12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

Community-based participatory research to engage disadvantaged communities: Levels of engagement reached and how to increase it. A systematic review

Community-based participatory research (CBPR) is one of the most used community engagement frameworks to promote health changes in vulnerable populations. The more a community is engaged, the more a program can impact the social determinants of health. The present study aims to measure the level of engagement reached in randomized controlled trials (RCTs) using CBPR in disadvantaged populations, and to find out the CBPR components that better correlate with a higher level of engagement. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Embase, Web of Science, MEDLINE, Cochrane and Scopus databases were queried. Engagement level was assessed using the revised version of IAP2 spectrum, ranging from "inform" to "shared leadership" . Fifty-one RCTs were included, belonging to 36 engagement programs. Fourteen CBPR reached the highest level of engagement. According to the multivariate logistic regression, a pre-existing community intervention was associated with a higher engagement level (OR = 10.08; p<0.05). The variable "institutional funding" was perfectly correlated with a higher level of engagement. No correlation was found with income status or type of preventive programs. A history of collaboration seems to influence the effectiveness in involving communities burdened with social inequities, so starting new partnerships remains a public health priority to invest on. A strong potentiality of CBPR was described in engaging disadvantaged communities, addressing social determinants of health. The key findings described above should be taken into account when planning a community engagement intervention, to build up an effective collaborative field between researchers and population.

Study protocol for type II hybrid implementation-effectiveness trial of strategies for depression care task-sharing in community health stations in Vietnam: DEP Project

BACKGROUND

It is not clear what the most effective implementation strategies are for supporting the enactment and sustainment of depression care services in primary care settings. This type-II Hybrid Implementation-Effectiveness study will compare the effectiveness of three system-level strategies for implementing depression care programs at 36 community health stations (CHSs) across 2 provinces in Vietnam.

METHODS

In this cluster-randomized controlled trial, CHSs will be randomly assigned to one of three implementation conditions: (1) Usual Implementation (UI), which consists of training workshops and toolkits; (2) Enhanced Supervision (ES), which includes UI combined with bi-weekly/monthly supervision; and (3) Community-Engaged Learning Collaborative (CELC), which includes all components of ES, combined with bi-monthly province-wide learning collaborative meetings, during which cross-site learning and continuous quality improvement (QI) strategies are implemented to achieve better implementation outcomes. The primary outcome will be measured based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation quality, and Maintenance) using indicators on implementation, provider, and client factors. The secondary outcome examines factors associated with barriers and facilitators of quality implementation, while the tertiary outcome evaluates the incremental cost-effectiveness ratio of services provided in the ES and CELC conditions, relative to UI condition for depression care. A total of 1,296 clients receiving depression care at CHSs will be surveyed at baseline and 6-month follow-up to assess mental health and psychosocial outcomes (e.g., depression and anxiety severity, health function, quality of life). Additionally, 180 CHS staff and 180 non-CHS staff will complete pre- and post-training evaluation and surveys at baseline, 6, 12, and 24 months.

DISCUSSION

We hypothesize that the additional implementation supports will make mental health service implementation superior in the ES and CELC arms compared to the UI arm. The findings of this project could identify effective implementation models and assess the added value of specific QI strategies for implementing depression care in primary care settings in Vietnam, with implications and recommendations for other low- and middle-income settings. More importantly, this study will provide evidence for key stakeholders and policymakers to consider policies that disseminate, scale up, and advance quality mental health care in Vietnam.

TRIAL REGISTRATION

NCT04491045 on Clinicaltrials.gov. Registered July 29, 2020.

Realist review of community coalitions and outreach interventions to increase access to primary care for vulnerable populations: a realist review

BACKGROUND

There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents.

OBJECTIVE

To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations.

METHODS

A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening.

RESULTS

We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the "reach" of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered.

CONCLUSION

Realist reviews can help guide the development of locally adapted primary health care interventions.

Multi-Sector Assessment and Client-Perception of Social Need at Long-Term Follow-Up of a Group-Randomized Trial of Community-Engaged Collaborative Care for Adults with Depression

Understanding client perceptions of need for underlying social determinant support may improve services for depression care. This secondary analysis examines perceptions of "social needs" related to housing and employment, financial, and legal (EFL) concerns among individuals with depression. Data were analyzed from Community Partners in Care, a randomized comparative effectiveness trial of multi-sector collaborative care for depression among a sample of people who were predominantly racial/ethnic minorities and low-income. Adults with depression (n = 980) in both interventions were surveyed at 36-month follow-up for (1) being asked about and (2) having social needs for housing or EFL concerns. In multivariate models, life difficulty and mental health visits in non-healthcare sectors predicted being asked about housing and EFL. Lower social determinants of health-related life satisfaction increased the odds of having unmet housing and EFL needs. These findings underscore the role of non-healthcare organizations as community resources for depression care and in screening and addressing social needs.

