Product Details

Author Information

Corresponding Author
Natalia Deeb-Sossa
Chicana/o Studies Department
University of California at Davis
Davis, CA 95618
United States
p: 5302205582
ndeebsossa@ucdavis.edu

Authors (listed in order of authorship):
Sergio Aguilar-Gaxiola
Center for Reducing Health Disparities

Katherine Elliott

William Sribney

Cristiana Giordano

Cristina G. Magaña

Ronald King

Marbella Sala
center for Reducing Health Disparities

Elizabeth Miller

Joshua Breslau

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health, Social & Behavioral Sciences

What specific topics does your product address?

Access to health care, Advocacy, Community engagement, Health disparities, Mental health, Minority health, Poverty, Social determinants of health

Does your product focus on a specific population(s)?

Adolescents, American Indian/Alaska Native, Asian, Black or African-American, Immigrant, Latino/Hispanic, LGBTQ, Men, Rural, Uninsured, Women

What methodological approaches were used in the development of your product, or are discussed in your product?

Case study , Community-based participatory research , Focus group , Qualitative research, Participant observation

What resource type(s) best describe(s) your product?

Case study, Manual/how to guide

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

The UC Davis Center for Reducing Health Disparities (CRHD), with funding from the California Department of Mental Health, collected accounts with communities underserved by mental health services.These community members identified mental health and health needs, concerns, strengths, assets and resources, as well as developed recommendations for prevention and early-intervention programs.Using a community engagement process, we interviewed key informants and conducted focus groups with Latinas/os (including agricultural workers), African Americans, Asian/Pacific Islanders, Native Americans and other underserved groups in 10 counties across California. Participants identified social determinants such as poverty and discrimination as major factors affecting mental health and the quality of life of those living with mental illness and recommended that the improvement of social conditions be a key objective of prevention efforts. County, state and national mental health policy makers will need to consider delivering not only traditional mental health services, but also services that address the inequities and social exclusion experienced by members of underserved communities. The reports that summarize the community voices through this project is appropriate for use by any health policy maker, health provider, advocate or community member, as evidence of the need for equity and full inclusion of vulnerable populations as measured by access to necessary quality services that promote mental health, wellness, resiliency, and recovery in these communities.

2. What are the goals of the product?

The UC Davis Center for Reducing Health Disparities (CRHD), with funding from the California Department of Mental Health, engaged and collected accounts of communities that are underserved by mental health services and excluded in community stakeholder processes. Our purposes were to engage underserved communities across California and identify community mental health and health needs and concerns, strengths, assets and resources, as well as develop recommendations for prevention and early-intervention programs.

The CRHD also hoped to increase the participation of unserved and underserved communities in California in mental health policy implementation, create bridges between these communities and county administrations, and empower community members and leaders by bringing the results of the outreach project to communities.

3. Who are the intended audiences or expected users of the product?

The CRHD disseminated its findings to communities, county administrators and planners, and others stakeholders. The CRHD embarked on a systematic dissemination and technical assistance process, working with communities, community based organizations and leaders, counties ,and other stakeholders (e.g. policy makers, health officials, public health CBOs, community engaged researchers).

The reports are appropriate for use as evidence of the need for equity and full inclusion of marginalized populations. The reports may also be a helpful guide of successful outreach, and suggest specific strategies that might be employed to nurture more equitable, sustained partnerships with underserved communities.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

The California Department of Mental Health contracted CRHD to conduct a community engagement project aimed at increasing the participation of underserved communities in defining principles and priorities for prevention and early intervention and laying the foundation for ongoing engagement. This information and the principles of community engagement that guided this project were summarized in two documents. To provide communities with the most relevant information, the CRHD conducted separate qualitative data analyses aimed at identifying needs, priorities, and assets for each specific target group. In addition, an aggregate summary was created for wide distribution. This summary provided the overall results of the study in a brief and easy-to-read format.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Our work is grounded on the principles of community based participatory research (1, 2) and utilized community focus group methods and initiatives (3, 4). Our goal was to learn from communities abour their mental health needs, which have been widely documented (9-14). Community engagement has been defined over the last two decades in multiple, evolving ways. One definition from the Centers for Disease Control Public Health Practice Program Office is, “Loosely defined, community engagement is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.” (5) More operationally, community engagement is “applying institutional resources … to address and solve challenges facing communities through collaboration with these communities.” (6) The community engaged process we undertook is based on the perspective that recognizes that people who live in communities where any data gathering is conducted have the right to participate in the process of defining problems, in mobilizing assets and strengths (individuals, social networks, and institutions) as well as in designing and implementing interventions/solutions (1, 2, 7).

