Conversations on telemental health: listening to remote and rural First Nations communities

Introduction: Telemental health involves technologies such as videoconferencing to deliver mental health services and education, and to connect individuals and communities for healing and health. In remote and rural First Nations communities there are often challenges to obtaining mental healthcare in the community and to working with external mental health workers. Telemental health is a service approach and tool that can address some of these challenges and potentially support First Nations communities in their goal of improving mental health and wellbeing. Community members’ perspectives on the usefulness and appropriateness of telemental health can greatly influence the level of engagement with the service. It appears that no research or literature exists on First Nations community members’ perspectives on telemental health, or even on community perspectives on the broader area of technologies for mental health services. Therefore, this article explores the perspectives on telemental health of community members living in two rural and remote First Nations communities in Ontario, Canada. Methods: This study was part of the VideoCom project, a collaborative research project exploring how remote and rural First Nations communities are using ICTs. This current exploration was conducted with the support of Keewaytinook Okimakanak (KO), our partner in Northwestern Ontario. With the full collaboration of the communities’ leadership, a team involving KO staff and VideoCom researchers visited the two communities in the spring of 2010. Using a participatory research design, we interviewed 59 community members, asking about their experiences with and thoughts on using technologies and their attitudes toward telemental health, specifically. A thematic analysis of this qualitative data and a descriptive quantitative analysis of the information revealed the diversity of attitudes among community members. Finally, based on a discussion with the community


Introduction
The focus of this article is community perspectives on telemental health, using two rural and remote First Nations communities as a case-study. Telemental health -using information and communication technologies (ICT) (primarily videoconferencing) to support mental health and well-being -is a service offered to these communities through Keewaytinook Okimakanak Telemedicine (KOTM).

Keewaytinook Okimakanak (KO) is the Northern Chiefs
Tribal Council in Ontario, Canada.
By way of background, within the First Nations and Indigenous telemental health context, a small body of research exists on: (i) the advantages, disadvantages, and concerns of telemental health with First Nations communities; (ii) the perspectives of mental health workers who work with remote and rural First Nations communities on telemental health; and (iii) the experience of telemental health clients. However, there is a paucity of research about the relevancy of telemental health to remote and rural First Nations communities, and the perspectives of community members on using this approach to service.
We begin to address this gap by actually 'listening' to the community members. Within this study we are exploring the perspectives of rural and remote First Nations community members on the approach of using videoconferencing for mental health services -telemental health. What are seen as the advantages and the concerns?
Given that telemental health is accessible in many remote and rural First Nations communities in Ontario (and other provinces), and the KO tribal council sees value in it (as evidenced in the establishment of KO Telemedicine), it seemed important to explore community members' own thoughts and concerns about using telemental health. This could allow for increased discussion about using the service in communities, and how telemental health services might help support the community's needs and interests. This in turn could facilitate positive and mindful engagement with the technology.
In the following sections, there will be a review of the topic of mental health in remote and rural First Nations communities, followed by a review of the area of telemental health with First Nations communities, including the advantages, disadvantages or challenges, and past studies on the topic. Community resources for addressing mental health issues are often strained, for a variety of reasons (eg limited funding, lack of infrastructure) 6 . Often, individuals need to leave their communities to seek treatment. This often places individuals at greater risk for health and wellness problems, and indeed this has been recognized as a problem by mental health professionals who have experience working with remote and rural First Nations communities 7 .Therefore, telemental health provides a mechanism to connect individuals and communities with a wide variety of mental health services.

Mental health and First Nations communities
Remote and rural First Nations communities could benefit from culturally-safe 8 and appropriate mental health services and resources for individuals seeking intervention at that level. Many traditional First Nations cultures have holistic conceptualizations of health and wellness 9 . Although an examination of how telemental health can be integrated into a holistic framework, or the specific content of any interactions through telemental health are not a focus of this article, these are clearly issues that need to be addressed both in research and practice.
It is important to emphasize that the authors do not believe that outside help and telemental health is 'the answer' to the communities' need for resources or change; instead, telemental health offers an option to help support certain goals. If the various levels of conditions in the community (cultural, social, political, economic) could be improved so that the community was no longer in need of telemental health services, or if all issues could be appropriately dealt with within the community, that would be ideal. However, a detailed discussion of interventions of this type is outside of the scope of this article. Further, healthy communities and all communities always have individuals who sometimes need services.
As Varadharajan proposes, there are a variety of levels at which these issues can be addressed, including the individual, family, community, spiritual, social, economic, and political levels, among possible others (p143) 10 : Because colonization in all its complexity affects all our lives on many levels, from the trivial to the profound, the process of 'de-colonization' cannot but be equally intricate and multidimensional.
Telemental health is a tool that can be used in supporting change and development at many if not all of these levels.
Using telemental health at an individual and group levelconnecting people for therapy, group support, sharing circles, and education -is the focus of this article.