Study protocol for comparing Screening, Brief Intervention, and Referral to Treatment (SBIRT) to referral as usual for depression in African American churches

Background

Depression is a leading cause of disability worldwide. African American adults, compared to White adults, are half as likely to be screened for depression in primary care settings. Disparities in depression screening contribute to poor clinical outcomes, as African Americans with depression are more disabled and sicker longer compared to Whites. African American churches are trusted settings that provide access to supports for depression. Indeed, in the first study of its kind, the investigators found that 20% of adults in African American churches screened positive for depression using the Patient Health Questionnaire-9 (PHQ-9). However, no subjects with a positive screen (PHQ-9 ≥ 10) accepted a treatment referral when offered by research personnel. Community Health Workers, who are trusted paraprofessionals from the target community, may bridge the gap between depression screening and treatment. The investigators have trained and certified 112 Community Health Workers from 45 African American churches in New York City to deliver an evidence-based intervention called Screening, Brief Intervention, and Referral to Treatment (SBIRT). Thus, the aim of the current study is to test the impact of Community Health Worker-delivered depression screening in Black churches on engagement with clinical services.

Methods

Using a hybrid type 1 effectiveness-implementation design, we propose a 2-arm, mixed-methods cluster randomized controlled trial. Church study sites will be randomized to either SBIRT (intervention arm) or referral as usual (usual care arm). This trial will be conducted with 600 church members across 30 churches (300 intervention; 300 usual care). Our primary outcome is treatment engagement, defined as attending a depression-related clinical visit. Secondary outcomes will be changes in Mental Health-Related Quality of Life and depressive symptoms at 3 and 6 months post-screening. Lastly, we will conduct a concurrent, mixed-methods (qualitative-quantitative) process evaluation to assess contextual facilitators and barriers of screening and referral.

Discussion

This is the first randomized trial of a church-placed, community health worker-delivered intervention for depression in African American populations. This study may provide a novel and effective approach to increasing depression identification and treatment linkage in economically disadvantaged populations with high depression rates.

Trial registration

ClinicalTrials.govNCT04524767. Registered on 21 August 2020.

Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation

BACKGROUND

Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis.

OBJECTIVES

To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events.

MAIN RESULTS

We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies.

AUTHORS' CONCLUSIONS

The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.

Engaging Community Networks to Improve Depression Services: A Cluster-Randomized Trial of a Community Engagement and Planning Intervention

This paper explores the effects of a group-randomized controlled trial, Community Partners in Care (CPIC), on the development of interagency networks for collaborative depression care improvement between a community engagement and planning (CEP) intervention and a resources for services (RS) intervention that provided the same content solely via technical assistance to individual programs. Both interventions consisted of a diverse set of service agencies, including health, mental health, substance abuse treatment, social services, and community-trusted organizations such as churches and parks and recreation centers. Participants in the community councils for the CEP intervention reflected a range of agency leaders, staff, and other stakeholders. Network analysis of partnerships among agencies in the CEP versus RS condition, and qualitative analysis of perspectives on interagency network changes from multiple sources, suggested that agencies in the CEP intervention exhibited greater growth in partnership capacity among themselves than did RS agencies. CEP participants also viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. These descriptive results help to identify plausible mechanisms of action for the CPIC interventions and can be used to guide development of future community engagement interventions and evaluations in under-resourced communities.

Improving access for the vulnerable: a mixed-methods feasibility study of a pop-up model of care in south-eastern Melbourne, Australia

Access to appropriate health and social care is challenging for vulnerable populations. We used a 'pop-up' delivery model to bring community-based services in contact with communities with poor access to health and social care. Our aim was to examine whether pop-up events improve access to essential health and social support services for selected vulnerable communities and increase collaboration between community-based health and social services. Set in south-eastern Melbourne, two pop-up events were held, one with people at risk of homelessness attending a community lunch and the other with South Sudanese women helping at-risk youth. Providers represented 20 dental, housing, justice, employment and mental health services. We made structured observations of each event and held semi-structured interviews with consumers and providers. Pre-post surveys of managers assessed acceptability and perceived impact. We reached 100 community participants who had multiple needs, particularly for dentistry. Following the events, participants reported increased knowledge of services and access pathways, community members spoke of increased trust and partnerships between service providers were fostered. The pop-up model can increase provider collaboration and provide new options for vulnerable populations to access needed services. 'Bringing the service to the person' is a compelling alternative to asking consumers to negotiate complex access pathways.

Applying Community-Partnered Participatory Research Approaches to Develop COVID-19 Solutions

Ethn Dis. 2020;30(3):433-436; doi:10.18865/ed.30.3.433

Preparedness and Community Resilience in Disaster-Prone Areas: Cross-Sectoral Collaborations in South Louisiana, 2018

Objectives. To determine how community-based organizations (CBOs) define priorities for bolstering community resilience, challenges in addressing these priorities, and strategies to address challenges.Methods. The Community Resilience Learning Collaborative and Research Network (C-LEARN) is a multiphase study examining opportunities to improve community resilience to the threats of disaster and climate change in South Louisiana. Phase I of C-LEARN involved using the National Health Security Strategy and Implementation Plan for directed content analysis of key informant interviews with CBO representatives from 47 agencies within South Louisiana between February and May 2018.Results. CBO interviewees highlighted the importance of forging relationships and building trust through diverse cross-sector collaborations and partnerships before disasters. Such collaborations and partnerships were shown to tailor disaster response to the needs of particular communities and populations as well as address key challenges such as gaps in information, services, and resources.Conclusions. Our results encourage a culture of community resilience and community preparedness through partnerships and community-engaged strategies. C-LEARN will utilize the results of our interviews in the design of phase II of our agency-level coalition-building intervention.

