Mental Health, Rural Health, Veterans Health
Conditions
Keywords
Mental Health, Veterans Health, Rural, Motivational Interviewing
Brief summary
The purpose of this study is to investigate health problems among rural Veterans. The research project also aims to test a new telephone-based approach for helping Veterans who need treatment connect with the appropriate care. This study will help us to better understand the kinds of problems Veterans experience. The study will also help us to find better ways to help Veterans get the help they may need.
Detailed description
Project Background: One in five Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) Veterans resides in rural areas and primarily receives care from VA Community-Based Outpatient Clinics (CBOCs). Compared to their urban counterparts, rural Veterans experience a significantly greater MH burden and poorer outcomes. Nevertheless, less than 10% of OEF/OIF/OND Veterans with a new PTSD diagnosis attend a minimum number of sessions required for evidence-based treatment, with rurality being one of the strongest predictors of poor engagement. The investigators' pilot study in urban OEF/OIF/OND Veterans demonstrated that telephone Motivational Interviewing (MI) delivered by research staff significantly improved MH treatment initiation and retention in care. However, the investigators do not know whether telephone MI will have as strong an effect on MH treatment engagement when implemented by VA staff in CBOCs serving rural Veterans. Project Objectives: As a part of the Center for Mental Healthcare and Outcomes Research (CeMOHR) CREATE application to improve rural Veterans' access to evidence-based mental healthcare, the overall goal of this project is to adapt, implement and test an MI-based coaching intervention to improve MH services engagement at CBOCs serving rural Veterans. The specific aims of this project are: (1) Conduct a developmental formative evaluation of perceived barriers to MH treatment engagement and adapt the MI-based treatment engagement intervention and implementation strategy to the needs of stakeholders; (2) Conduct a randomized multi-site pragmatic effectiveness trial comparing MH Referral alone with MH Referral plus MI-based coaching; and (3) Conduct an implementation-focused formative evaluation and use this information to make mid-course corrections to the implementation strategy based on stakeholder and key informant input. Methods: The investigators will conduct the pragmatic effectiveness trial of the telephone motivational coaching intervention to determine whether, in comparison to MH Referral alone, telephone MI coaching improves MH treatment initiation and retention, the use of e-health MH resources, and perceived need and readiness for and access to MH treatment among rural Veterans who use CBOCs (Aim 2). Impact: This research will help close the knowledge gap about barriers to care and preferences for MH services among rural Veterans. In addition, information from this project will be used to develop implementation toolkits for MH treatment engagement interventions for rural Veterans. Finally, this project will determine the effectiveness of a telephone Motivational Interviewing engagement intervention using e-health adjuncts, thereby filling a gap in the scientific literature about whether novel interventions can be used by VA staff in CBOCs to overcome rural-urban disparities in MH treatment engagement.
Interventions
BEHAVIORALMotivational Coaching
Telephone-based Motivational Interviewing aimed at getting Veterans to engage or retain mental health treatment
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
DOUBLE (Subject, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* a Veteran over age 18 * a resident of VISN 16 or 21 catchment areas receiving care at a CBOC with no plans to re-locate within 8 months of enrollment * positive for 1 or more of the following disorders: PTSD, depression, generalized anxiety disorder, panic disorder, high-risk drinking, and/or illicit substance use
Exclusion criteria