Telemental health in a First Nations context
The Telemental health is a mental health service approach which uses videoconferencing (and potentially other ICT) to connect those engaged with the service for a variety of activities, including (but not limited to): support groups and group therapy, assessments, individual therapy, and psychoeducation. Since the mid-1990s the use of telemental health in Canada and in First Nations communities across Canada has been growing 12 . Telemental health has been conceived of as a vehicle for connecting remote and rural communities to mental health services where otherwise access to certain resources within their own communities would not be possible 6,7,12,16,17 .
For instance, the KO telepsychiatry pilot project 16 was a ground-breaking venture that sought to connect certain rural and remote First Nations communities in Northwestern Ontario with psychiatric services. A driving force behind the project was the objective of supplementing current mental health services and reducing wait times. At that time (and arguably still today) mental health clients in the communities were often dependent on external regional services with limited presence in the communities, and/or they were often required to leave their home community to receive care. Currently, both in-person (again, as provided by external regional services, and certain in-community resources) and telemental health services are available in KO communities 18  Perhaps an excellent example of an ehealth/telehealth project that follows this creed is the Fort Chipewyan Project 21 .
Specifically, remote First Nations communities in Alberta are working together using videoconferencing to provide traditional medicine to Aboriginal communities. This project started out with a typical health and physiotherapy focus, and has evolved into 'tele-spirituality', connecting spiritual Indigenous leaders to various communities. Indeed, according to Gideon, Aboriginal leaders view ehealth as a tool and a means to improve 'access to, and control over, health services'. Further, telemental health and ehealth in general in First Nations communities has been touted as having the potential to facilitate a new environment that is healthy, empowering, and key to social change 21 . Indeed, the AFN has proposed a strategy for increased broadband network connectivity which could help support these initiatives 15 . However, the success of any community's telemental health initiative will depend on how the tool is engaged with. Therefore, it is critical that First Nations communities be involved in the development of health, mental health, and telemental health policies.

Advantages and challenges of telemental health with First Nations
First Nations communities that have been able to access telemental health services have experienced and reported many benefits 6,16 . These include increased access to services, client satisfaction, and decreased costs. Telemental health has also been proposed as a mechanism for facilitating networking and support among community mental health workers and mental health workers outside the communities, in addition to allowing increased flexibility at the local level for the management of mental health services 16  ...strategic tool, capable of improving the access to and quality of mental health services at the local or community level. They foresee a great potential for rural and remote communities in particular, where serious shortages of health professionals are felt.
The report outlined a number of key challenges to reaching this potential. These include: a lack of service providers, underdeveloped ICT infrastructures, insufficient funding, a lack of capacity to implement projects, and 'cultural issues'.
In addition, as in the general telehealth climate, difficulties also exist related to reimbursing service providers and licensing; some mental health associations have developed guidelines for telemental health use by practitioners, and others have yet to do so.
Looking beyond Canada, telemedicine and telemental health is used with Indigenous peoples in Australia 25,27 . In the USA,

Shore et al have explored telemental health for rural
American Indian communities 28 . They concluded that 'safety nets' and emergency protocol (support resources and a plan to respond in the case of crisis or necessity) in addition to guidelines are necessary to facilitate telemental health for these rural communities. Furthermore, collaboration with local service providers can be beneficial, because their knowledge of and connection to the community can help