Depression Remission From Community Coalitions Versus Individual Program Support for Services: Findings From Community Partners in Care, Los Angeles, California, 2010-2016

Objectives. To explore effects of coalitions (Community Engagement and Planning [CEP]) versus technical assistance (Resources for Services [RS]) for depression collaborative care and the effects of social determinants on long-term remission outcomes. Methods. We randomized 95 health care and community programs in Los Angeles County, California, to CEP or RS. In 2010, 1246 depressed (Patient Health Questionnaire [PHQ-8] ≥ 10) adults enrolled and were invited for baseline and 6-, 12-, and 36-month surveys. Of 598 3-year completers, 283 participated at 4 years (2016). We examined effects of CEP versus RS, social factors (e.g., family income, food insecurity) on time to and periods in clinical (PHQ-8 < 10) and community-defined (PHQ-8 < 10 or PHQ-2 < 3; mental health composite score [MCS-12] > 40, or mental wellness) remission during the course of 3 years, and at 4 years. Results. We found that CEP versus RS increased 4-year depression remission and, for women, community-defined remission outcomes during the course of 3 years. Social factors and clinical factors predicted remission. Conclusions. At 4 years, CEP was more effective than RS at increasing depression remission. Public Health Implications. Coalitions may improve 4-year depression remission, while addressing social and clinical factors associated with depression may hold potential to enhance remission.

Structural Interventions to Reduce and Eliminate Health Disparities

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.

Outcomes of two quality improvement implementation interventions for depression services in adults with substance use problems

Background: Comorbid depression and substance use disorders (SUDs) are associated with poor health and social outcomes disproportionately affecting under-resourced communities.Objectives: To test the hypothesis that a coalition approach to collaborative care (CC) for depression would improve outcomes of hazardous drinking and behavioral health hospitalizations, relative to technical assistance, for individuals with comorbid substance use problems. Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Methods: Two depression CC implementation approaches were compared: Resources for Services (RS) provided expert technical support for CC toolkits to individual programs. Community engagement and planning (CEP) supported multi-sector coalitions in collaborating in planning, adapting, implementing and monitoring CC toolkits. One thousand eighteen individuals with depression (PHQ-8 ≥10) enrolled. Regression analyses estimated intervention effects in participants with comorbid substance use problems (n = 588, 281 females, 307 males). Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Results: There were no significant baseline differences by intervention status among participants with depression and substance use problems. Intervention effects on primary outcomes including depression were not significant at 6 months. Compared to RS, CEP significantly reduced alcohol consumption (CEP = 1.6, RS = 2.1, p = .038), probability of behavioral health hospitalizations (OR = 0.50, p = .036), and use of specialty mental health visits (IRR = 0.52, p = .027), while increasing use of faith-based depression services (IRR = 3.4, p = .001).Conclusions: Given feasibility and possible benefits, CEP should be considered a promising approach to implementing depression CC with potential benefits to adults with comorbid substance use problems.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014

Racial/ethnic minorities in the United States are more likely than Whites to have severe and persistent mental disorders and less likely to access mental health care. This comprehensive review evaluates studies of mental health and mental health care disparities funded by the National Institute of Mental Health (NIMH) to provide a benchmark for the 2015 NIMH revised strategic plan. A total of 615 articles were categorized into five pathways underlying mental health care and three pathways underlying mental health disparities. Identified studies demonstrate that socioeconomic mechanisms and demographic moderators of disparities in mental health status and treatment are well described, as are treatment options that support diverse patient needs. In contrast, there is a need for studies that focus on community- and policy-level predictors of mental health care disparities, link discrimination- and trauma-induced neurobiological pathways to disparities in mental illness, assess the cost effectiveness of disparities reduction programs, and scale up culturally adapted interventions.

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities

INTRODUCTION

Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.

METHODS AND ANALYSIS

The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.

ETHICS AND DISSEMINATION

The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT02986126.

Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic-Community Health Systems

Academic health centers (AHCs) play a significant role in educating the health care workforce, conducting innovative biomedical and clinical research, and delivering high-quality patient care. Much work remains, however, to adequately address the social determinants of health and equity that affect communities where patients live, work, and play. Doing so will help achieve the Quadruple Aim while addressing the unjust social structures that disproportionately impact communities of color and vulnerable populations. AHCs have a timely opportunity to focus their leading roles in education, research, and clinical care on social determinants, moving outside their walls to create academic-community health systems: a collection of academic-community partnerships advancing health equity through collaboration, power sharing, and cocreation.This Perspective proposes four strategies to start developing academic-community health systems. First, embark on all efforts through cocreation with communities. Second, address how future health care professionals are recruited. Third, build the right skills and opportunities for health care professionals to address health inequities. Finally, develop research agendas to evaluate programs addressing inequities. A fully realized vision of an academic-community health system will demonstrate interdependence between AHCs and the community. While considerable AHC resources are invested in building community capacity to improve health and health equity, health systems will also benefit in a multitude of ways, including increasing the diversity of ideas and experiences integrated into health systems. These strategies will support AHCs to embed across each arm of the tripartite mission a focus on partnering with communities to advance health equity together.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

