How Should We Measure Effectiveness of Medical-Legal Partnerships?

Medical-legal partnerships (MLPs) try to mitigate health inequity by uniting legal and health professionals to respond to legal determinants of patients' health. While there is a long tradition of "patients-to-policy" work in MLPs, the current empirical evidence base has evaluated MLP effectiveness by assessing benefits to individual patients, clinicians, and hospital and legal systems. This article calls for future research to measure how community power, which includes shifting power to impacted communities to develop and lead equity-focused agendas, is built as both a process and an outcome of MLPs.

Designing and Developing a Medical-Legal Partnership to Address Cancer Patients' Health-Harming Legal Needs.

The Georgetown University's Cancer Legal Assistance and Well-being Project launched in 2020 as a medical-legal partnership that works with health care providers at a Washington, D.C. safety-net hospital to treat the health-harming legal needs of historically and intentionally marginalized patients with cancer.

Maintaining Family Engagement During Home Visitor Turnover: a Mixed Methods Study of Best Practices.

Evidence-based home visiting services (EBHV) are available in states and localities nationwide through the federally-funded Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Nevertheless, the anticipated benefits of EBHV, such as improved child developmental outcomes and increased positive parenting practices, may be undermined by the fact that most families withdraw from services earlier than the model developers planned. Prior studies have linked family attrition with staff turnover. The current study used a mixed methods design to investigate the conditions under which families remained active in the home visiting program after their assigned home visitor resigned. Coincidence Analysis revealed that giving families advance notice (at least 1 month) prior to the home visitors' upcoming resignation or developing a strong positive working alliance with the inheriting home visitor appears to independently make a difference for ongoing family engagement at 3 and 6 months following a staff transition. These findings suggest that emphasizing how staff turnover is managed may mitigate the risk of family withdrawal during these transitions.

Legal Needs and Health Outcomes for People with Cancer in Medical-Legal Partnership Programs: A Systematic Review.

Medical-legal partnerships (MLPs) integrate lawyers into medical teams to address patients' unmet legal needs that create barriers to good health and well-being (i.e., health-harming legal needs). This systematic review of the peer-reviewed literature focused on measuring 1) cancer patients' legal needs and 2) outcomes for cancer patients after receiving MLP services. Literature was searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for the period 2006-2022. Four articles met the inclusion criteria for objective one: three articles met the criteria for objective two. While limited, the literature provides data that when screened, cancer patients regularly struggle with health-harming legal needs. Preliminary evidence suggests that while MLPs can help resolve legal needs, measuring outcomes of MLP intervention is complex. Further peer-reviewed research is needed to better understand the unmet legal needs of cancer patients and the impact of MLPs on their health.

Leveraging Academic-Medical Legal Partnerships to Advance Health Justice.

Unmet legal needs contribute to housing, income, and food insecurity, along with other conditions that harm health and drive health inequity. Addressing health injustice requires new tools for the next generations of lawyers, doctors, and other healthcare professionals. An interprofessional group of co-authors argue that law and medical schools and other university partners should develop and cultivate Academic Medical-Legal Partnerships (A-MLPs), which are uniquely positioned to leverage service, education, and research resources, to advance health justice.

Co-creating a Legal Check-up in a School-based Health Center Serving Low-income Adolescents.

THE PROBLEM: Marginalized populations experience health-harming legal needs-barriers to good health that require legal advocacy to overcome. Medical-legal partnerships (MLPs) embed lawyers into the healthcare team to resolve these issues, but identifying patients with health-harming legal needs is complex, and screening practices vary across MLPs.Purpose of Article: Academic and community partners who collaborate in an MLP at a school-based health center (SBHC) share their process of co-creating a two-stage legal check-up for adolescents. KEY POINTS: Screening adolescents for health-harming legal needs is challenging. It took ongoing collaboration to refine the process to fit the needs of adolescents and meet the partners' goals. CONCLUSION: Social determinants of health play a significant role in health disparities, and there is a need for innovative solutions to screen and address these in vulnerable populations. Other partners can learn from our experiences to co-create their own approach to addressing health-harming legal needs.

The role of consultative alliance in infant and early childhood mental health consultation: Child, teacher, and classroom outcomes.