Participation in previous studies on telemental health in First Nations
It appears that no research or literature exists on First Nations community members' perspectives on telemental health, or even on community perspectives on the broader area of technologies for mental health services, or technologies in general.
Within the Canadian context, there are a handful of studies that have explored the experience of First Nations telemental health clients 6,16,30 . As mentioned earlier, a telepsychiatry pilot project was conducted in Northern Ontario in 2001.
According to the evaluation, telemental health clients reported high levels of satisfaction with the service (p.iv) 16 : ...almost all the clients indicated that the psychiatrist had helped them with their emotional problems, and that they would recommend the service to people they care about who have emotional problems.
In addition, clients found it beneficial to have access to the opportunity of receiving mental health services in their home community without the requirement for travel. It was also concluded that (p.iii) 16 : In contrast to western cultural expectations, the distance created by not being face-to-face with the psychiatrist appears to have helped clients feel comfortable with the psychiatrist. Finally, studies on telemental health that have explored the experience of mental health professionals who work with First Nations clients and communities will be reviewed. Understanding community members' perspectives on telemental health is crucial because as we know from the technology acceptance literature 31 , users' perceptions of the technology -especially in relation to its usefulness -will influence whether the approach is actually adopted and used. Past research has explored how perceptions of usefulness and ease of use of telemental health influence the use of telemental health among mental health professionals who work with remote and rural First Nations clients 7 . Despite the fact that we are not specifically investigating the 'constructs' of perceived usefulness and perceived ease of use in the current study, the underlying goal remains the same: to understand community members (users) perspectives of the technology, as this will be a contributing influence to their intention and actual use of it. At this point, it is also important to distinguish that this study is exploring attitudes toward the use of telemental health as an approach, and is not addressing the actual content of the services or therapy that will transpire during the session.

Method
VideoCom is a collaborative research project exploring how remote and rural First Nations communities are using ICTs.
VideoCom (http://videocom.firstnation.ca) is a partnership of three First Nations organizations and two research organizations that spans the Atlantic, Quebec, and Ontario regions. The current study was conducted with the support of KO, the authors' partner in Northwestern Ontario.
This partner representatives provided expertise, feedback and support throughout the various stages of this initiative, including the design of the project and interview guide, helping foster connections with the communities, aiding with recruitment, and other activities.

Participants
In total, 59 remote and rural First Nations community members participated. All participants were over 18 years; however, specific age information was not collected.
Participants reported holding a variety of roles and positions in the communities, including health workers, teachers, family members and caregivers (eg mothers), elders, leaders (Band Council members), community workers, part-time workers, technology support workers, and others. Our sample was 56% female and 44% male. In addition, certain participants spontaneously reported having personal experience with telemental health when the specific interview questions were asked. However, the interviewers did not ask about personal experience with the approach (as the interviews were not about personal or sensitive information), and therefore reporting how many participants had past experience would be an invalid and inappropriate representation. Furthermore, even though participants in the current study lived in communities that had access to telemental health, not all participants were aware of it and the majority had never used videoconferencing.

Materials
The structured interview guide had 12 sections; those relevant to this study include demographic and introductory information, and technologies for community health and wellness. Specifically, participants were asked about their thoughts on using technologies like videoconferencing for telemental health and counselling services in their communities. As a further exploration, interviewees were asked about their perspectives on whether mental health services that take place through video are less personal, or if instead the space created by video can make people feel more comfortable. advertising the study at a parallel outreach event (community video festival); and, in one community, placing an advertisement on the community television channel. Finally, the 'snowball approach' was quite effective: community members who participated in the research often (and spontaneously, without our direction) recommended the study to their family and friends.