A Comparative Effectiveness Trial of Depression Collaborative Care: Subanalysis of Comorbid Anxiety

The purpose of this exploratory subanalysis was to compare the effects of two depression quality improvement approaches on clinical outcomes and service utilization for individuals with comorbid depression/anxiety. This study used data from Community Partners in Care (CPIC), a cluster-randomized comparative effectiveness trial (N = 1,018; depression = 360; comorbid depression/anxiety = 658). Each intervention arm received the same quality improvement materials, plus either technical support (Resources for Services, RS) or support for collaborative implementation planning (Community Engagement and Planning, CEP). For the comorbid depression/anxiety subgroup, the collaborative planning arm was superior at improving mental health-related quality of life and mental wellness, as well as decreasing behavioral hospitalizations and homelessness risk at 6 months. The effects were not significant at 12 months. A collaborative planning process versus technical support for depression quality improvement can have short-term effects on mental wellness and social determinants of health among those with comorbid depression/anxiety.

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial

Objective

To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period.

Design

Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS.

Setting

Two Los Angeles communities.

Participants

Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino.

Interventions

CEP and RS to support programs in depression QI.

Main Outcome Measures

Intervention training and service-use costs over 12 months.

Results

CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs.

Conclusions

Compared with RS, CEP had higher planning and training costs with similar service-use costs.

Community Partners in Care: 6- and 12-month Outcomes of Community Engagement versus Technical Assistance to Implement Depression Collaborative Care among Depressed Older Adults

Objective

Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 95 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care in underserved communities. This exploratory subanalysis examines 6- and 12-month outcomes among CPIC participants aged >50 years.

Design

Community-partnered, cluster-randomized trial conducted between April 2010 and March 2012.

Setting

Hollywood-Metropolitan (HM) and South Los Angeles (SLA) Service Planning Areas (SPAs), Los Angeles, California.

Participants

394 participants aged >50 years with depressive symptoms (8-item Patient Health Questionnaire score ≥ 10).

Intervention

A community-partnered multi-sector coalition approach (Community Engagement and Planning [CEP]) vs individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care.

Main Outcome Measures

Depressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), community-prioritized outcomes including mental wellness, homelessness risk and physical activity, and services utilization.

Results

At 6 months, CEP was more effective than RS at improving MHRQL and mental wellness among participants aged >50 years; no differences were found in the effects of CEP vs RS on other outcomes. No significant outcome differences between CEP and RS were found at 12 months.

Conclusions

A multisector community coalition approach may offer additional benefits over individual program technical assistance to improve outcomes among depressed adults aged >50 years living in underserved communities.

Whole Person Care in Under-resourced Communities: Stakeholder Priorities at Long-Term Follow-Up in Community Partners in Care

Objective

Depressed individuals may require help from different agencies to address health and social needs, but how such coordination occurs in under-resourced communities is poorly understood. This study sought to identify priorities of Latino and African American depressed clients, explore whether service providers understand client priorities, and describe how providers address them.

Methods

Between October 2014 and February 2015, we interviewed 104 clients stratified by depression history and 50 representatives of different programs in health and social community agencies who participated in Community Partners in Care, a cluster-randomized trial of coalition-building approaches to delivering depression quality improvement programs. Clients were queried about their most pressing needs; program representatives identified their clients' needs and explained how they addressed them.

Results

Physical and mental health were clients' top priorities, followed by housing, caring for and building relationships with others, and employment. While persistently depressed clients prioritized mental health, those with improved depression prioritized relationships with others. Program representatives identified housing, employment, mental health, and improving relationships with others as clients' top priorities. Needs assessment, client-centered services, and linkages to other agencies were main strategies used to address client needs.

Conclusion

Depressed clients have multiple health and social needs, and program representatives in under-resourced communities understand the complexity of clients' needs. Agencies rely on needs assessment and referrals to meet their clients' needs, which enhances the importance of agency partnership in "whole person" initiatives. Our results illustrate agency capacity to adopt integrated care models that will address clients' multiple needs through multi-sector collaboration and describe potential strategies to help reach the goal of whole person care.

Commentary: Applying the Community Partners in Care Approach to the Opioid Crisis

Background

Given national concern over rising mortality from opioid use disorders (OUD) and challenges to increasing OUD treatment access, a coalition approach may hold promise to improve access and outcomes for diverse populations. We present considerations of a community-partnered working group on adapting the Community Partners in Care (CPIC) study and coalition approach to OUD.

Method

During January 2016 through January 2017, academic, provider, consumer and policy stakeholders reviewed options to adapt CPIC's Resources for Services (RS) for individual program technical assistance and Community Engagement and Planning (CEP) for coalition support to OUD treatments, integrating stakeholder input into design options with estimated sample sizes.

