Bowen Chung

Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

ABSTRACTBACKGROUNDDepression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.OBJECTIVETo compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use.DESIGNMatched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.PARTICIPANTSFrom 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.MEASURESSelf-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.RESULTSCEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05).CONCLUSIONCommunity engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Using Community Arts Events to Enhance Collective Efficacy and Community Engagement to Address Depression in an African American Community

OBJECTIVES We used community-partnered participatory research (CPPR) to measure collective efficacy and its role as a precursor of community engagement to improve depression care in the African American community of South Los Angeles. METHODS We collected survey data from participants at arts events sponsored by a CPPR workgroup. Both exploratory (photography exhibit; n = 747) and confirmatory (spoken word presentations; n = 104) structural equation models were developed to examine how knowledge and attitudes toward depression influenced community engagement. RESULTS In all models, collective efficacy to improve depression care independently predicted community engagement in terms of addressing depression (B = 0.64-0.97; P < .001). Social stigma was not significantly associated with collective efficacy or community engagement. In confirmatory analyses, exposure to spoken word presentations and previous exposure to CPPR initiatives increased perceived collective efficacy to improve depression care (B = 0.19-0.24; P < .05). CONCLUSIONS Enhancing collective efficacy to improve depression care may be a key component of increasing community engagement to address depression. CPPR events may also increase collective efficacy. Both collective efficacy and community engagement are relevant constructs in the South Los Angeles African American community.

Using a Community Partnered Participatory Research Approach to Implement a Randomized Controlled Trial: Planning Community Partners in Care

Quality improvement (QI) for depression in primary care can reduce disparities in outcomes. We describe how community-partnered participatory research was used to design Community Partners in Care, a randomized trial of community engagement to activate a multiple-agency network versus support for individual agencies to implement depression QI in underserved communities.

An Implementation Evaluation of the Community Engagement and Planning Intervention in the CPIC Depression Care Improvement Trial

The goal of this paper is to document and evaluate the process of implementing an evidence-based depression intervention in community settings through the use of community-academic partnered approaches. We discuss how and to what extent the goals of community engagement and collaborative planning were achieved in the intervention arm of the Community Partners in Care study that aimed to adapt evidence-based depression care toolkits for diverse agencies in Hollywood and South Los Angeles. We find that partnered research strategies have a potential to effectively engage community members around depression and involve them in intervention planning activities. Our results suggest that successful collaboration among diverse agencies requires that they understand what is expected of them, are comfortable with the role they choose to perform, and have organizational support to contribute to the project. To facilitate the development of collaborative relationships, time and effort should be devoted to explaining how collaboration among diverse agencies may take place.

Problem Gambling Knowledge and Perceived Community Impact Among Asian-Pacific Islanders and Non Asian-Pacific Islanders

Background Emerging data suggest that problem/pathological gambling may be highly prevalent among Asian-Pacific Islanders (APIs) and that can be a major concern to their communities. Methods This study surveyed problem/pathological gambling knowledge, attitudes, and perceived community impact of problem gambling among self-identified male and female APIs and non-APIs attending one of two API community events in Los Angeles County. Results Unexpectedly, our results indicated no effect for ethnicity with regards to ratings of problem/pathological gambling knowledge, community impact, or consequences. However, a gender effect with women reporting less problem/pathological-gambling-related knowledge than men, regardless of ethnicity was found. Over 40% of all respondents reported that problem/pathological gambling impacted their communities ‘a lot’, and the ratings for the impact of problem/pathological gambling was equal to ratings for other significant public health issues like diabetes, depression, drug abuse, and alcohol abuse. Discussion Based on these results, it is recommended that evidence-based legislation support the development of culturally-relevant prevention and intervention programs for problem/pathological gambling in Los Angeles County.

The Effects of Collaborative Care Training on Case Managers' Perceived Depression-Related Services Delivery.

OBJECTIVE This study examined the effects of a depression care quality improvement (QI) intervention implemented by using Community Engagement and Planning (CEP), which supports collaboration across health and community-based agencies, or Resources for Services (RS), which provides technical assistance, on training participation and service delivery by primarily unlicensed, racially and ethnically diverse case managers in two low-income communities in Los Angeles. METHODS The study was a cluster-randomized trial with program-level assignment to CEP or RS for implementation of a QI initiative for providing training for depression care. Staff with patient contact in 84 health and community-based programs that were eligible for the provider outcomes substudy were invited to participate in training and to complete baseline and one-year follow-up surveys; 117 case managers (N=59, RS; N=58, CEP) from 52 programs completed follow-up. Primary outcomes were time spent providing services in community settings and use of depression case management and problem-solving practices. Secondary outcomes were depression knowledge and attitudes and perceived system barriers. RESULTS CEP case managers had greater participation in depression training, spent more time providing services in community settings, and used more problem-solving therapeutic approaches compared with RS case managers (p<.05). CONCLUSIONS Training participation, time spent providing services in community settings, and use of problem-solving skills among primarily unlicensed, racially and ethnically diverse case managers were greater in programs that used CEP rather than RS to implement depression care QI, suggesting that CEP offers a model for including case managers in communitywide depression care improvement efforts.