Young children's social-emotional development is powerfully shaped by their early environments, which for many includes early childhood education (ECE). Infant and Early Childhood Mental Health Consultation (IECMHC) pairs teachers and infant and early childhood mental health (IECMH) consultants to promote teachers' capacity to foster positive social-emotional development in ECE. Although the outcomes of IECMHC have been well studied, little research has investigated how this model leads to changes for teachers and children. According to theory, the quality of the relationship between teachers and IECMH consultants, termed consultative alliance (CA), is a key mechanism of change. This study analyzed the role of CA on 6-month outcomes of IECMHC in a sample of 316 children, 289 teachers, and 62 IECMH consultants. Results from multilevel models suggested that stronger CA predicted greater improvements in teacher-child closeness and teacher-rated child attachment behaviors. In addition, a strong CA was related to greater improvement in classroom climate, teachers' self-efficacy, and teachers' perceptions of their jobs. This study upholds the centrality of relationship-building and parallel process in mental health consultation, and by advancing understanding of the mechanisms of change for IECMHC may provide salient implications for policy and practice.

El desarrollo socio-emocional de los niños pequeños es formado de manera poderosa por sus tempranos ambientes, los cuales, para muchos incluyen la educación en la temprana niñez (ECE). La Asesoría de Salud Mental del Infante y la Temprana Niñez (IECMHC) empareja maestros y Asesores de la Salud Mental del Infante y la Temprana Niñez (IECMH) para promover la capacidad de los educadores de crear un positivo desarrollo socio-emocional en ECE. A pesar de que los resultados de IECMHC han sido bien estudiados, poca investigación se ha enfocado en cómo este modelo conduce a cambios para educadores y niños. De acuerdo con la teoría, la calidad de la relación entre educadores y Asesores de IECMH, llamada Alianza Consultiva (CA), es un mecanismo clave para el cambio. Este estudio analizó el papel de la Alianza Consultiva en resultados de seis meses de IECMHC en un grupo muestra de 316 niños, 289 educadores y 62 Asesores de IECMH. Los resultados de modelos de multiniveles sugieren que una más fuerte CA predijo mayores mejoras en la cercanía entre educador y niño y las conductas de afectividad del niño evaluadas por el educador. Adicionalmente, una más fuerte CA se relacionó con una mayor mejora en el ambiente del aula de clases, la auto-efectividad de los educadores y las percepciones que los educadores tenían de su trabajo. Este estudio apoya la centralidad de establecer una relación y un proceso paralelo en la asesoría de salud mental, y por medio del avance en la comprensión de los mecanismos de cambio para IECMHC, pudiera proveer implicaciones destacadas para la política y la práctica.

Le développement socio-émotionnel des jeunes enfants est fortement formé par leurs premiers environnements, ce qui pour bien d'entre eux inclut l'enseignement préscolaire. L'approche IECMHC (Infant and Early Childhood Mental Health Consultation soit Consultation en Santé Mentale du Nourrisson et de la Petite Enfance) jumelle des enseignants et des consultants IECHM (Santé Mentale du Nourrisson et de la Petite Enfance) afin de promouvoir la capacité des enseignements à cultiver et à favoriser un développement socio-émotionnel positif dans l'enseignement préscolaire. Bien que les résultats de l'approche IECMHC aient été bien étudiés il existe peu de recherches sur la manière dont ce modèle mène à des changements pour les enseignants et les enfants. Selon la théorie, la qualité de la relation entre les enseignants et les Consultants IECMH, appelée Alliance Consultative (AC), est un mécanisme clé de changement. Cette étude a analysé le rôle de l'Alliance Consultative sur les résultats à six mois de la IECMHC chez un échantillon de 316 enfants, 289 enseignants, et 62 Consultants IECMH. Les résultats de modèles multi-niveaux ont suggéré qu'une AC plus forte prédisait des améliorations plus importantes dans le rapprochement enseignant-enfant et dans les comportements d'attachement de l'enfant évalués par l'enseignant. De plus une AC plus forte était liée à une amélioration plus importante du climat de la salle de classe, de l'auto-efficacité des enseignements et des perceptions que les enseignants se faisaient de leur travail. Cette étude maintient la centralité de la construction de la relation et du processus parallèle dans la consultation de santé mentale. En faisant progresser la compréhension des mécanismes de changement pour la IECMHC elle présente aussi des implications importantes pour les décisions stratégiques et la pratique.

A mixed methods evaluation of an intervention to prevent perinatal depression among Latina immigrants.

