Telehealth treatment engagement with Latinx populations during the COVID-19 pandemic

The mental health burden associated with the COVID-19 global pandemic is undeniable, and the psychological and emotional sequelae from the multiple losses might remain invisible for years to come. Among susceptible populations, Latinxs are at increased risk of contracting and spreading the virus, as a result of residing in densely populated areas, large representation in critical industries (eg, meat-packing plants, health care, factories), and underlying health conditions.¹ At the same time, Latinxs differ from other racial and ethnic communities in their attitudes towards obtaining physical and behavioural health services in response to the COVID-19 pandemic. Due to fear of deportation, privacy concerns, and distrust resulting from a history of xenophobia in the USA, Latinxs, especially those among the undocumented and non-citizen community, are more hesitant to trust medical and mental health professionals, engage in treatment, or embrace the use of technology as a method of service delivery.2, 3, 4

Data from the 2018 National Survey on Drug Use and Health⁵ revealed that nearly 40% of Latinx adults between 26 and 49 years of age with serious and persistent mental illness did not receive necessary treatment. Despite the noted susceptibility, even when care is available, Latinx individuals are more likely to prematurely drop out of treatment and report dissatisfaction with available care than White Americans.⁶ The development, promotion, and dissemination of culturally and linguistically congruent treatments has been identified as one way of addressing the treatment gap. Prior to COVID-19, the use of technology and telehealth interventions had been suggested as one possible response.⁷ Data from the Pew Research Center show that Latinxs use technology at similar rates to other groups in the USA.⁸ For example, smartphone use is at 79%, compared with 82% for the White community and 80% for the Black community. Despite this finding, there are multiple factors that might make the transition to telehealth stressful, such as living situations that include insufficient space or privacy at home and restricted access to internet data, Wi-Fi, or a large enough viewing screen. One therapeutic intervention that can offer support in the transition from office-based treatment to telehealth is motivational interviewing, a collaborative conversation style for strengthening a person's own motivation and commitment to change.⁹ Appropriate use of the relational (ie, collaboration, acceptance, compassion, and evocation) and technical (ie, open questions, affirmations, reflections, and summary statements) elements of motivational interviewing can go a long way in developing the necessary foundation to support telehealth interventions. We propose the use of T-HOLA (the word hola means hello in Spanish), an acronym designed to offer practical guidance to providers engaging Latinx patients in telehealth interventions through the application of motivational interviewing skills and consideration of cultural values: (1) orient to Telehealth; (2) engage in Health education; (3) provide Options; (4) utilise active Listening skills; and (5) assess Adherence to cultural values. See the panel for a detailed summary of the T-HOLA framework.

Panel. T-HOLA: telehealth engagement considerations with Latinx patients.

T: orient to telehealth

An initial step is to provide the patient with an orientation to the telehealth platform. A strategy consistent with motivational interviewing that can be used is the elicit-provide-elicit technique, in which the clinician first elicits from the patient their understanding of telehealth. With permission, the clinician provides the necessary information to fill in the blanks, and then ends by making sure the patient understands the information or by asking the patient for their assessment of or reaction to that information.⁹ Additionally, the clinician can concretely provide the patient with technical assistance in how to set up their phone, tablet, or computer and connect via telehealth.

H: engage in health education

The elicit-provide-elicit technique allows the clinician to present information in a collaborative fashion. For example, information about the importance of wearing a face mask in public, frequent handwashing, physical distancing, and the need to seek immediate medical attention if symptoms develop. The use of open-ended questions to inquire about precautions (eg, when at work, what steps do you take to keep yourself safe?) and affirmations to reinforce efforts the patient is making to protect themselves and people around them (eg, you love your family and are taking the proper steps to keep everyone in the home safe) can help to address misunderstandings and misconceptions.

O: provide options

Clinicians can further strengthen the collaborative relationship and support the patient's sense of autonomy by providing options as to their preferred method of communication. For patients who express ambivalence about engaging with their clinician via technology, the clinician might be able to affirm the patient's past efforts and successes in using such mediums as Facetime, WhatsApp, Facebook, and other apps to communicate with family and friends.

L: use active listening skills

Active listening encompasses effortful practice in attempting to perceive the meaning behind someone's words and in working towards empathic understanding. However, a number of communication roadblocks and traps exist that only serve to undercut the therapeutic alliance.⁹ A clinician making a purposeful effort to listen to what the patient is saying will be in a better position to engage in strategic open questions and reflections.

A: assess adherence to cultural values

To maximise engagement early on, integrating an assessment of cultural values might facilitate the therapeutic alliance and help manage ambivalence.¹⁰ Personalismo refers to the extent to which an individual wants to maintain harmonious relationships with others. From a clinical standpoint, the patient might prefer interpersonal contact that focuses on getting to know the clinician as an individual. For example, spending some time engaging in small talk can show the patient that the clinician sees the individual holistically and not just in the context of a set of presenting problems. Respeto refers to the degree to which one shows respect and mutual deference. This cultural value is often influenced by a patient's gender, age, and generational status. Finally, confianza refers to a sense of trust and intimacy within an interpersonal relationship and is considered an essential component in psychotherapy. In working with an existing patient in the clinic who is hesitant to transition to telehealth, it might be the confianza that has been established that encourages the patient to take the leap and try it out. In assessing the degree to which these cultural values are of significance to the patient, the appropriate application of evocative open questions and reflections communicated in a manner that highlights acceptance and compassion is key.

COVID-19 has forced many health and behavioural health professionals to expand beyond their comfort zone and engage in telehealth as a primary means of patient care. Parallel to the learning curve for providers has been the learning curve for patients as they navigate a new reality of engaging with the members of their clinical team through telephone, video, and internet-based platforms. Despite the potential for greater access to care for Latinx communities, the consequences of long-standing mistrust, stigma, and an existing ambivalence towards mental health treatment need to be considered. Interventions that appeal to an individual's valued role in their community (eg, as a provider or family member) might engage and retain a patient in services more successfully than interventions that do not, regardless of the modality in which these interventions are delivered. While the world waits for an eventual return to some degree of normalcy, finding effective ways of engaging Latinx individuals in available treatments in a manner that is culturally sensitive is essential and professionally responsible.