Ethics of health research in communities: perspectives from the southwestern United States

PURPOSE

The increasing attention paid to community-based research highlights the question of whether human research protections focused on the individual are adequate to safeguard communities. We conducted a study to explore how community members perceive low-risk health research, the adequacy of human research protection processes, and the ethical conduct of community-based research.

METHODS

Eighteen focus groups were conducted among rural and urban Hispanic and Native American communities in New Mexico using a semistructured guide. Group transcriptions were analyzed using iterative readings and coding, with review of the analytic summary by group members.

RESULTS

Although participants recognized the value of health research, many also identified several adverse effects of research in their communities, including social (community and individual labeling, stigmatization, and discrimination) and economic (community job losses, increased insurance rates, and loss of community income). A lack of community beneficence was emphasized by participants who spoke of researchers who fail to communicate results adequately or assist with follow-through. Many group members did not believe current human research and data privacy processes were adequate to protect or assist communities.

CONCLUSIONS

Ethical review of community-based health research should apply the Belmont principles to communities. Researchers should adopt additional approaches to community-based research by engaging communities as active partners throughout the research process, focusing on community priorities, and taking extra precautions to assure individual and community privacy. Plans for meaningful dissemination of results to communities should be part of the research design.

State mental health policy: It's never too late to do it right: lessons from behavioral health reform in New Mexico

This column describes an initiative to reform the public behavioral health system in New Mexico, which has placed publicly funded services under the management of a single for-profit private corporation. The authors discuss problems that they attribute to the state's "top-down model of planning and implementation": complex documentation requirements that increase administrative burden on providers, unrealistically high expectations for a comprehensive information technology system, inadequate monitoring that hampers assessment of reform, and insufficient attention to the rural safety net. They call on other states to better incorporate experiences of those delivering and receiving services into the design and timing of reform initiatives.

Community participation in New Mexico's behavioral health care reform

In 2005, New Mexico implemented a unique reform in managed behavioral health services that seeks to ensure delivery of consumer-driven, recovery-oriented care to low-income individuals. Distinguishing features of the reform are the Local Collaboratives (LCs), regionally based community organizations designed by state government to represent behavioral health concerns of New Mexico's diverse cultural populations. We examine community response to the LCs, focusing on two broad sets of themes derived from 18 months of ethnographic fieldwork. The first set--structure and function--encompasses several issues: predominance of provider versus consumer voice; insufficient resources to support internal operations; imposition of state administrative demands; and perceived lack of state response to LC efforts. The second set--participation and collaboration--reveals how problems of information flow and other logistical factors impact involvement in LCs and how the construction of "community" introduced under this initiative exacerbates tensions across localities with varied histories and populations.

Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change

In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.

Capacity for delivering culturally competent mental health services in New Mexico: results of a statewide agency survey

The Federal government has promoted National Standards for Culturally and Linguistically Appropriate Services (CLAS) to reduce mental health disparities among Hispanic and Native American populations. In 2005, the State of New Mexico embarked upon a comprehensive reform of its behavioral health system with an emphasis on improving cultural competency. Using survey methods, we examine which language access services (i.e., capacity for bilingual care, interpretation, and translated written materials) and organizational supports (i.e., training, self-assessments of cultural competency, and collection of cultural data) mental health agencies in New Mexico had at the onset of a public sector mental health reform (Office of Minority Health 2001).

Medicaid managed care for mental health services: the survival of safety net institutions in rural settings

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.

Dialogues on mixed-methods and mental health services research: anticipating challenges, building solutions

Increasingly, contemporary mental health services research projects aim to combine qualitative and quantitative components. Yet researchers often lack theoretical and practical guidance for undertaking such studies. In September 2006 the authors convened under the auspices of the National Institute of Mental Health at a working conference, "Mixed Methods in Community-Based Mental Health Services Research." This meeting provided the opportunity for participants to share their experiences in conducting mixed-methods research, to critically consider problems they had encountered and their solutions, and to develop guiding principles for others conducting similar research. The authors' discussions, which are described in this article, emphasize that the problems encountered by mixed-methods research teams are rarely simple misunderstandings but often reflect epistemological differences that are overlooked in the study planning phases. Failure to acknowledge these different worldviews may result in significant tensions between members of the study team, use of qualitative methods that are insufficient or inappropriate for a particular research question, or serious conflicts when team members belatedly discover they are interpreting key concepts -- or each other's research techniques -- differently. The authors conclude that ongoing communication is the organizing principle for robust and effective mixed-methods research. Among the recommendations for preventing problems are collaboration between quantitative and qualitative researchers during the study design phase; open acknowledgement of the philosophical approaches brought to the study by various team members; and because not all challenges can be anticipated, a shared willingness to negotiate emerging problems.