Objective: The effectiveness of a cognitive behavioural intervention to prevent perinatal depression in low-income Latina immigrant pregnant women and mothers receiving WIC services was evaluated in a mixed methods study using a community based observational design.Background: The Mothers and Babies Course is a preventive intervention for perinatal depression that is based on cognitive behavioural theory (CBT). CBT is an evidence-based treatment and preventive intervention for perinatal depression.Method: Phase 1 includes 86 Latinas, predominantly Central American immigrant women at high risk for depression, who self-selected into the Mothers and Babies Course, a six-week Spanish CBT group intervention aimed at teaching women mood regulation skills to prevent the onset of depression. Participants, who were recruited from the Women, Infants, and Children services, completed measures of depression and psychopathology at pre-, 6 weeks, and 3 months post-intervention. Phase 2 includes qualitative interviews with a randomly selected subsample (n = 26) from Phase 1 to understand the mechanisms and impact of participants' experiences with the intervention and study.Results: Results indicated no significant differences in depressive symptoms among participants with varied attendance levels (0 class; 1-3 classes = non-completers; 4-6 classes = completers). None of the participants met diagnostic criteria for major depressive disorder at the final data collection period. Despite the varied attendance, both quantitative and qualitative results indicated that completers and non-completers reported similar experiences in the intervention and benefiting from study participation.Conclusion: Conducting mixed methods research highlights the complexity of understanding who can benefit from preventive interventions.

Expulsion prevention: Framework for the role of infant and early childhood mental health consultation in addressing implicit biases.

Young children of color-especially boys-are at disproportionate risk for suspension and expulsion from early care and education settings. Infant and Early Childhood Mental Health Consultation (IECMHC) is an approach associated with lower than expected expulsion rates, but the mechanisms through which it may influence preschool expulsion are unknown. This paper reflects on the parallels between IECMHC and interventions created to reduce implicit bias. Based on interviews with leaders in IECMHC practice, implementation, and evaluation, a theoretical framework was created to articulate how IECMHC is hypothesized to affect expulsion by first reducing the influence of implicit bias on disciplinary decisions. Implications for practice and research are provided.

Los pequeños niños de raza negra -especialmente los varones- están bajo un riesgo desproporcionado en cuanto a la suspensión y expulsión de lugares donde se les presta cuidado y educación tempranos. La Consulta de Salud Mental en la Infancia y la Temprana Niñez (IECMHC) es un acercamiento asociado con niveles más bajos de expulsión que los que se esperan, pero se desconocen los mecanismos a través de los cuales la misma pudiera influir en la expulsión prescolar. Este artículo reflexiona sobre los paralelos entre IECMHC y las intervenciones creadas para reducir los prejuicios implícitos. Con base en entrevistas con los líderes en la práctica, implementación y evaluación de IECMHC, se creó un marco de trabajo para articular cómo IECMHC se plantea como hipótesis para afectar la expulsión por medio de reducir primero la influencia de los implícitos prejuicios sobre las decisiones disciplinarias. Se aportan las implicaciones para la práctica y la investigación.

Les jeunes enfants de couleur - surtout les garçons - sont à risque disproportionné de suspension et d'expulsion d'établissements d'éducation et de crèches. La Consultation de Santé Mentale du Nourrisson et de la Petite Enfance (abrégé en anglais ECMHC) est une approche liée à des taux d'expulsion moins élevés que les taux d'expulsion auxquels on s'attend, mais les mécanismes au travers desquels elle pourrait influencer l'expulsion des crèches sont méconnus. Cet article porte sur les parallèles entre la IECHMH et les interventions créées afin de réduire les préjugés implicites. Basé sur des entretiens avec des praticiens de la pratique de l'IECMHC, sa mise en place et son évaluation, une structure théorique a été créée afin d'articuler la manière dont on suppose que l'IECHHC affecte l'expulsion en réduisant d'abord l'influence des préjugés implicites sur les décisions disciplinaires. Des implications pour la pratique et la recherche sont présentées.

Developing a Model to Address Mental Health, Substance Use, and Intimate Partner Violence Among Home Visiting Clients.

Perinatal women enrolled in home visiting (HV) programs exhibit high rates of depression, substance use, and intimate partner violence (IPV). While HV programs have increasingly screened for these psychosocial risks, initiation and uptake of community-based services to address these risks remain challenging. This project used a community-engaged research approach to engage key HV stakeholders in developing the screening, referral, and individualized prevention and treatment (SCRIPT) model. We highlight how a group of key HV stakeholders-the SCRIPT Advisory Panel-collaborated with academic researchers to develop the SCRIPT model by reviewing literature on HV programs' response to psychosocial risk factors and qualitative data obtained from mental health, substance use, and IPV service providers to whom HV programs referred clients. SCRIPT focuses on (a) screening for psychosocial risks, (b) developing partnerships with outside agencies to address these risk factors, and (c) establishing concrete and systematic processes for client referral and monitoring with outside agencies. SCRIPT provides a structured model for HV programs to systematically identify clients for key psychosocial risks and structure their referral and monitoring process when working with social service agencies. Future work should examine the impact of SCRIPT on mental health, substance use, and IPV service access and use by a vulnerable population.