Findings

The working group recommended Community Reinforcement and Family Treatment (CRAFT) as a stakeholder-support intervention to facilitate uptake and adherence to Medications for Addiction Treatment (MAT). Recommended implementation interventions for MAT/CRAFT were expert technical assistance supplemented by organizational readiness, and CEP for coalition support with a Learning Collaborative. Power estimation suggests that to compare implementation intervention effects on abstinence would require a somewhat larger enrolled sample and 3-4 times the screening sample as CPIC, and for mortality, at least 5-10 times the enrolled sample as CPIC.

Discussion

Stakeholders viewed the CPIC design and interventions as feasible and acceptable as community-wide approaches for addressing the opioid epidemic, but comparing impacts on mortality would require large, multi-site trials.

Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders' Views of its Promise and Challenge

Objective

To understand potential for multi-sector partnerships among community-based organizations and publicly funded health systems to implement health improvement strategies that advance health equity.

Design

Key stakeholder interviewing during HNI planning and early implementation to elicit perceptions of multi-sector partnerships and innovations required for partnerships to achieve system transformation and health equity.

Setting

In 2014, the Los Angeles County (LAC) Board of Supervisors approved the Health Neighborhood Initiative (HNI) that aims to: 1) improve coordination of health services for behavioral health clients across safety-net providers within neighborhoods; and 2) address social determinants of health through community-driven, public agency sponsored partnerships with community-based organizations.

Participants

Twenty-five semi-structured interviews with 49 leaders from LAC health systems, community-based organizations; and payers.

Results

Leaders perceived partnerships within and beyond health systems as transformative in their potential to: improve access, value, and efficiency; align priorities of safety-net systems and communities; and harness the power of communities to impact health. Leaders identified trust as critical to success in partnerships but named lack of time for relationship-building, limitations in service capacity, and questions about sustainability as barriers to trust-building. Leaders described the need for procedural innovations within health systems that would support equitable partnerships including innovations that would increase transparency and normalize information exchange, share agenda-setting and decision-making power with partners, and institutionalize partnering through training and accountability.

Conclusions

Leaders described improving procedural justice in public agencies' relationships with communities as key to effective partnering for health equity.

Maintaining Internal Validity in Community Partnered Participatory Research: Experience from the Community Partners in Care Study

Objective

With internal validity being a central goal of designed experiments, we seek to elucidate how community partnered participatory research (CPPR) impacts the internal validity of public health comparative-effectiveness research.

Methods

Community Partners in Care (CPIC), a study comparing a community-coalition intervention to direct technical assistance for disseminating depression care to vulnerable populations, is used to illustrate design choices developed with attention to core CPPR principles. The study-design process is reviewed retrospectively and evaluated based on the resulting covariate balance across intervention arms and on broader peer-review assessments. Contributions of the CPIC Council and the study's design committee are highlighted.

Results

CPPR principles contributed to building consensus around the use of randomization, creating a sampling frame, specifying geographic boundaries delimiting the scope of the investigation, grouping similar programs into pairs or other small blocks of units, collaboratively choosing random-number-generator seeds to determine randomized intervention assignments, and addressing logistical constraints in field operations. Study protocols yielded samples that were well-balanced on background characteristics across intervention arms. CPIC has been recognized for scientific merit, has drawn attention from policymakers, and has fueled ongoing research collaborations.

Conclusions

Creative and collaborative fulfillment of CPPR principles reinforced the internal validity of CPIC, strengthening the study's scientific rigor by engaging complementary areas of knowledge and expertise among members of the investigative team.

Community Partnership in Precision Medicine: Themes from a Community Engagement Conference

Background

Patient and community engagement in under-resourced communities is a key issue for precision medicine research. We report proceedings from a community-academic partnered conference in Los Angeles to promote community understanding of precision medicine and generate engagement recommendations.

Methods

Planning group review of planning, presentations, and audience discussions from facilitator notes and participant survey data from a one-day conference.

Findings

Community-academic planning broadened community participation and presentations. More than 80% of survey participants indicated they would participate in the national precision medicine initiative, and most were willing to share diverse sources of data. Discussions identified trust concerns related to historical research abuses, data privacy, potential effects of findings on health care, personal safety, research procedures, the time-frame for benefit, and confusion about different initiatives. Concerns were balanced by belief in science to improve health. Recommendations included a community partnered participatory approach with support for local community and academic teams to engage stakeholders with written/online resources and partnered workgroups addressing key concerns.

Conclusion

Conference participants expressed high willingness to participate in precision medicine studies, but discussions highlighted trust and transparency issues and suggested community partnered research with local capacity building.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

Significance

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

Objective

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

Design

Secondary analyses of a cluster-randomized trial.

Setting

93 health care and community-based programs in two neighborhoods.

Participants

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

Intervention

CEP or RS for implementing depression quality improvement programs.