Participation in Training for Depression Care Quality Improvement: A Randomized Trial of Community Engagement or Technical Support

Depressive disorders are leading causes of disability in the United States with racial disparities in access to, quality and outcomes of care in under-resourced communities.1-7 Primary care, depression quality improvement programs using team-based, chronic disease management can improve quality and care outcomes for depressed adults, including racial and ethnic minorities.8-17 Under healthcare reform, Medicaid behavioral health homes incentivize partnerships among healthcare, mental health, and social-community agencies (e.g. parks, senior centers), by noting “ Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources.”18 However, few guidelines exist to organize diverse agencies into systems supporting chronic disease management. Also, no studies exist comparing the effects of alternative training approaches for depression quality improvement with diverse providers from healthcare and social-community programs. This study analyzes data from Community Partners in Care (CPIC), a group-level, randomized, comparative-effectiveness study of two implementation approaches for evidence-based, depression quality improvement toolkits adapted for diverse healthcare and social-community settings. One implementation approach relies on more traditional technical assistance to individual programs (Resources for Services, RS). The other (Community Engagement and Planning, CEP) used community-partnered, participatory research (CPPR) principles to support collaborative planning across programs to implement the same depression care toolkits through a network.19-25 Programs randomized to each approach included healthcare and social-community programs.20-21 Six-month follow-up revealed that relative to RS, CEP improved depressed clients’ mental health-related quality of life, increased physical activity, and reduced homelessness risk factors; while reducing behavioral health hospitalizations and specialty medication visits, and increasing depression services use in primary care/public health, faith-based and park/community center programs with continued effects on mental health-related quality of life at 12-months.20,25 This study focuses on CPICs main intervention effects for primary program (i.e. program training participation) and staff-level (i.e. total training hours) outcomes, participation in evidence-based, depression quality improvement trainings. We hypothesized that CEP would lead to a broader range of staff training options than RS. To determine what types of organizations would participate in trainings, we compared interventions’ effects by program type (i.e. healthcare versus social-community). Based on prior work, we hypothesized that CEP relative to RS would increase mean hours of training participation, especially for social-community programs where such training is novel.26-28 To inform future depression quality improvement dissemination efforts in safety-net communities, we conducted exploratory analyses of interventions’ effects on staff training participation for each depression quality improvement component and by services sector.OBJECTIVE Community engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs. METHODS Matched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components. RESULTS CEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management. CONCLUSIONS CEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

Community Engagement Compared With Technical Assistance to Disseminate Depression Care Among Low-Income, Minority Women: A Randomized Controlled Effectiveness Study

OBJECTIVES To compare the effectiveness of a (CEP) versus a technical assistance approach (Resources for Services, or RS) to disseminate depression care for low-income ethnic minority women. METHODS We conducted secondary analyses of intervention effects for largely low-income, minority women subsample (n = 595; 45.1% Latino and 45.4% African American) in a matched, clustered, randomized control trial conducted in 2 low-resource communities in Los Angeles, California, between 2010 and 2012. Outcomes assessed included mental health, socioeconomic factors, and service use at 6- and 12-month follow-up. RESULTS Although we found no intervention difference for depressive symptoms, there were statistically significant effects for mental health quality of life, resiliency, homelessness risk, and financial difficulties at 6 months, as well as missed work days, self-efficacy, and care barriers at 12 months favoring CEP relative to RS. CEP increased use of outpatient substance abuse services and faith-based depression visits at 6 months. CONCLUSIONS Engaging health care and social community programs may offer modest improvements on key functional and socioeconomic outcomes, reduce care barriers, and increase engagement in alternative depression services for low-income, predominantly ethnic minority women.

Comorbid Depression and Substance Abuse Among Safety-Net Clients in Los Angeles: A Community Participatory Study

OBJECTIVE Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history. METHODS The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined. RESULTS Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms. CONCLUSIONS Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Perceived sources of stress and resilience in men in an African American community.

Background: Little is known about the perceived causes of stress and what strategies African American men use to promote resiliency. Participatory research approaches are recommended as an approach to engage minority communities. A key goal of participatory research is to shift the locus of control to community partners.Objective: To understand perceived sources of stress and tools used to promote resiliency in African American men in South Los Angeles.Methods: Our study utilized a community-partnered participatory research approach to collect and analyze open-ended responses from 295 African American men recruited at a local, cultural festival in Los Angeles using thematic analysis and the Levels of Racism framework.Results: Almost all men (93.2%) reported stress. Of those reporting stress, 60.8% reported finances and money and 43.2% reported racism as a specific cause. More than 60% (63.4%) reported that they perceived available sources of help to deal with stress. Of those noting a specific source of help for stress (n = 76), 42.1% identified religious faith. Almost all of participants (92.1%) mentioned specific sources of resiliency such as religion and family.Conclusions: Stress owing to psychosocial factors such as finances and racism are common among African American men. But, at the same time, most men found support for resiliency to ameliorate stress in religion and family. Future work to engage African American men around alleviating stress and supporting resiliency should both take into account the perceived causes of stress and incorporate culturally appropriate sources of resiliency support.