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

CITATIONS

(1) Israel BA, Schulz AJ, Parker EA, Becker AB. (1998) Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 19:173–202

(2) Minkler, M., & Wallerstein, N. (2003) (eds). Community-Based Participatory Research in Health, SF, Jossey-Bass Publishers.

(3) Israel, BA., Eng E, Schulz A, and Parker EA. (2005) (eds). Methods in Community Based Participatory Research for Health. San Francisco, CA: John Willey & Sons, Inc.

(4) Rhodes, S.D., K.C. Hergenrather, A. Wilkin, J. A.Ortega, and J.Montaño. (2006) Preventing HIV infection among young immigrant Latino men: results from focus groups using community-based participatory research. J. Natl Med Assoc. 2006 April; 98(4): 564–573.

(5) CDC Public Health Practice Program Office. 1997. “Principles of Community Engagement” extracted from: http://www.cdc.gov/phppo/pce/.

(6) Commission on Community-Engaged Scholarship in the Health Professions. (2005). Linking Scholarship and Communities: The Report of the Commission on Community-Engaged Scholarship in the Health Professions.

(7) Kretzmann, J. P. and McKnight, J. L. (1993) Building Communities from the Inside Out. Evanston, IL: Asset-Based Community Development Institute, Northwestern University.

(8). Ryan, G. & Weisner, T. (1998). Content Analysis of words in brief descriptions: How father and mothers describe their children. In de Munck, V. C., & Sobo, E. J. (Eds.) Using methods in the field. Walnut Creek, CA: Altamira Press.

(9) Aday, L. A. (2001) At risk in America: the health and health care needs of vulnerable populations in the United States. San Francisco, CA: Jossey Bass Inc.

(10) Roberts, L.W., J Battaglia, and R. S. Epstein. (1999). Frontier Ethics: Mental Health Care Needs and Ethical Dilemmas in Rural Communities. Psychiatr Serv 50:497-503.

(11) Harman, J.S., G. E. Childs, and K. J. Kelleher. (2000). Mental Health Care Utilization and Expenditures by Children in Foster Care. Arch Pediatr Adolesc Med.(154):1114-1117.

(12) Chun-Chung Chow, J. , K. Jaffee, and L. Snowden. (2003). Racial/Ethnic Disparities in the Use of Mental Health Services in Poverty Areas. American Journal of Public Health 93(5):792-797.

(13) Vega WA, Kolody B, Aguilar-Gaxiola SA. (2001). Help-seeking for mental health problems among Mexican-Americans. Journal of Immigrant Health, 3(3):133-140.

(14) Alderete E, Vega WA, Kolody B, Aguilar-Gaxiola SA. (2000). Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California. American Journal of Public Health, 90(4):608-614.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The project involved engaging with and learning from 1) cultural brokers: state, county, and community leaders with knowledge about specific underserved populations and with established trust in communities; 2) key informant interviews with community leaders and mental health and social service providers; and 3) 30 focus groups with underserved communities in 10 counties across California.

Focus groups were selected following two basic principles. First, the groups are comprised of members of communities that are historically underserved by mental health services. The identification of underserved communities was driven by available data concerning four interrelated issues: 1) Groups with low levels of use of mental health services; 2) Groups that face barriers to participation in the policy making process in public mental health; 3) Groups with low rates of insurance coverage for mental health care; and 4) Groups that have been identified as priorities for mental health services. Second, input into the focus group selection process was solicited from key informants and cultural brokers who were interviewed in the initial stages of community engagement. This allowed the selection process to emerge from the engagement with communities.

