A call for digital inclusion initiatives in mental health services: An integrative review.

WHAT IS KNOWN ON THE SUBJECT?: Digital tools such as video calls or mobile phone applications (apps) are increasingly used in the provision of mental healthcare. There is evidence that people with mental health problems are more likely to face digital exclusion: that is, they do not have access to devices and/or skills to use technology. This leaves some people unable to use digital mental health services (e.g., apps or online appointments) or to benefit more generally from access to the digital world (e.g., online shopping or connecting with others virtually). People can be digitally included through initiatives that provide devices, Internet and digital mentoring to increase knowledge and confidence when using technology. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Some initiatives in academic studies and grey literature have been shown to increase access to and knowledge of technology, but this has been outside of mental health care settings. There are currently limited digital inclusion initiatives that take into consideration the specific needs of people with mental health problems, and how they can be equipped and familiarised with digital technologies to help their recovery journey and everyday life activities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further work is needed to improve the provision of digital tools in mental health care, with more practical digital inclusion initiatives to ensure equal access for all. If digital exclusion is not addressed, the gap between people with and those without digital skills or access to technology will continue to grow, enlarging mental health inequalities. INTRODUCTION: The rise in the provision of digital healthcare during the pandemic has called attention to digital exclusion: inequality in access and/or capacity to use digital technologies. Digital exclusion is more profound in people with mental health problems, leaving an implementation gap of digital practice in mental health services. Identify the available evidence of (a) addressing digital exclusion in mental health care and (b) the practical solutions to enhance uptake of digital mental health. Digital inclusion initiatives were searched from both academic and grey literature available and published between the years 2007 and 2021. A limited number of academic studies and initiatives were found that supported people with mental health difficulties who had limited skills and/or access to overcome digital exclusion. Further work is needed to combat digital exclusion and establish ways to reduce the implementation gap in mental health services. Access to devices, Internet connectivity and digital mentoring for mental health service users is essential. More studies and programmes are needed to disseminate impact and results for digital inclusion initiatives for people with mental health problems and to inform best practice for digital inclusion within mental health services.

Petrou C ，Jameel L ，Nahabedian N ，Kane F ... -  《-》

Do We Still Have a Digital Divide in Mental Health? A Five-Year Survey Follow-up.

Nearly everyone in society uses the Internet in one form or another. The Internet is heralded as an efficient way of providing mental health treatments and services. However, some people are still excluded from using Internet-enabled technology through lack of resources, skills, and confidence. Five years ago, we showed that people with severe mental illness were at risk of digital exclusion, especially middle-aged patients with psychosis and/or people from black or minority ethnic groups with psychosis. An understanding of the breadth of potential digital exclusion is vital for the implementation of digital health services. The aim of this study is to understand the context of digital exclusion for people who experience mental illness. We conducted a survey involving people with a primary diagnosis of psychosis or depression in London, United Kingdom. A total of 241 participants were recruited: 121 with psychosis and 120 with depression. The majority of surveys were collected face-to-face (psychosis: n=109; depression: n=71). Participants answered questions regarding familiarity, access, use, motivation, and confidence with Internet-enabled technologies (ie, computers and mobile phones). Variables predicting digital exclusion were identified in regression analyses. The results were compared with the survey conducted in 2011. Digital exclusion has declined since 2011. Online survey collection introduced biases into the sample, masking those who were likely to be excluded. Only 18.3% (20/109) of people with psychosis in our sample were digitally excluded, compared with 30% (28/93) in 2011 (χ21=3.8, P=.04). People with psychosis had less confidence in using the Internet than people with depression (χ21=7.4, P=.004). Only 9.9% (24/241) of participants in the total sample were digitally excluded, but the majority of these people had psychosis (n=20). Those with psychosis who were digitally excluded were significantly older than their included peers (t30=3.3, P=.002) and had used services for longer (t97=2.5, P=.02). Younger people were more likely to use mobile phones. Digitally excluded participants cited a lack of knowledge as a barrier to digital inclusion, and most wanted to use the Internet via computers (rather than mobile phones). Digital exclusion is lower, but some remain excluded. Facilitating inclusion among this population means helping them develop skills and confidence in using technology, and providing them with access. Providing mobile phones without basic information technology training may be counterproductive because excluded people may be excluded from mobile technology too. An evidence-based digital inclusion strategy is needed within the National Health Service to help digitally excluded populations access Internet-enabled services.