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

OBJECTIVE

To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.

DATA SOURCES/STUDY SETTING

Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.

STUDY DESIGN

Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.

DATA COLLECTION/EXTRACTION METHODS

SURVEY

multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.

PRINCIPAL FINDINGS

The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.

CONCLUSIONS

MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.

"We never used to do things this way": behavioral health care reform in New Mexico

This column describes the first year of efforts in New Mexico to reform the behavioral health system. The process, guided by principles of cultural exchange theory, seeks to establish a "collaborative culture" among all stakeholders involved, including state agencies, consumers, families, advocates, and providers. Challenges have included inadequate system funding; insufficient development of skill sets among state personnel; underestimation of time and labor needed to address complex tasks; varying federal statutory and funder requirements for individual agencies; lack of a solid infrastructure for data collection, management, and dissemination; and clear definitions of the roles and relationships of local stakeholders to the state leadership group.

Pragmatic help seeking: How sexual and gender minority groups access mental health care in a rural state

OBJECTIVE

This qualitative study examined how lesbian, gay, bisexual, and transgender (LGBT) people in rural areas of the poor and multiethnic state of New Mexico access secular (professional and lay) and sacred (indigenous and Christian) mental health care resources.

METHODS

In-depth, semistructured interviews were used to document the help-seeking processes of 38 rural LGBT people.

RESULTS

Obtaining assistance was complicated by the ideal of self-reliance and the view of mental illness as a sign of weakness. Financial considerations and a lack of and community-based LGBT social networks also exerted substantial influence on help seeking. Many LGBT people would strategically remain silent about their sexuality or gender status and rely on their family ties to access the range of secular and sacred resources that are most commonly available in medically underserved rural communities.

CONCLUSIONS

Although persons from sexual and gender minority groups often experience positive outcomes as a result of help seeking, some LGBT people remain vulnerable to anti-LGBT sentiments that persist within secular and sacred sectors of rural health care systems.

Brief reports: Unequal treatment: mental health care for sexual and gender minority groups in a rural state

OBJECTIVE

This qualitative study examined the social dynamics of communities and clinic settings that impede the delivery of culturally relevant services to lesbian, gay, bisexual, and transgender (LGBT) people living in rural areas.

METHODS

Ethnographic interviews were conducted with 20 providers in rural areas to document their perceptions of LGBT mental health care.

RESULTS

A majority of rural providers claimed that there is no difference between working with LGBT clients and non-LGBT clients. This neutral therapeutic posture may be insufficient when working with rural LGBT clients. Despite providers' claims of acceptance, lack of education about LGBT mental health issues, and homophobia influenced services for rural LGBT people. LGBT clients had been denied services, discouraged from broaching sexuality and gender issues by providers, and secluded within residential treatment settings.

CONCLUSIONS

The challenges of ensuring access to quality care for this population are magnified by provider discourses of "therapeutic neutrality."

Power, Blame, and Accountability: Medicaid Managed Care for Mental Health Services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.

State mental health policy: Another chance to do it right: redesigning public behavioral health care in New Mexico

This month, two columns on mental health reform in New Mexico discuss the transformation of stewardship for mental health in the state of New Mexico and illustrate that these changes are moving along in a direction recommended by the President’s New Freedom Commission on Mental Health. Psychiatric Services will be following these innovative plans with great interest, and we thank the authors of these columns for sharing their perspectives with us. The first column is by Cathleen E. Willging, Ph.D., and Rafael M. Semansky, M.P.P., who shared their perspective on problems with Medicaid reform in New Mexico in an earlier column (1). Now they share lessons they have learned that can inform the new reform in the state. The second column is by Pamela S. Hyde, J.D., a longtime expert in mental health policy and administration who now serves as secretary of the Human Services Department in the Richardson administration in New Mexico (2). In her column she describes plans for transforming stewardship for mental health in the state. These two contributions exemplify what we have been trying to do in the State Mental Health Policy column for many years. They also mark the end of my tenure as column editor. Fred C. Osher, M.D., an expert in state mental health systems, will take over as column editor as I move into the role of Editor of Psychiatric Services. Dr. Osher has served as an advisor to me on many previous columns, and I know that he will oversee the column with skill and creativity.