The groups ranged from 4 to 15 participants. The focus group schedule included discussion of overall community-level concerns, perceptions of mental health problems (not defined for the groups), existing resources and assets, and recommendations for prevention and early intervention efforts. Written consent forms were reviewed, confidentiality discussed, and questions answered about how information would be utilized and disseminated back. Consent forms were translated into appropriate languages, and back translated for accuracy. For youth ages 14–17, parental consent was obtained along with youth assent. The focus groups lasted about 60 minutes. The protocols were approved by UC Davis Human Subjects Research Committee. Focus groups were conducted at times convenient for participants and in locations safe, accessible, and known to participants. When necessary, transportation and child care were arranged with the assistance of community agencies. Focus group participants received $30 pre-paid gift cards.

Data Analysis

Focus groups were audiotaped and transcribed verbatim. Those conducted in Spanish were transcribed into Spanish, then translated into English. Those in Hmong were transcribed directly into English by a bilingual transcriptionist/interpreter. The facilitator conducting the focus group reviewed all the transcripts for accuracy. Transcribed data were analyzed using a content analysis approach with Atlas-TI v.5 software. Content analysis is a qualitative data analytic strategy that involves generating and applying codes to “chunks” of text, and then reviewing the text by its code category to detect themes (8). A preliminary read of several focus group transcripts as well as the existing focus group schedule guided the development of an initial code list, agreed upon by the entire coding team.
Initial codes related to key themes of interest such as community mental health concerns, definitions of prevention and early intervention, and experiences of isolation and social exclusion. No new codes were added after the eighth transcript. The expanded code list included impact of poverty, lack of access to education and services, and emphasis on health promotion. Utilizing a consensus coding approach, each transcript was coded by two coders, with discrepancies discussed and resolved by each pair.
Community leaders, cultural brokers, and key informants provided recommendations on issues and areas of discussion to address with the communities they represented. The dialogue with community members did not use a structured question format. Instead, the recommendations provided by cultural brokers and key informants informed general content areas that were addressed across all communities.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

The CRHD after identifying underserved communities and specific special populations to be contacted, CRHD program managers got in touch with persons within state, county, city, and university networks known for having a trusting relationship with specific groups and/or extensive networks in communities and willing to assist with the community engagement process. Cultural brokers assisted the research team to identify grass-roots organizations and community leaders from multiple different vantage points (e.g., legal, health, social services, education, and housing). Contact was made with these agencies and individuals to begin to map existing community-based services, community resources, and assets, as well as community concerns regarding mental health. In-person meetings were arranged to discuss potential collaboration and to review the MHSA PEI objectives and the purpose of the project. Key informant interviews were then arranged. Key informants assisted the program managers in determining the feasibility of focus groups, the priority groups to include, and identifying participants for the focus groups, including helping to find the appropriate venue, child care, transportation, language needs, and type of food to order.

Cultural brokers and key informants reviewed the informed consent documents and descriptions of the project for readability and understandability, and provided assistance with interpreting.

Key informants were identified with the assistance of cultural brokers. The aims of the key informant interviews were to identify specific populations with whom to conduct focus groups, to review the focus group questions and adapt these as necessary to the specific groups planned, and to determine strategies for recruiting and organizing focus groups. The interview also explored overall community concerns, existing community resources and assets, specific mental health problems, existing prevention and early intervention programs, and challenges of outreach and engagement in the community, as well as ideas for improving PEI efforts.

The focus groups selected represented the outcome of a collaborative process between project staff and community members from selected underserved populations. The groups consisted of community members, ranging from 4 to 15 participants.

The CRHD also partnered with communities in devising strategies to 1) disseminate the input from these efforts and 2) to start empowering communities to use this input to advocate for their mental health needs. This phase of the project entailed: 1) additional data analysis to provide communities with information specifically related to their group 2) consultation with key informants and cultural brokers 3) planning and implementing dissemination of findings and development of strategies for sustainability of relationships.

Consultation of key informants determined the nature of the dissemination approach and therefore, each community approach was different and tailored to each community’s needs. For example, CRHD conducted several meetings with Hmong leaders to identify goals for the dissemination and to develop a dissemination approach that would meet these goals. Through this consultation, it was determined that a central challenge for improving Hmong mental health is the lack of awareness of mental health problems and the stigma surrounding mental illness. The Hmong leaders along with the CRHD team planned an event that involved a presentation about the findings of the CRHD project, a panel presentation by community members affected by mental illness, and a discussion period in which community members could learn directly from county personnel about resources available in the county and opportunities to participate in mental health policy setting.