Robotham D ，Satkunanathan S ，Doughty L ，Wykes T ... -  《JOURNAL OF MEDICAL INTERNET RESEARCH》

Impact of Digital Inclusion Initiative to Facilitate Access to Mental Health Services: Service User Interview Study.

Digital exclusion, characterized by a lack of access to digital technology, connectivity, or digital skills, disproportionally affects marginalized groups. An important domain impacted by digital exclusion is access to health care. During COVID-19, health care services had to restrict face-to-face contact to limit the spread of the virus. The subsequent shift toward remote delivery of mental health care exacerbated the digital divide, with limited access to remote mental health care delivery. In response, Camden and Islington National Health Service Foundation Trust launched the innovative Digital Inclusion Scheme (DIS). This study aimed to examine the impact of facilitating digital inclusion in mental health access. Camden and Islington National Health Service Foundation Trust implemented the trust-wide DIS for service users who were digitally excluded, that is, were without devices or connectivity or reported poor digital skills. The scheme provided access to a loan digital device (a tablet), internet connectivity devices, and mobile data, as well as personalized digital skills support. The DIS went live in October 2021 and received 106 referrals by June 2022. Semistructured interviews were conducted with 12 service users to ask about their experience of accessing the DIS. A thematic analysis identified themes and subthemes relating to the extent of their digital exclusion before engaging with the scheme and the impact of accessing a scheme on their ability to engage with digital technology and well-being. There were 10 major themes. A total of 6 themes were related to factors impacting the engagement with the scheme, including digital exclusion, relationship to the trust, the importance of personalized digital support, partnership working, device usability and accessibility, and personal circumstances. The remaining 4 themes spoke to the impact of accessing the scheme, including improved access to services, impact on well-being, financial implications, and a greater sense of empowerment. Participants reported an increased reliance on technology driving the need for digital inclusion; however, differences in motivation for engaging with the scheme were noted, as well as potential barriers, including lack of awareness, disability, and age. Overall, the experience of accessing the DIS was reported as positive, with participants feeling supported to access the digital world. The consequences of engaging with the scheme included greater perceived access to and control of physical and mental health care, improved well-being, and a greater sense of empowerment. An overview of the lessons learned are provided along with suggestions for other health care settings that are looking to implement similar schemes.

Oliver A ，Chandler E ，Gillard JA 《JMIR Mental Health》

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. Rapid review of articles published between January 2000 and May 2020. We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km . We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Osborne SR ，Alston LV ，Bolton KA ，Whelan J ，Reeve E ，Wong Shee A ，Browne J ，Walker T ，Versace VL ，Allender S ，Nichols M ，Backholer K ，Goodwin N ，Lewis S ，Dalton H ，Prael G ，Curtin M ，Brooks R ，Verdon S ，Crockett J ，Hodgins G ，Walsh S ，Lyle DM ，Thompson SC ，Browne LJ ，Knight S ，Pit SW ，Jones M ，Gillam MH ，Leach MJ ，Gonzalez-Chica DA ，Muyambi K ，Eshetie T ，Tran K ，May E ，Lieschke G ，Parker V ，Smith A ，Hayes C ，Dunlop AJ ，Rajappa H ，White R ，Oakley P ，Holliday S ... -  《-》

School-based interventions for reducing disciplinary school exclusion: a systematic review.

This Campbell systematic review examines the impact of interventions to reduce exclusion from school. School exclusion, also known as suspension in some countries, is a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom (in-school) or on school premises (out-of-school). In some extreme cases the student is not allowed to come back to the same school (expulsion). The review summarises findings from 37 reports covering nine different types of intervention. Most studies were from the USA, and the remainder from the UK. Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included. The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear. School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion. Four intervention types - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution. There is no impact of the interventions on antisocial behaviour. Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention. Array Array

Valdebenito S ，Eisner M ，Farrington DP ，Ttofi MM ，Sutherland A ... -  《-》