Outcomes and Analyses

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

Results

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

Conclusions

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

A Window of Opportunity: Visions and Strategies for Behavioral Health Policy Innovation

Objective

The New York City's Thrive (ThriveNYC) and the Los Angeles County Health Neighborhood Initiative (HNI) are two local policies focused on addressing the social determinants of behavioral health as a preventive strategy for improving health service delivery. On January 29, 2016, leaders from both initiatives came together with a range of federal agencies in health care, public health, and policy research at the RAND Corporation in Arlington, Virginia. The goal of this advisory meeting was to share lessons learned, consider research and evaluation strategies, and create a dialogue between stakeholders and federal funders - all with the purpose to build momentum for policy innovation in behavioral health equity.

Methods

This article analyzes ethnographic notes taken during the meeting and in-depth interviews of 14 meeting participants through Kingdon's multiple streams theory of policy change.

Results

Results demonstrated that stakeholders shared a vision for behavioral health policy innovation focused on community engagement and social determinants of health. In addition, Kingdon's model highlighted that the problem, policy and politics streams needed to form a window of opportunity for policy change were coupled, enabling the possibility for behavioral health policy innovation.

Conclusions

The advisory meeting suggested that local policy makers, academics, and community members, together with federal agents, are working to implement behavioral health policy innovation.

Case Study of Resilient Baton Rouge: Applying Depression Collaborative Care and Community Planning to Disaster Recovery

BACKGROUND

Addressing behavioral health impacts of major disasters is a priority of increasing national attention, but there are limited examples of implementation strategies to guide new disaster responses. We provide a case study of an effort being applied in response to the 2016 Great Flood in Baton Rouge.

METHODS

Resilient Baton Rouge was designed to support recovery after major flooding by building local capacity to implement an expanded model of depression collaborative care for adults, coupled with identifying and responding to local priorities and assets for recovery. For a descriptive, initial evaluation, we coupled analysis of documents and process notes with descriptive surveys of participants in initial training and orientation, including preliminary comparisons among licensed and non-licensed participants to identify training priorities.

RESULTS

We expanded local behavioral health service delivery capacity through subgrants to four agencies, provision of training tailored to licensed and non-licensed providers and development of advisory councils and partnerships with grassroots and government agencies. We also undertook initial efforts to enhance national collaboration around post-disaster resilience.

CONCLUSION

Our partnered processes and lessons learned may be applicable to other communities that aim to promote resilience, as well as planning for and responding to post-disaster behavioral health needs.

Improving Depression Care for Adults With Serious Mental Illness in Underresourced Areas: Community Coalitions Versus Technical Support

OBJECTIVE

Community Partners in Care (CPIC) was a group-randomized study of two approaches to implementing expanded collaborative depression care: Community Engagement and Planning (CEP), a coalition approach, and Resources for Services (RS), a technical assistance approach. Collaborative care networks in both arms involved health care and other agencies in five service sectors. This study examined six- and 12-month outcomes for CPIC participants with serious mental illness.

METHODS

This secondary analysis focused on low-income CPIC participants from racial-ethnic minority groups with serious mental illness in underresourced Los Angeles communities (N=504). Serious mental illness was defined as self-reported severe depression (≥20 on the Patient Health Questionnaire-8) at baseline or a lifetime history of bipolar disorder or psychosis. Logistic and Poisson regression with multiple imputation and response weights, controlling for covariates, was used to model intervention effects.

RESULTS

Among CPIC participants, 50% had serious mental illness. Among those with serious mental illness, CEP relative to RS reduced the likelihood of poor mental health-related quality of life (OR=.62, 95% CI=.41-.95) but not depression (primary outcomes); reduced the likelihood of having homelessness risk factors and behavioral health hospitalizations; increased the likelihood of mental wellness; reduced specialty mental health medication and counseling visits; and increased faith-based depression visits (each p<.05) at six months. There were no statistically significant 12-month effects.

CONCLUSIONS

Findings suggest that a coalition approach to implementing expanded collaborative depression care, compared with technical assistance to individual programs, may reduce short-term behavioral health hospitalizations and improve mental health-related quality of life and some social outcomes for adults with serious mental illness, although no evidence was found for long-term effects in this subsample.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

SIGNIFICANCE

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

OBJECTIVE

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

DESIGN

Secondary analyses of a cluster-randomized trial.

SETTING

93 health care and community-based programs in two neighborhoods.

PARTICIPANTS

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

INTERVENTION

CEP or RS for implementing depression quality improvement programs.

OUTCOMES AND ANALYSES

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

RESULTS

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

CONCLUSIONS

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Towards a practical model for community engagement: Advancing the art and science in academic health centers

Introduction

Community engagement (CE) has become more prevalent among academic health centers (AHCs), with significant diversity in practices and language. The array of approaches to CE contributes to confusion among practitioners.

Methods

We have reviewed multiple models of CE utilized by AHCs, Clinical and Translational Science Awards, and higher education institutions overall. Taking these models into consideration, we propose a comprehensive model of CE that encompasses a broader spectrum of activities and programs.

Results

The CE Components Practical Model includes 5 components: Community Outreach and Service, Education, Clinical Care, Research, and Policy and Advocacy. The components are supported by the foundational elements within administrative functions and infrastructure.