The Sacramento Gay and Lesbian Center and the CRHD team, for example, created a program that involved a presentation by CRHD, a presentation of a needs assessment project conducted by the community itself, and the screening of a youth-produced documentary film about LGBTQ issues for Sacramento youth. Similarly, dissemination approaches for the African American, Native American and Parent Advocates were tailored to meet the needs of these communities.

In total six feedback sessions were conducted with communities: two with the African American community, one with the Native American community, one with the Hmong community, one with the LGBTQ community, and two with the Parent Advocates. Three follow-up meetings were conducted: two with the Hmong community and one with the LGBTQ community.
The analysis of the mental health needs and priorities, and the principles of community engagement that guided the implementation of this project were summarized in two documents..

To provide communities with the most relevant information, the CRHD conducted separate qualitative data analyses aimed at identifying needs, priorities, and assets for each specific target group. The results of these analyses were combined with the results of 30 key informant interviews conducted within these communities and written summaries were prepared for each group. In addition, an aggregate summary was created for wide distribution. This summary provided the overall results of the study in a brief and easy-to-read format. Drafts of summaries were circulated to cultural brokers from participating communities. Feedback was obtained from cultural brokers and integrated into the summaries.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

The project was significant as it increased the participation and involvement of underserved communities in mental health policy implementation, created bridges between communities and county administrations, and empowered community members and leaders by bringing the results of the outreach project to communities. The CRHD did this, by conveying its findings to communities, county administrators and planners, and others stakeholders. The CRHD embarked on a systematic dissemination and technical assistance process, working with communities, community based organizations and leaders, counties, and other stakeholders.

As noted above, dissemination of the results and empowerment of communities were specific goals of this project. The CRHD outreached to communities and developed relationships that were sustained and mutually beneficial. Example of these efforts included: 1) consultation and assistance for funding of local programs, 2) facilitation of community participation in MHSA processes by providing communities with information and updates regarding local MHSA events, and 3) facilitation of the development of community-county partnerships.

To further facilitate relationships with county mental health departments, county representatives were invited to attend dissemination presentations, when vetted and approved by key informants. In every case, county representatives accepted the invitation and attended and participated in all the presentations provided to the communities. This allowed an opportunity for county representatives to develop relationships with historically marginalized groups in their area. It was hoped that bringing community members and county representatives together would lead county administrators to have a greater awareness of the needs, assets, and recommendations of underserved communities. In addition, it was expected that these newly fostered relationships would encourage community members to become more actively involved in mental health decision-making in their area.

To further facilitate the participation of underserved communities in local MHSA PEI processes, the CRHD provided technical assistance to two counties for their community engagement activities. The CRHD conducted several meetings to 1) generate criteria for selecting target underserved groups in the county and identifying these groups, 2) conduct a preliminary asset mapping, 3) train on community engagement, and 4) begin the process of community engagement with underserved groups.

Finally, as a result, in part, of our findings and the attention to the mental health disparities in California, the Department of Mental Health (DMH), in partnership with Mental Health Services Oversight and Accountability Commission (MHSOAC), and in coordination with California Mental Health Directors Association (CMHDA) and the California Mental Health Planning Council called for a statewide policy initiative as a means to improve access, quality of care, and increase positive outcomes for racial, ethnic and cultural communities. This initiative, entitled the California Reducing Disparities Project has been allocated $3 million dollars from the Mental Health Services Act (MHSA) state administrative funding.

