Engaging underrepresented patient groups in specialised treatment – qualitative results from the PROVIDE-C randomised trial on integrated mental health video consultations for depression and anxiety

Müller et al. BMC Public Health (2025) 25:3817 https://doi.org/10.1186/s12889-025-25235-1 BMC Public Health Open Access RESEARCH Engaging underrepresented patient groups in specialised treatment – qualitative results from the PROVIDE-C randomised trial on integrated mental health video consultations for depression and anxiety Selina Müller1 , Alexa Ritter-von Kramer1, Justus Tönnies1, Alina Wildenauer1, Michel Wensing2, Hans Christoph Friederich1,3 and Markus W. Haun1,3* Abstract Background Mental health specialist video consultations (MHSVC) offer a promising way to address the growing burden of depression and anxiety. However, their acceptance among groups with lower mental health care uptake and limited technology literacy remains underexamined. Objective This study explores how underrepresented patients—elderly, rural, and male individuals with depression or anxiety—experience and accept MHSVC after participating in PROVIDE-C, a randomized trial evaluating a fivesession MHSVC intervention in primary care. Methods A qualitative interview study in rural Germany used inductive content analysis and the Technology Acceptance Model (TAM). TAM suggests that perceived usefulness and ease of use influence technology adoption. Results Among 21 PROVIDE-C participants, attitudes toward MHSVC were largely positive. Patients found the intervention useful for therapeutic alliance, symptom relief, and treatment measures, with many preferring continued sessions. Prior mental health care experience and strong primary care relationships increased acceptance. Some patients, already familiar with videoconferencing due to COVID-19, adapted easily, while those with lower technology literacy relied on technical support in primary care to engage with MHSVC for the first time. Conclusions Embedding MHSVC in primary care enhances access for patients hesitant about mental health treatment or unfamiliar with digital tools. The PROVIDE model effectively reaches underserved populations, namely elderly, rural patients, improving access to specialized care and reducing depression and anxiety symptoms, as evidenced by its demonstrated effectiveness. Trial registration ClinicalTrials.gov, United States National Institutes of Health NCT04316572. Prospectively, registered on 20 March 2020. *Correspondence: Markus W. Haun Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Müller et al. BMC Public Health (2025) 25:3817 Page 2 of 13 Keywords Mental health, Primary care, Integrated care, Telemedicine, Implementation, Qualitative research Background Mental health disorders contribute significantly to the global burden of disease, with depression and anxiety— the most common psychological disorders—estimated to have increased by approximately 25% during the COVID19 pandemic, exacerbating personal and economic challenges worldwide [1]. Specialised mental health care is effective in treating depression and anxiety [2], but access rates differ among patient groups. Mental health services tend to be used more frequently by younger, predominantly female individuals, while help-seeking behaviour is generally lower in men and declines with age [3]. Further, long waiting times, particularly in rural areas, often delay access to care, risking symptom deterioration and chronification [4, 5]. Barriers such as limited mobility and poor infrastructure in rural or suburban areas further contribute to reduced treatment uptake [5, 6]. Leveraging technology to improve access to mental health care is a promising option and telemental health has been shown to be effective [7] and cost-efficient [8] in treating depression and/or anxiety, especially suitable for rural populations. Yet, older and rural adults remain underserved regarding telemental health, compared to the general population [9, 10]. Barriers to telemental healthcare in elderly include digital literacy gaps, sensory or cognitive limitations, lack of social support, or stigma [11–13]. Nevertheless, tailoring telemental health intervention to older adults’ needs by targeted training or technology support can lead to successful engagement and satisfaction [14, 15]. These findings highlight the need for interventions adapted to the specific needs of older adults in rural settings, which is the focus of our study. Primary care physicians (PCPs), as trusted gatekeepers to the healthcare system, are often the first point of contact for individuals with mental health concerns. However, PCPs frequently face time constraints that hinder adequate diagnosis and treatment [16]. Especially for older people in rural areas and lack of mobility, there is little possibility to visit specialists outside the PCP’s office [17], leaving them underrepresented in and at risk of inequitable access to specialised mental health care [18]. Integrated care models [19], which embed specialised mental health services into primary care, along with advancements in telehealth, offer a promising avenue to expand access irrespective of geographical or logistical barriers [20]. The PROVIDE project (ImPROve crosssectoral collaboration between primary and psychosocial care through implementing VIDEo consultations in primary care; ClinicalTrials.gov NCT04316572) integrated telemental health into primary care by offering mental health specialist video consultations (MHSVC) directly within PCP practices [21]. The intervention led to small but significant reductions in depression and anxiety symptoms, as well as psychological distress linked to somatic symptoms, highlighting its potential to improve access to specialised care in primary care settings [21]. While existing studies suggest that MHSVC can support therapeutic relationships and symptom relief [22], little is known about the experiences of older male patients from rural areas—groups often underrepresented in digital interventions due to limited technology literacy and a higher risk of digital exclusion [11, 23]. Studies specifically focusing on older adults’ engagement with telemental interventions for depression or anxiety are sparse [24]. Understanding t (...truncated)