Conclusions

This model will accomplish the following: (1) reduce confusion about CE; (2) provide a broader understanding of CE; and (3) increase the ability of CE practitioners to interact with each other through this common reference and engage in advancing CE scholarship.

A Community-Partnered, Participatory, Cluster-Randomized Study of Depression Care Quality Improvement: Three-Year Outcomes

OBJECTIVE

Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 93 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) for implementing depression quality improvement in underserved communities. CEP was more effective than RS in improving mental health-related quality of life, reducing behavioral health hospitalizations, and shifting services toward community-based programs at six months. At 12 months, continued evidence of improvement was found. This study examined three-year outcomes.

METHODS

Among 1,004 participants with depression who were eligible for three-year follow-up, 600 participants from 89 programs completed surveys. Multiple regression analyses estimated intervention effects on poor mental health-related quality of life and depression, physical health-related quality of life, behavioral health hospital nights, and use of services.

RESULTS

At three years, no differences were found in the effects of CEP versus RS on depression or mental health-related quality of life, but CEP had modest effects in improving physical health-related quality of life and reducing behavioral health hospital nights, and CEP participants had more social- and community-sector depression visits and greater use of mood stabilizers. Sensitivity analyses with longitudinal modeling reproduced these findings but found no significant differences between groups in change from baseline to three years.

CONCLUSIONS

At three years, CEP and RS did not have differential effects on primary mental health outcomes, but CEP participants had modest improvements in physical health and fewer behavioral health hospital nights.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors

OBJECTIVE

The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients.

METHODS

In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use.

RESULTS

For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients.

CONCLUSIONS

Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

Community Partners in Care: 6-Month Outcomes of Two Quality Improvement Depression Care Interventions in Male Participants

OBJECTIVE

Limited data exist on approaches to improve depression services for men in under-resourced communities. This article explores this issue using a sub-analysis of male participants in Community Partners in Care (CPIC).

DESIGN

Community partnered, cluster, randomized trial.

SETTING

Hollywood-Metropolitan and South Los Angeles, California.

PARTICIPANTS

423 adult male clients with modified depression (PHQ-8 score≥10).

INTERVENTIONS

Depression collaborative care implementation using community engagement and planning (CEP) across programs compared with the more-traditional individual program, technical assistance (Resources for Services, RS).

MAIN OUTCOME MEASURES

Depressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), mental wellness, services utilization and settings.

RESULTS

At screening, levels of probable depression were moderate to high (17.5%-47.1%) among men across services sectors. Intervention effects on primary outcomes (PHQ-8 score and MHRQL) did not differ. Men in CEP compared with RS had improved mental wellness (OR 1.85, 95% CI 1.00-3.42) and reduced hospitalizations (OR .40, 95% CI .16-.98), with fewer mental health specialty medication visits (IRR 0.33, 95% CI .15-.69), and a trend toward greater faith-based depression visits (IRR 2.89, 95% CI .99-8.45).

CONCLUSIONS

Exploratory sub-analyses suggest that high rates of mainly minority men in under-resourced communities have high prevalence of depression. A multi-sector coalition approach may hold promise for improving community-prioritized outcomes, such as mental wellness and reduced hospitalizations for men, meriting further development of this approach for future research and program design.

Potential prognostic value of clinical characteristics, hormone status and major depressive disorder in breast cancer

AIM

To identify independent factors predicting overall survival (OS) of breast cancer (BC) patients.

PATIENTS & METHODS

Two hundred and eighty one women with BC were recruited and clinical characteristics including lymphovascular invasion, clinical stage of Tumor Node Metastasis and positive axillary lymph nodes were documented; immunohistochemistry/fluorescence in situ hybridization was used to examine the expression of estrogen receptor, progesterone receptor, HER2 and Ki-67; major depressive disorder was assessed with Diagnostic and Statistical Manual of Mental Disorders V.

RESULTS

Multivariable analyses indicated that in BC patients, lymphovascular invasion, Tumor Node Metastasis, pN, Ki-67 and major depressive disorder were significantly negatively correlated with OS; estrogen receptor was significantly positively associated with OS.

CONCLUSION

Early diagnostic approaches and effective psychologic intervention are indispensable for BC patients.

Using Stakeholder Input to Inform an Innovative Research and Policy Initiative to Improve Depression in Safety Net Communities

THE PROBLEM

Depression quality improvement programs based on chronic disease management models have been shown to improve depression outcomes. Nonetheless, access to and the use of such programs is limited in minority, under-resourced communities.

PURPOSE OF ARTICLE

We report on the outcomes of a Delphi-based consensus exercise conducted by our partnership at a community-wide conference in Los Angeles. Participants identified and prioritized the needs of depressed individuals that should be addressed in a county-wide Health Neighborhood Initiative designed to increase existing mental health, substance use, healthcare, and social services for individuals with low socioeconomic position.

KEY POINTS

Participants agreed that housing is the number one priority. Delphi results also illustrate the importance of addressing social, spiritual, and healthcare access needs of depressed individuals.

CONCLUSIONS

Our study shows how to systematically engage community-based organizations, patients, families, and community members in the process of improving the design of community-wide health policy initiatives.