* hearing- impaired, * no working telephone, * Veterans with self-reported (and/or CPRS-confirmed) diagnoses of schizophrenia, psychosis or bipolar disorder, or active suicidality or homicidality * received mental health treatment within the last 60 days and/or has future appointments for mental health treatment in the next 30 days
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Mental Health (MH) Treatment Engagement | 26 months | Motivational Coaching (vs. Control) on MH treatment initiation. This will be measured by self-report and by checking the subjects medical record. The investigators will adjust by clustering for CBOC and region as well as potential confounding by other covariates |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mental Health (MH) Treatment Retention | 26 months | Motivational Coaching (vs. Control) on MH treatment retention. This will be measured by self-report and by checking the subjects medical record. The investigators will adjust by clustering for CBOC and region as well as potential confounding by other covariates |
Other
| Measure | Time frame | Description |
|---|---|---|
| Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | 26 months | Depression, anxiety, panic, PTSD, tobacco, alcohol, cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogen, opioid, and QOL domains: physical health, psychological health, social relationships, and environment. Ranges of scores: depression: 0-27, anxiety: 0-4, panic: 0-4, PTSD: PTSD: 0-80., tobacco: 0-31, alcohol: 0-39, cannabis use: 0-39, cocaine: 0-39, amphetamine: 0-39, inhalants: 0-39, sedatives: 0-39, hallucinogen: 0-39, opioid: 0-39, QOL physical health: 4-20, QOL psychological health: 4-20, QOL social relationships: 4-20, QOL environment: 4-20. Higher scores mean worse outcomes for mental health symptoms and substance use scores; higher scores mean worse outcomes for quality of life measures. |
| Self-care Activities | 26 months | Five types of self-care activities to relieve stress: internet or mobile applications, community groups (church groups, gun clubs), community classes (Yoga, cooking), alternative treatments (acupuncture, chiropractor, massage), and other self-care activities (meditation, fishing, walking). |
Countries
United States
Participant flow
Recruitment details
(1) CBOC providers will refer veterans; (2) VA administrative data will be used to identify veterans; (3) veteran self-referral; (4) snowball sampling
Pre-assignment details
Baseline assessment was used to determine mental health eligibility. Those who did not score high enough on mental health symptoms AND/OR had recently had recently had a mental health visit and/or a schedule mental health visit were excluded.
Participants by arm
| Arm | Count |
|---|---|
| Motivational Coaching Telephone based Motivational Coaching sessions
Motivational Coaching: Telephone-based Motivational Interviewing aimed at getting Veterans to engage or retain mental health treatment | 140 |
| Referral Alone This is the current standard of care | 140 |
| Total | 280 |
Baseline characteristics
| Characteristic | Motivational Coaching | Referral Alone | Total |
|---|---|---|---|
| Age, Continuous | 50.1 years STANDARD_DEVIATION 13.1 | 51.2 years STANDARD_DEVIATION 13.8 | 50.7 years STANDARD_DEVIATION 13.4 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 7 Participants | 13 Participants | 20 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 131 Participants | 127 Participants | 258 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 1 Participants | 0 Participants | 1 Participants |
| Mental Health Treatment Experiences in the last 5 years Counseling by chaplain or other religious person | 6 Participants | 10 Participants | 16 Participants |
| Mental Health Treatment Experiences in the last 5 years Counseling by Social Worker | 19 Participants | 18 Participants | 37 Participants |
| Mental Health Treatment Experiences in the last 5 years Inpatient Psychiatric Treatment | 5 Participants | 5 Participants | 10 Participants |