Procedure
Interviews lasted between 20 min and one hour and participants were given a $20 honorarium. Participants were advised that participation was voluntary, anonymous, and confidential.
The research protocols complied with Canadian (Tri-Council) guidelines for research with Aboriginal participants, and all participants (and their data) were treated in accordance with the ethical guidelines outlined by the American Psychological Association. Ethics approval was sought and obtained from the University of New Brunswick and the National Research Council. Ownership, Control, Access, and Possession (OCAP) principles also informed the design of the study 33 . In total, 56 in-person interviews were conducted in the communities, and 3 telephone interviews were conducted afterwards.
All 59 interview audio-recordings were transcribed and the transcripts imported into the qualitative analysis software program NVivo (www.qsrinternational.com). The transcript sections related to telemental health were coded thematically for advantages and perceptions of usefulness, and concerns.
Typically, when performing a thematic analysis, subthemes and data are only reported if more than one individual has raised the same issue, so as to avoid 'n of 1' issues. However, because this is new and exploratory research, all concerns of community members were identified, even if the point was only raised by one participant.
Because the researchers were interested in community members' attitudes toward telemental health, during the analysis the researchers chose to categorize responses as either positive (eg telemental health is a good idea, useful), negative (eg telemental health is not a good idea, is not appropriate), or neutral (eg not sure if it is useful or not). The data were then entered into SPSS (www.spss.com) to facilitate a descriptive analysis. Two researchers were involved with the coding/categorization, and several components of the interviews were coded, in addition to the telemental health question. An inter-rater reliability check was completed for the overall process. The analysis demonstrated a 97% agreement rate. This inter-rater analysis was completed based on 10% of the data (6 complete interviews).
Finally, in addition to the quantitative and qualitative analyses that are offered and described above, a 'ways forward' section was also developed in collaboration with the KOTM staff (including the community telehealth coordinators for the two communities). Once the initial draft of this article was complete, the co-authors met by telephone to discuss and determine possible ways to address the concerns that were being raised by community members.
Based on that discussion, we offer possible 'ways forward'. We would encourage communities and organizations who are engaged with telemental health to consider whether actively engaging on the topic (eg discussion) might also be useful for them. The ideas we will discuss are not intended to be prescriptive, or exhaustive.

Thematic analysis
The interview responses were coded for advantages and disadvantages/concerns. Within each of these domains, several subthemes were identified. Advantages will be explored first. Under the umbrella of usefulness, telemental health was seen as a way to increase access to helpful mental health services, and provide continuity of care to clients. For the approach to be considered useful, trust was identified as essential. Further, telemental health was associated with decreases in expenditures in terms of travelling time and expenses. Last, participants reported that clients may feel free to disclose when participating in telemental health, compared with in-person services.

Advantages of telemental health
Usefulness: Community members reported that they viewed telemental health as being potentially very useful in their communities. Telemental health was seen as a tool to enable: (i) greater continuity of mental health care for community members; and (ii) greater access to mental health services overall, as demonstrated by the following quotes.
The first quote also speaks to the theme of trust -trust in the technology/approach and trust that the approach will 'honour them':

Concerns/disadvantages of telemental health
In addition to the positive attitudes toward the use of telemental health, community members also voiced a variety of concerns about it. These included concerns about the appropriateness of using videoconferencing for mental health services, and concern that the approach may not be culturally appropriate. In addition, again the theme of trust was raisedthis time in the context of how building trust (an important component of the therapeutic relationship in any kind of therapy or in interactions in general) over video is likely difficult, and how it is better done with a community member. Further, the theme of preferring to leave the community for service was identified. In addition, the concern that telemental health may detract from capacity building within the community was raised, along with the issues of problems with the technology, and concerns about privacy. The criticism was raised that if people do not have running water in their homes, how helpful is telemental health? Despite the fact that many people reported positive views toward telemental health, clearly many concerns were present as well.
Concern about the appropriateness of using videoconferencing: Several participants were wary about the appropriateness of using videoconferencing for accessing mental health services. Participants who voiced these concerns often noted that mental health work and healing is something that needs to be done 'in person'. One participant explained that the importance of human contact was imbedded in First Nations culture, and just because the service approach may benefit certain stakeholders, does not mean that it is appropriate.
Expected difficulty with building trust over video was noted as well. The quotes below demonstrate these concerns: Probably just for follow up but not for initial visits ... Probably follow up will work, once they've already established that relationship with a person.

(Community member participant)
Privacy and security issues: Community members raised some valid and important concerns about privacy, security, and confidentiality. Some participants noted the difficulty of achieving privacy in the office setting where the videoconference unit was located. Other participants voiced concern over who would be able to access and view their private video session while it was taking place, and what exactly would be happening with the video transmission.

I tried it and I didn't feel comfortable talking on there because I feel like a [staff person] would hear what you're saying…she closed the door but I still didn't feel comfortable with it. (Community member participant)
The last participant was asked if her experience of telemental health would have been different if she could have accessed it within her own home: VideoCom interviewer: …If you had it in a more private place, like in your own home, would that be better?
Community member participant: Yeah, for me it would be.
Safety concerns: Some participants also voiced concern around the safety of telemental health, and what would happen if an individual was in a crisis or was unsafe and the mental health worker was only connected through video at a distant site. This participant discusses how in a time of crisis they would prefer to be with someone in person.