The Role of Faith-Based Organizations in the Depression Care of African Americans and Hispanics in Los Angeles

OBJECTIVE

This study examined use of depression care provided by faith-based organizations (FBOs) by African Americans and Hispanics and factors associated with the receipt of such care, including mental illness severity and use of traditional mental health services.

METHODS

The study used baseline data from the Community Partners in Care study, a group-randomized trial comparing a community-partnered approach with a technical-assistance approach to improving depression care in underresourced communities in Los Angeles. A sample of 947 individuals (48% African American, 27% non-U.S.-born Hispanic, 15% U.S.-born Hispanic, and 10% non-Hispanic white) were surveyed about recent visits to a religious or spiritual place and receipt of FBO depression care. Descriptive analyses compared racial-ethnic, sociodemographic, and health service use variables for three groups: those who did not attend a religious place, those who attended a religious place and did not receive FBO depression services, and those who received FBO depression services. Multinomial logistic regression was used to identify predictors of receipt of FBO depression care.

RESULTS

A larger proportion of African Americans and non-U.S.-born Hispanics received FBO faith-based depression services compared with non-Hispanic whites and with U.S.-born Hispanics. Receipt of FBO depression services was associated with younger age, lifetime diagnosis of mania, use of primary care depression services, and receipt of a mental health service from a substance abuse agency.

CONCLUSIONS

FBO depression services were used in the community, especially by persons from racial-ethnic minority groups. Collaborative efforts between FBOs and traditional health services may increase access to depression services for African Americans and Latinos.

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.

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.

The Impact of Community Engagement on Health, Social, and Utilization Outcomes in Depressed, Impoverished Populations: Secondary Findings from a Randomized Trial

BACKGROUND

Disparities in depression care exist among the poor. Community Partners in Care (CPIC) compared a community coalition model with technical assistance to improve depression services in under-resourced communities. We examine effects on health, social, and utilization outcomes among the poor and, non-poor depressed, and poor subgroups.

METHODS

This study analyzed clients living above (n = 268) and below (n = 750) the federal-poverty level and, among the poor, 3 nonoverlapping subgroups: justice-involved (n = 158), homeless and not justice-involved (n = 298), and other poor (n = 294). Matched programs (n = 93) from health and community sectors were randomly assigned to community engagement and planning (CEP) or resources for services (RS). Primary outcomes were poor mental health-related quality of life and 8-item Patient Health Questionnaire scores, whereas community-prioritized and utilization outcomes were secondary. Effects were scrutinized using false discovery rate-adjusted P values to account for multiple comparisons.

RESULTS

In the impoverished group, CEP and RS clients of participating study programs did not differ in primary outcomes, but CEP more than RS improved mental wellness among the depressed poor (unadjusted P = .004) while providing suggestive evidence for other secondary outcomes. Within the poor subgroups, evidence favoring CEP was only suggestive but was strongest among justice-involved clients.

CONCLUSIONS

A coalition approach to improving outcomes for low-income clients with depression, particularly those involved in the justice system, may offer additional benefits over standard technical assistance programs.

Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation

The aim was to meta-analyze randomized controlled trials of calcium plus vitamin D supplementation and fracture prevention. Meta-analysis showed a significant 15 % reduced risk of total fractures (summary relative risk estimate [SRRE], 0.85; 95 % confidence interval [CI], 0.73-0.98) and a 30 % reduced risk of hip fractures (SRRE, 0.70; 95 % CI, 0.56-0.87).

INTRODUCTION

Calcium plus vitamin D supplementation has been widely recommended to prevent osteoporosis and subsequent fractures; however, considerable controversy exists regarding the association of such supplementation and fracture risk. The aim was to conduct a meta-analysis of randomized controlled trials [RCTs] of calcium plus vitamin D supplementation and fracture prevention in adults.

METHODS

A PubMed literature search was conducted for the period from July 1, 2011 through July 31, 2015. RCTs reporting the effect of calcium plus vitamin D supplementation on fracture incidence were selected from English-language studies. Qualitative and quantitative information was extracted; random-effects meta-analyses were conducted to generate summary relative risk estimates (SRREs) for total and hip fractures. Statistical heterogeneity was assessed using Cochran's Q test and the I (2) statistic, and potential for publication bias was assessed.

RESULTS

Of the citations retrieved, eight studies including 30,970 participants met criteria for inclusion in the primary analysis, reporting 195 hip fractures and 2231 total fractures. Meta-analysis of all studies showed that calcium plus vitamin D supplementation produced a statistically significant 15 % reduced risk of total fractures (SRRE, 0.85; 95 % confidence interval [CI], 0.73-0.98) and a 30 % reduced risk of hip fractures (SRRE, 0.70; 95 % CI, 0.56-0.87). Numerous sensitivity and subgroup analyses produced similar summary associations. A limitation is that this study utilized data from subgroup analysis of the Women's Health Initiative.

CONCLUSIONS

This meta-analysis of RCTs supports the use of calcium plus vitamin D supplements as an intervention for fracture risk reduction in both community-dwelling and institutionalized middle-aged to older adults.

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

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.