n = 10) or Teams (n = 1) between December 2022 and March 2023. Interview duration was between 12 and 41 minutes. All interview participants were referred to Isaac Navicare through general practitioners or school guidance officers. No interview participants took up the offer of sharing a reflection in the two weeks following their interview. All interview participants reported that they had been referred to Isaac Navicare by a local provider such as a general practitioner or a school guidance officer. Five participants had received support for themselves, four as the parent of a child requiring mental health support, and two participants had received support for both themselves and one or more children. All participants were Bowen Basin residents at the time they were referred to Isaac Navicare.

Reach

Between 25 October 2021 and 8 November 2022, 197 people (128 adults and 69 minors under 18 years of age) were referred to Isaac Navicare. Demographic characteristics are presented in Table 1. Although the service officially launched on 9 November 2021, service providers began referring clients prior to the launch as soon as they were aware of the service (n = 4). On intake, 48.4% of adult clients were unemployed. Furthermore, 37.5% of adults and 37.7% of minors had a government concession card, i.e., disability, aged, low income, or carer’s pension card. Interview participants reported that they felt some groups within the community, particularly young people, were missing out on being able to access mental health supports. There was strong agreement that the Isaac community was largely unaware of Isaac Navicare, limiting the potential client pool.

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Table 1. Demographic characteristics of persons who engaged with Isaac Navicare.

https://doi.org/10.1371/journal.pone.0298655.t001

Effectiveness

Suitability of recommended services.

In total, 276 referrals were made by the care navigator, primarily for mental health treatment (psychology, counselling or social work) as presented in Table 2. Some clients had multiple referrals, the maximum being 13 (Table 2). Conversely, some of the clients in the “did not refer” category had multiple contacts with a care navigator to discuss options, without proceeding to referral, either for mental health or wrap-around support services.

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Table 2. Referrals in and out of Navicare.

https://doi.org/10.1371/journal.pone.0298655.t002

Of the interview participants, 90.9% (n = 10) stated that the service they were referred to was appropriate for their needs, or that they were able to try another service until they found one that was appropriate. One participant had not been able to make an appointment. Another participant acknowledged how the rapport between her daughter and the psychologist was hard to establish and so looked for a more suitable match:

My daughter had a lot of problems, so she can’t seem to connect with any psychologist, but [care navigator] was always offering to pick a different one. (Parent)

Treatment modality.

Preferred treatment modalities are presented in Table 3. A preference for face-to-face sessions was expressed by 111 (56.3%) clients. Nevertheless, of the 156 clients referred for mental health treatment, most referrals (n = 108, 69.2% of mental health referrals) were made for video or phone telehealth due to a lack of suitable local providers and long waiting lists (Table 3). Of note, 42.6% of clients (n = 84) had access to a free Employee Assistance Program (EAP) psychology or counselling service through their workplace, or parents’ workplace for minors, however only 4 clients (4.8% of those with EAP) chose to use the EAP service. Reasons for declining EAP were: insufficient sessions (n = 33); lack of specialists (n = 27); privacy concerns (n = 22); previous experience with EAP was not helpful (n = 14); long travel time (n = 1); long wait time (n = 1); and access to Workcover (n = 1).

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Table 3. Mental health treatment modality–preferred versus referral made.

https://doi.org/10.1371/journal.pone.0298655.t003

Notably, 4.6% of Navicare clients did not receive a referral to any mental health support services and were referred to wrap-around support services only. The people in this group reported that they were experiencing poor mental due to situational stressors. When Navicare completed referrals for the wrap-around support services relevant to each client’s needs, the immediate mental health toll was relieved, and these individuals stated that they no longer felt the need to speak with a mental health practitioner.

Adoption

In total, 206 referrals were received for 197 clients as presented in Table 2. Nine clients were referred to Navicare by two different service providers. In each instance one was from a GP. Only 24 (11.7%) referrals were self/family or website referrals, and the remaining 88.3% were from local health or community service providers or schools.

Implementation

Having a local navigator was regarded as important by interview participants, even though some had not met the navigator face-to-face. Participants particularly valued the care navigator’s detailed knowledge of local providers and challenges. Interview participants were not aware of the supported tele-health site. Nevertheless, five clients were referred to this service. Ten interview participants said the site was a good idea and they could think of people who would use it. They had not used it themselves due to distance, appropriate set up at home, or ability to access local face-to-face services. Some participants could not identify the difference between the care navigation service and mental health service providers, with some believing them to be one and the same.

Maintenance: Adaptations and sustainability

Interview participants described a lack of awareness of Isaac Navicare in the local community, and recommended promotion of the service directly to the community, not just to service providers. Participants felt strongly that the service needed to be expanded to other townships in the Bowen Basin region to increase accessibility. Further, the service was quickly operating at capacity which indicates the need for and success of the pilot but also the need for more care navigators.