| Mental Health Treatment Experiences in the last 5 years Internet/Mobile Application treatment program/supp | 9 Participants | 10 Participants | 19 Participants |
| Mental Health Treatment Experiences in the last 5 years Marital, relationship or family counseling | 13 Participants | 8 Participants | 21 Participants |
| Mental Health Treatment Experiences in the last 5 years Mental Health- Individual or Group Counseling | 73 Participants | 76 Participants | 149 Participants |
| Mental Health Treatment Experiences in the last 5 years Primary Care | 50 Participants | 43 Participants | 93 Participants |
| Mental Health Treatment Experiences in the last 5 years Psychiatric medication | 81 Participants | 85 Participants | 166 Participants |
| Mental Health Treatment Experiences in the last 5 years Research study | 7 Participants | 4 Participants | 11 Participants |
| Mental Health Treatment Experiences in the last 5 years Self-help group | 10 Participants | 5 Participants | 15 Participants |
| Mental Health Treatment Experiences in the last 5 years Substance Abuse Treatment | 8 Participants | 12 Participants | 20 Participants |
| Mental Health Treatment Experiences in the last 5 years Telephone counseling program | 10 Participants | 16 Participants | 26 Participants |
| PCL-5 | 25.0 units on a scale STANDARD_DEVIATION 19 | 27.6 units on a scale STANDARD_DEVIATION 18.1 | 26.3 units on a scale STANDARD_DEVIATION 18.6 |
| Race (NIH/OMB) American Indian or Alaska Native | 5 Participants | 3 Participants | 8 Participants |
| Race (NIH/OMB) Asian | 2 Participants | 0 Participants | 2 Participants |
| Race (NIH/OMB) Black or African American | 28 Participants | 36 Participants | 64 Participants |
| Race (NIH/OMB) More than one race | 8 Participants | 9 Participants | 17 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 1 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 8 Participants | 15 Participants | 23 Participants |
| Race (NIH/OMB) White | 87 Participants | 76 Participants | 163 Participants |
| Readiness Ruler: Assessment of Motivation for Treatment How confident are you that you would get treatment | 5.9 units on a scale STANDARD_DEVIATION 3.4 | 6.4 units on a scale STANDARD_DEVIATION 3.3 | 6.1 units on a scale STANDARD_DEVIATION 3.4 |
| Readiness Ruler: Assessment of Motivation for Treatment How important is it for you to receive treatment r | 5.2 units on a scale STANDARD_DEVIATION 3.1 | 5.9 units on a scale STANDARD_DEVIATION 3.5 | 5.5 units on a scale STANDARD_DEVIATION 3.3 |
| Readiness Ruler: Assessment of Motivation for Treatment How ready are you to receive treatment right now f | 6.2 units on a scale STANDARD_DEVIATION 3.3 | 6.9 units on a scale STANDARD_DEVIATION 3.4 | 6.6 units on a scale STANDARD_DEVIATION 3.4 |
| Region of Enrollment United States | 139 Participants | 140 Participants | 279 Participants |
| Severity Measure for Depression-Adult (PHQ-9) | 11.3 units on a scale STANDARD_DEVIATION 6.1 | 12.2 units on a scale STANDARD_DEVIATION 5.9 | 11.8 units on a scale STANDARD_DEVIATION 6 |
| Severity Measure for Generalized Anxiety Disorder-Adult | 1.5 units on a scale STANDARD_DEVIATION 0.9 | 1.5 units on a scale STANDARD_DEVIATION 0.9 | 1.5 units on a scale STANDARD_DEVIATION 0.9 |
| Severity Measure for Panic Disorder-Adult | 0.8 units on a scale STANDARD_DEVIATION 1 | 0.9 units on a scale STANDARD_DEVIATION 1 | 0.8 units on a scale STANDARD_DEVIATION 1 |
| Sex: Female, Male Female | 27 Participants | 17 Participants | 44 Participants |
| Sex: Female, Male Male | 112 Participants | 123 Participants | 235 Participants |
| WHO - ASSIST V3 Alcohol | 7.8 units on a scale STANDARD_DEVIATION 8.4 | 7.6 units on a scale STANDARD_DEVIATION 8.7 | 7.7 units on a scale STANDARD_DEVIATION 8.5 |
| WHO - ASSIST V3 Amphetamine | 0.2 units on a scale STANDARD_DEVIATION 0.9 | 0.5 units on a scale STANDARD_DEVIATION 1.6 | 0.4 units on a scale STANDARD_DEVIATION 1.3 |
| WHO - ASSIST V3 Cannabis | 3.2 units on a scale STANDARD_DEVIATION 4.8 | 3.5 units on a scale STANDARD_DEVIATION 6 | 3.3 units on a scale STANDARD_DEVIATION 5.4 |