Adaptation of an evidence-based postpartum depression intervention: feasibility and acceptability of mothers and babies 1-on-1.

BACKGROUND: Mothers and Babies (MB) is a cognitive-behavioral intervention with demonstrated efficacy in reducing depressive symptoms and preventing depressive episodes among perinatal women when delivered in a group format by mental health professionals. Study aims were to describe the adaptation of MB into a 1-on-1 modality (MB 1-on-1) and provide data on the adapted intervention's acceptability and feasibility. METHODS: Seventy-five home visitors trained on MB 1-on-1 delivered the 15-session intervention to 1-2 clients. Client acceptability data assessed intervention enjoyment, comprehension, and usefulness. Home visitor feasibility and acceptability data measured amount of intervention material delivered, client comprehension, and client engagement. RESULTS: Home visitors were all female with 8.8 years of experience on average. 117 clients completed acceptability surveys. Average client age was 21.9 years and 41% were pregnant. Home visitors completely covered 87.9% of sessions and reported clients totally understood MB material 82.5% of the time across sessions, although variability was found in comprehension across modules. 82.0% of clients found MB 1-on-1 enjoyable and 91.6% said they totally understood sessions, when averaged across sessions. Clients enjoyed content on noticing one's mood and pleasant activities. Implementation challenges were client engagement, facilitating completion of personal projects, and difficulty shifting between didactic and interactive activities. CONCLUSIONS: Clients found MB 1-on-1 to be enjoyable, easily understood, and useful. Home visitors reported excellent implementation fidelity and felt clients understood MB material. A refined 12-session version of MB 1-on-1 should be examined for its effectiveness in reducing depressive symptoms, given encouraging feasibility and acceptability data.

A Technical Assistance Model for Guiding Service and Systems Change.

Technical assistance (TA) has been a ubiquitous part of the implementation of policies, programs, and services across public and private enterprise for decades. There have been few attempts to identify critical components of TA and evaluate its effectiveness. Qualitative analysis of interviews with experienced TA providers suggested a continuum of practice anchored at each end by approaches termed content-driven and relationship-based. Content-driven approaches focus on information transfer and referral whereas relationship-based approaches center on the facilitation of behavior and systems change. TA is almost always a mix of these approaches. Fitting the right approach to each situation is the key to success. The structure of TA is conceptualized as a three-phase set of activities (decision-making, implementation, and evaluation) supported by an effective partnership and informed by the overarching context. The strategies for effective TA are consistent with major theories of behavior change but need to be further evaluated and refined.

Integrating Perinatal Depression Screening Into WIC at a Federally Qualified Health Center.

THE PROBLEM: Perinatal depression (PD) is a prevalent condition among low-income women, yet screening during pregnancy and in the first year postpartum is not routine practice in the United States. PURPOSE: A team of academic and community partners share experiences with integrating depression screening into a Special Supplemental Nutrition Program for Women Infants and Children (WIC) that is co-located at an urban Federally Qualified Health Center (FQHC). KEY POINTS: Academic and community partners shared an interest in integrating depression screening into WIC; however, there were implementation challenges. The partners identified strategies to mitigate barriers to screening in the WIC program. As a result, more than 1,000 pregnant and postpartum women were screened for depression and referred for additional services. CONCLUSION: Successful integration of the Patient Health Questionnaire, a 2-question validated depression screener in this co-located WIC program, demonstrates the feasibility of this approach for other communities.

Preventing Perinatal Depression in High Risk Women: Moving the Mothers and Babies Course from Clinical Trials to Community Implementation.

A growing research literature highlights the public health need for preventive interventions to reduce symptoms and incidence of perinatal depression among vulnerable populations. The Mothers and Babies (MB) course is a cognitive-behavioral intervention designed to teach mood regulation skills to English- and Spanish-speaking low-income women at high risk for perinatal depression. We describe the development of the MB course and evaluate the extent to which research findings support efficacy, effectiveness, and dissemination based on the Society for Prevention Research Standards Committee's standards of evidence. Our review of research and implementation activities suggests that the MB intervention demonstrates promising evidence for efficacy in reducing depressive symptoms; empirical support for prevention of major depressive episodes is still preliminary. Work is in progress to evaluate program effectiveness and prepare for broad dissemination and implementation. The MB course shows promise as an intervention for low-income women at risk for perinatal mood issues. Spanish and English intervention materials have been developed that can be delivered in different settings (hospitals, home visiting), in different dosages (6, 8, or 12 sessions), and via different modalities (group, individual). Evaluating the MB course against current standards is intended to inform other prevention intervention development research.