10. Please describe why you chose the presentation format you did.

For the CRHD team it was of outmost importance that the format privileged the community members’ voices, preserved the personal accounts, summarized the findings, and made it easy to read and was accessible to the communities. As a result we had extensive discussions with the funding agency and we shared the drafts with community members who gave us feedback.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

This project in community engagement was implemented in a context of increasing recognition of the prevalence and impact of health disparities on state, national, and international levels. Many policy makers and health organizations have turned their attention to the social determinants of health as critical factors in the reduction of disparities. There is an increasing acknowledgment of the central role that social and environmental conditions play in determining the mental health of communities and that health disparities have multiple determinants and none operates in isolation. This acknowledgement is in line with an increasing understanding at the federal, state and local levels that social circumstances and environmental factors place minority groups at a distinct disadvantage in health and disease. This realization remarkably coincides with the input received from community voices through this project. It is important to note the confluence of voices calling for changes in social and economic conditions that impact the health and mental health of communities, and for prevention strategies to include social determinants--which community voices collected in this project have identified as critical precursors to mental health problems.

The current project was limited in scope as it was conducted in a relatively brief timeframe, a 9 month period. Given this limitation, the results do not represent a comprehensive assessment of community needs, and instead were intended as a “first step” in engaging communities in ongoing and bidirectional conversations about their mental health needs and recommended strategies and programs to address these.

Differences in needs and priorities across groups do not imply that those issues are important to some communities and not others. There are important issues that these communities face but which were not addressed due to time limitations. Likewise, given the short time frame to conduct this project, the findings from a limited number of underserved communities can be neither exhaustive nor summative with recommendations; rather, this report documents some key, recurrent themes that may assist in the planning and implementation of the PEI component of the MHSA as counties make concerted efforts to reach out and engage underserved communities.
The results of this community consultation were intended to inform the state policy and program development and implementation process, and involved the survey of diverse groups in several counties across the state of California. The results, therefore, reflect a breadth of perspectives, rather than an in-depth survey of individual community needs. Individual county outreach and engagement efforts may yield different results. Thus, the current consultation is not intended to guide mental health priority-setting at the county level, but rather the results detailed in this report will inform state development of plan requirements.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

This product embodied the principles of community based participatory research at every stage. It was a collaboration between project staff and community members from selected underserved populations that selected the members of the 10 focus groups. The groups consisted of community members, ranging from 4 to 15 participants. Each focus group was conducted by a facilitator, and a recorder also took notes. Written consent forms were reviewed verbally in detail, confidentiality discussed, and questions answered about how the information would be utilized and disseminated back to communities. All consent forms were translated into appropriate languages, and back translated for accuracy. For youth ages 14–17, parental consent was obtained along with youth assent. The focus groups generally lasted about 60 minutes. The protocols for both key informant interviews and focus groups were approved by the UC Davis Human Subjects Research Committee.

Key informants assisted the program managers in determining the feasibility of focus groups, the priority groups to include, and identifying participants for the focus groups, including helping to find the appropriate venue, child care (if needed), transportation, language needs, and type of food to order.

Cultural brokers and key informants reviewed the informed consent documents and descriptions of the project for readability and understandability, and provided assistance with interpreting when necessary. Community agencies, cultural brokers, and key informants were all reimbursed for their time and effort in helping to recruit participants and organize the focus groups. Community agencies received stipends to cover use of their space, staff time and effort, and assistance with recruitment. Some of the cultural brokers generously offered their time and shared their perspectives without compensation even when it was offered. They regarded their collaboration as part of their job in connecting people of different backgrounds to each other. Others received stipends for their time at $50 per hour (some required additional effort to assist with recruitment and extended hours). Key informants who were interviewed received $30 stipends to thank them for their time.

In addition, program managers participated when appropriate in existing interagency collaborative meetings and community meetings to learn more about community-wide concerns, as well as to support interested community members to engage in the county MHSA process. The dissemination approach was also the result of a partnership between the CRHD and communities.

The CRHD also partnered with key informants to determine the nature of the dissemination approach and therefore, each community approach was different and tailored to each community’s needs. In each consultation, communities and researchers devised strategies to 1) disseminate the input from these efforts and 2) to start empowering communities to use this input to advocate for their mental health needs. At the same time, community partners and researchers 1) did additional data analysis to provide communities with information specifically related to their group and 2) planned and implemented dissemination of findings and development of strategies for sustainability of relationships. A total six feedback sessions were conducted with communities: two with the African American community, one with the Native American community, one with the Hmong community, one with the LGBTQ community, and two with the Parent Advocates. Three follow-up meetings were conducted: two with the Hmong community and one with the LGBTQ community.