I think that it's just so impersonal using technology. That's just my personal opinion. If I was going through a mental health crisis, I'd prefer to have someone there to touch me or just to say, it's okay, rather than doing it over the video. (Community member participant)
Interference with capacity building: One participant raised an important point of consideration -could telemental health detract from capacity building in the community, since the typical set-up involves connecting a client with a therapist who is elsewhere? This is related to the premise that a community should develop resources with mental health workers or healers in the community to address any issue that comes up, instead of having community members seek services outside of the community.
The following individual reported concerns around the use of telemental health and when asked if telemental health would be more appropriate for helping with the continuity of in person, regional services: I don't think it [telemental health] should be used in the mental health field. Secondarily, I don't think there should be any regional services [therapists who work in an urban centre and visit the community periodically] because I think we need to build a capacity in each community. We need to have our own mental health counselling in the community.

(Community participant)
Problems with the technology: A minority of participants reported actual personal experience with telemental health (please note that the participants were not asked whether they had personally used the service, but some described their experiences spontaneously). Of those who did, one participant noted that she found it positive and helpful but noted an issue with using the technology. Fortunately, she also noted that she did not perceive the technical issues to detract from her overall positive experience:

Overall diversity of opinions
As illustrated, the quantitative results demonstrate a diversity of opinions (Fig1). Specifically, 47% of the participants were categorized as having a positive response toward telemental health, 32% as having a negative response, and 21% as neutral or undecided.

Discussion and Conclusions
Based on the thematic analysis of interview responses, we now have considerable information to help us begin to understand different perspectives and concerns about telemental health. To begin with the advantages of using the approach, participants associated the use of telemental health with the potential increase in access to mental health services, and an increase in continuity of mental health care. Participants noted that the need to travel outside of the community to access resources would be reduced, as would the time and cost associated with travel. Additionally, some participants also felt that communicating with a therapist through videoconferencing would facilitate client comfort and disclosure. Indeed, this same benefit has been noted in past research 7,16,19,28 . In summary, many participants saw telemental health as being potentially very useful for their community.
In contrast, however, a number of participants also felt that it would not be useful or helpful for their community. Many  Participants raised concerns about privacy and safety in using telemental health. Increasing privacy and safety needs to be a top priority in telemental health. Resources (like a 'safety net', a counsellor or contact available for the client in the community) and a safety plan need to be in place for any telemental health clients. Further, there are a variety of things that could be done in a health center setting to help increase privacy. Ideally, the individual who is using telemental health would be aware of all precautions taken to ensure their privacy and would be asked if a sufficient level of privacy was achieved. For example, headphones could be used, or a 'white-noise maker' could be set up outside the room. The room used for telemental health consultations needs to be as sound-proof as possible.
Addressing issues of privacy underscores the need for flexibility in the setting of telemental health. Currently, the majority of (if not all) telemental health sessions take place at the community health center or nursing station. , , Som, e individuals may fear the stigma that could be attached to their seeking mental health services, and some may not feel comfortable going to the nursing station for fear that their anonymity will be compromised. In some areas of telehealth, home-visits are possible, and in this study one participant noted that she would have felt more comfortable accessing telemental health from her home. However, using videoconferencing at a nursing station, or at home, is not always ideal. For example, depending on the home situation and how many people reside there, privacy may be even more limited. Therefore, communities and organizations need to be open to increasing the flexibility of telemental health and engaging the client in co-determining aspects of the setting that may be safest and most beneficial for them.
Finally, it is necessary to 'think outside the box'. Using

Conclusion
If communities decide to engage with telemental health and find it rewarding, participation in telemental health will increase naturally over time as people experience its benefits and usefulness. Al though First Nations communities are forging new models for telehealth delivery, the introduction of telehealth into remote and rural First Nations communities is relatively new given the history of the communities and their familiarity with other technologies. One KOTM staff author recalls that a couple of years ago the idea was raised to use telehealth to facilitate first-aid and CPR training in remote and rural First Nations communities. The response at the time was that it may not be possible or appropriate.
Currently, this type of training is offered via videoconferencing and the initiative has been reported as very successful.
Valuing Indigenous knowledge can help us understand community members' experiences of and concerns with telemental health and inform more successful and appropriate initiatives. Most importantly, any ways forward for community telemental health initiatives need to be community driven and community led.