A systematic review of perinatal depression interventions for adolescent mothers.

Poor, adolescent, racial/ethnic minority women are at great risk for developing perinatal depression. However, little research has been conducted evaluating interventions for this population. We conducted a systematic review of preventive and treatment interventions for perinatal depression tested with adolescents, with a focus on low income, minority populations. Nine research-based articles (including one that reported on two studies) were reviewed systematically, and quality ratings were assigned based on a validated measure assessing randomization, double-blinding, and reporting of participant withdrawals. Two treatment studies were identified, both of which were successful in reducing depression. Eight prevention studies were located, of which four were more efficacious than control conditions in preventing depression. Studies sampled mostly minority, low socioeconomic status adolescents. No consistent characteristics across efficacious interventions could be identified. This review underscores the need for researchers to further investigate and build an evidence base.

Using an Optimality Index to Understand Perinatal Health Disparities: A Pilot Study With Latina Immigrants.

PURPOSE: This study demonstrates preliminary evidence of the utility of an optimality index as a simple tool for monitoring complications across the perinatal period. METHOD: The medical records of 147 Latina women participating in a preventive randomized controlled trial for perinatal depression were reviewed for outcomes across the perinatal period. RESULTS: Application of the optimality index found optimality scores ranging from 77.3% to 97.7% in a Latina immigrant population known to have low rates of low-birthweight infants and preterm birth. Optimality scores were significantly lower among women who had a preterm birth or low-birthweight infant. DISCUSSION: The ability of optimality indices to capture within-group variability will allow for a more nuanced understanding of the antecedents and sequelae of negative birth outcomes. IMPLICATIONS FOR PRACTICE: Increasing reliance on electronic medical records will facilitate the calculation of optimality scores that can be used to track patterns of perinatal health disparities.

Six-month outcomes from a randomized controlled trial to prevent perinatal depression in low-income home visiting clients.

Perinatal depression (PD) has negative consequences for mothers and children and is more prevalent among women of low socioeconomic status. Home visitation programs serve low-income pregnant women at risk for PD. This study tested the efficacy of a group-based cognitive behavioral intervention (Mothers and Babies Course; MB) in reducing depressive symptoms and preventing the onset of perinatal depression among low-income women enrolled in home visitation. A randomized controlled trial was conducted. Seventy-eight women who were pregnant or had a child less than 6 months of age and who were assessed as at risk for PD were randomized to the MB intervention or usual home visiting services. Depressive symptoms were assessed at baseline and 1-week, 3- and 6-months post-intervention; depressive episodes were assessed with a clinical interview at the 6-month follow-up. Depressive symptoms declined at a significantly greater rate for intervention participants than usual care participants between baseline and 1-week, 3 and 6 months post-intervention. At the 6-month follow-up, 15 % of women who received the MB intervention had experienced a major depressive episode as compared with 32 % of women receiving usual care. Integrating mental health interventions into home visitation appears to be a promising approach for preventing PD. Cognitive behavioral techniques can be effective in preventing depression in perinatal populations and treating it.

The latent symptom structure of the Beck depression inventory: second edition in Latina pregnant women.

Pregnancy represents a unique period of time when women are at an increased risk of developing depression. Although the Beck Depression Inventory-Second Edition (BDI-II) is one of the most widely used self-report measures of depression symptomology, its psychometric properties and underlying factor structures have not been determined for antenatal women and among Latinas. The current study evaluated the latent symptom structure of the BDI-II in a community-based sample of Latina pregnant women (N = 217) identified to be at high risk for depression. Exploratory factor analyses were used to identify underlying salient individual item loadings for two- and three-factor models. Confirmatory factor analyses then examined several different indices to determine the best model fit. Examination of exploratory and confirmatory factor analyses supports a three-factor oblique structure of the BDI-II composed of Cognitive-Affective, Somatic, and Pregnancy Symptoms. The three-factor model provides clinicians with the ability to target specific constellations of depressive symptoms instead of relying on the BDI-II total score that represents the overall severity of depression in this population.