| WHO - ASSIST V3 Cocaine | 0.5 units on a scale STANDARD_DEVIATION 2.5 | 0.8 units on a scale STANDARD_DEVIATION 3.3 | 0.7 units on a scale STANDARD_DEVIATION 2.9 |
| WHO - ASSIST V3 Hallucinogens | 0.1 units on a scale STANDARD_DEVIATION 0.4 | 0.2 units on a scale STANDARD_DEVIATION 0.6 | 0.1 units on a scale STANDARD_DEVIATION 0.5 |
| WHO - ASSIST V3 Inhalants | 0.01 units on a scale STANDARD_DEVIATION 0.2 | 0.2 units on a scale STANDARD_DEVIATION 1.6 | 0.1 units on a scale STANDARD_DEVIATION 1.1 |
| WHO - ASSIST V3 Opioids | 0.2 units on a scale STANDARD_DEVIATION 2.5 | 0.9 units on a scale STANDARD_DEVIATION 4 | 0.6 units on a scale STANDARD_DEVIATION 3.3 |
| WHO - ASSIST V3 Sedatives | 0.8 units on a scale STANDARD_DEVIATION 4.1 | 0.4 units on a scale STANDARD_DEVIATION 2.1 | 0.6 units on a scale STANDARD_DEVIATION 3.3 |
| WHO - ASSIST V3 Tobacco | 8.6 units on a scale STANDARD_DEVIATION 9.9 | 8.3 units on a scale STANDARD_DEVIATION 9.9 | 8.5 units on a scale STANDARD_DEVIATION 9.9 |
| WHOQOL-BREF Environment | 14.6 units on a scale STANDARD_DEVIATION 2.9 | 14.1 units on a scale STANDARD_DEVIATION 2.9 | 14.3 units on a scale STANDARD_DEVIATION 2.9 |
| WHOQOL-BREF Physical Health | 12.0 units on a scale STANDARD_DEVIATION 3.7 | 11.9 units on a scale STANDARD_DEVIATION 3.3 | 12.0 units on a scale STANDARD_DEVIATION 3.5 |
| WHOQOL-BREF Psychological Health | 13.3 units on a scale STANDARD_DEVIATION 3.1 | 12.9 units on a scale STANDARD_DEVIATION 2.6 | 13.1 units on a scale STANDARD_DEVIATION 2.8 |
| WHOQOL-BREF Social Relationships | 13.0 units on a scale STANDARD_DEVIATION 4.2 | 12.7 units on a scale STANDARD_DEVIATION 4 | 12.8 units on a scale STANDARD_DEVIATION 4.1 |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 140 | 0 / 140 |
| other Total, other adverse events | 4 / 140 | 2 / 140 |
| serious Total, serious adverse events | 3 / 140 | 2 / 140 |
Outcome results
Primary
Mental Health (MH) Treatment Engagement
Motivational Coaching (vs. Control) on MH treatment initiation. This will be measured by self-report and by checking the subjects medical record. The investigators will adjust by clustering for CBOC and region as well as potential confounding by other covariates
Time frame: 26 months
Population: Including 272 patients who provided primary outcome data (excluding those who withdrew).
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Motivational Coaching | Mental Health (MH) Treatment Engagement | 78 Participants |
| Referral Alone | Mental Health (MH) Treatment Engagement | 74 Participants |
Comparison: Compare 2 groups in regard to time to first mental health treatment using Cox proportional hazards regression.p-value: 0.6695% CI: [0.81, 1.58]Regression, Cox
Secondary
Mental Health (MH) Treatment Retention
Motivational Coaching (vs. Control) on MH treatment retention. This will be measured by self-report and by checking the subjects medical record. The investigators will adjust by clustering for CBOC and region as well as potential confounding by other covariates
Time frame: 26 months
Population: Including patients who provided primary outcome data.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Motivational Coaching | Mental Health (MH) Treatment Retention | 67 Participants |
| Referral Alone | Mental Health (MH) Treatment Retention | 62 Participants |
Other Pre-specified
Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures.
Depression, anxiety, panic, PTSD, tobacco, alcohol, cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogen, opioid, and QOL domains: physical health, psychological health, social relationships, and environment. Ranges of scores: depression: 0-27, anxiety: 0-4, panic: 0-4, PTSD: PTSD: 0-80., tobacco: 0-31, alcohol: 0-39, cannabis use: 0-39, cocaine: 0-39, amphetamine: 0-39, inhalants: 0-39, sedatives: 0-39, hallucinogen: 0-39, opioid: 0-39, QOL physical health: 4-20, QOL psychological health: 4-20, QOL social relationships: 4-20, QOL environment: 4-20. Higher scores mean worse outcomes for mental health symptoms and substance use scores; higher scores mean worse outcomes for quality of life measures.
