Barriers and facilitators to implementing electronic patient reported outcome screening for mental illness and substance use disorders at HIV clinics in Alabama: a qualitative study

Eaton et al. BMC Health Services Research (2025) 25:1462 https://doi.org/10.1186/s12913-025-13596-7 BMC Health Services Research Open Access RESEARCH Barriers and facilitators to implementing electronic patient reported outcome screening for mental illness and substance use disorders at HIV clinics in Alabama: a qualitative study Ellen Eaton1*, C. Greer McCollum1, Kelly W. Gagnon2, Anna-Julia Enid Kutsch1* and Kaylee Burgan1 Abstract Background People living with HIV face disproportionately high rates of mental health issues (MH) and substance use disorders (SUD), which can contribute to reduced antiretroviral treatment (ART) adherence. When left untreated, these psychosocial comorbidities pose an additional threat to the goals of the Ending HIV Epidemic Initiative, which aims to optimize HIV outcomes in states like Alabama, where the rural burden of HIV is among the highest in the nation. Fortunately, electronic patient reported outcome measures (ePROs) are effective in screening for MH and SUD in a wide variety of care settings, facilitating early referrals to evidence-based interventions. In this study, we use the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to the implementation of depression, anxiety, and SUD ePROs in HIV clinics in Alabama, an Ending the HIV Epidemic Priority Jurisdiction. Methods We interviewed 15 clinical and non-clinical staff at five Ryan White HIV/AIDS Program (RWHP) funded HIV clinics in Alabama. We queried their experiences with an ePRO intervention starting in 2022. We used a rapid analysis technique to explore themes related to the Characteristics of Individuals, Process, Characteristics of Innovation, and Inner Setting domains of CFIR. Two experienced qualitative researchers conducted the semi-structured interviews and iteratively analyzed the transcripts. Results We identified a variety of barriers and facilitators to implementation of MH and SUD ePROs in HIV clinics that fell under all four included domains. Participants reported significant staff turnover and/or limited staff capacity as primary barriers to consistent implementation. Sites also reported the lack of ongoing training and onboarding at the site level as a barrier that further impeded capacity and understanding. Positively, though, participants also reported that the intervention enhanced patient-provider communication and increased the rate of MH and SUD identification. *Correspondence: Ellen Eaton Anna-Julia Enid Kutsch Full list of author information is available at the end of the article © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Eaton et al. BMC Health Services Research (2025) 25:1462 Page 2 of 9 Having a site champion as the primary point of contact, both internally and externally to the investigation team, was a key facilitator. The champions also increased team motivation and kept the intervention on track. Tablets were key to the intervention, enabling automatic results of ePROs. Conclusions Despite numerous barriers, such as staff turnover, participants found the intervention to be easy to use, brief, and effective. This success was largely attributed to several facilitating factors, such as the use of tablets and the support of site champions. Key Words Electronic patient-reported outcomes, HIV care delivery, Mental health screening, Substance use disorders, Implementation science, Consolidated Framework for Implementation Research Barriers and facilitators, Rural health services, Ending the HIV Epidemic initiative, Digital health interventions Text box 1. Contributions to the Literature Here are five key reasons why this study is a substantial contribution to the literature: 1. Addresses a Critical Gap in HIV Care The study highlights the underutilization of electronic patient-reported outcome measures (ePROs) for mental health (MH) and substance use disorder (SUD) screening in HIV care, particularly in rural and resourcelimited settings like Alabama. By focusing on a high-burden region, it provides crucial insights into implementation challenges that have not been extensively studied. 2. Utilizes an Established Implementation Science Framework By applying the Consolidated Framework for Implementation Research (CFIR), the study systematically identifies barriers and facilitators to ePRO adoption in HIV clinics. This structured approach enhances the study’s rigor and ensures findings are actionable for policymakers and practitioners. 3. Demonstrates Real-World Implementation Challenges and Solutions in the Deep South The study’s qualitative approach, including interviews with clinical and non-clinical staff, captures on-the-ground experiences with ePRO implementation. Key findings—such as the role of site champions, the impact of staff turnover, and the necessity of ongoing training—offer practical guidance for scaling ePROs in similar settings. 4. Contributes to the Ending the HIV Epidemic (EHE) Initiative which focuses on Alabama and other poor, rural states By focusing on a priority jurisdiction (Alabama), the study directly supports national efforts to optimize HIV outcomes. It underscores the importance of integrating behavioral health screening into HIV care and provides an evidence-based model that can be adapted in other high-burden areas. 5. Advances Digital Health Solutions for Underserved Populations The study reinforces the effectiveness of digital screening tools in improving patient-provider communication and increasing MH and SUD identification rates. Given the barriers to traditional care in rural areas, the findings highlight how technology-driven interventions can enhance healthcare access and equity. Introduction Across the US, there is an epidemic of mental health issues (MH) and substance use disorders (SUD), with an estimated 48.7 million people aged 12 years or older (17.3%) having a substance use disorder, 59.3 million adults (23.1%) having any mental health disorder, and 21.5 million adu (...truncated)