Time frame: 26 months
Population: Including patients who reported mental health symptoms, substance use, and quality of life.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | tobacco | 8.8 score on a scale | Standard Deviation 9.5 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | inhalants | 0 score on a scale | Standard Deviation 0 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | panic | 0.6 score on a scale | Standard Deviation 0.9 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | sedatives | 0.5 score on a scale | Standard Deviation 2.9 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | alcohol | 7.1 score on a scale | Standard Deviation 7.7 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | halluninogens | 0.2 score on a scale | Standard Deviation 1.1 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | anxiety | 1.2 score on a scale | Standard Deviation 0.9 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | opioid | 0.5 score on a scale | Standard Deviation 2.7 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | cannabis | 3.1 score on a scale | Standard Deviation 4.8 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL physical health domain | 12.6 score on a scale | Standard Deviation 3.7 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | PTSD | 25.1 score on a scale | Standard Deviation 18.4 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL psychological health domain | 13.4 score on a scale | Standard Deviation 2.8 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | cocaine | 0.7 score on a scale | Standard Deviation 2.9 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL social relationships domain | 13.3 score on a scale | Standard Deviation 3.9 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | depression | 9.4 score on a scale | Standard Deviation 6.2 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL environment domain | 14.4 score on a scale | Standard Deviation 2.5 |
| Motivational Coaching | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | amphetamine | 0.3 score on a scale | Standard Deviation 1.6 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL environment domain | 13.6 score on a scale | Standard Deviation 2.6 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | depression | 11.1 score on a scale | Standard Deviation 6.5 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | anxiety | 1.3 score on a scale | Standard Deviation 0.8 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | panic | 0.7 score on a scale | Standard Deviation 0.9 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | PTSD | 29.7 score on a scale | Standard Deviation 16.7 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | tobacco | 9.2 score on a scale | Standard Deviation 10 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | alcohol | 7.7 score on a scale | Standard Deviation 8.6 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | cannabis | 4.6 score on a scale | Standard Deviation 6.7 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | cocaine | 0.9 score on a scale | Standard Deviation 2.5 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | amphetamine | 0.7 score on a scale | Standard Deviation 2.5 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | inhalants | 0.2 score on a scale | Standard Deviation 1.4 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | sedatives | 0.8 score on a scale | Standard Deviation 3.1 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | halluninogens | 0.2 score on a scale | Standard Deviation 0.8 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | opioid | 0.9 score on a scale | Standard Deviation 3.8 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL physical health domain | 12.0 score on a scale | Standard Deviation 3.1 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL psychological health domain | 12.7 score on a scale | Standard Deviation 2.5 |
| Referral Alone | Mental Health Symptoms, Substance Use Scores and Quality of Life (QOL) Measures. | QOL social relationships domain | 12.1 score on a scale | Standard Deviation 3.8 |
Other Pre-specified
Self-care Activities
Five types of self-care activities to relieve stress: internet or mobile applications, community groups (church groups, gun clubs), community classes (Yoga, cooking), alternative treatments (acupuncture, chiropractor, massage), and other self-care activities (meditation, fishing, walking).
Time frame: 26 months
Population: Including participants who responded to survey questions during follow-up.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Motivational Coaching | Self-care Activities | Community groups | 59 Participants |
| Motivational Coaching | Self-care Activities | Alternative treatments | 40 Participants |
| Motivational Coaching | Self-care Activities | Community classes | 31 Participants |
| Motivational Coaching | Self-care Activities | Self-care activities | 111 Participants |
| Motivational Coaching | Self-care Activities | Internet or mobile applications | 84 Participants |
| Referral Alone | Self-care Activities | Self-care activities | 109 Participants |
| Referral Alone | Self-care Activities | Internet or mobile applications | 63 Participants |
| Referral Alone | Self-care Activities | Community groups | 52 Participants |
| Referral Alone | Self-care Activities | Community classes | 16 Participants |
| Referral Alone | Self-care Activities | Alternative treatments | 38 Participants |