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.

An implementation evaluation of the community engagement and planning intervention in the CPIC Depression Care Improvement Trial.

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

Community-partnered evaluation of depression services for clients of community-based agencies in under-resourced communities in Los Angeles.

BACKGROUND: As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. OBJECTIVE: To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles. DESIGN: Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. PARTICIPANTS: Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. MAIN MEASURES: Comparisons by setting in 6-month retrospective recall of depression services use. KEY RESULTS: Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. CONCLUSIONS: Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities.

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

Using a community partnered participatory research approach to implement a randomized controlled trial: planning community partners in care.

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

Effects of psychosocial and situational variables on substance abuse among homeless adults.

Finding direct and indirect influences of salient psychosocial and situational variables on problem substance use among homeless people is important in designing evidence-based, effective, and relevant interventions for this special population. A stress-coping paradigm in conjunction with situational items specialized for homeless people was used to explore predictive relationships in a sample of homeless adults (N = 664) among (a) psychosocial variables of self-esteem, social support, positive and negative coping, and emotional distress, (b) situational variables of homelessness history and quality of recent housing, and (c) outcomes of alcohol use, injection drug use (IDU), and non-IDU. Lower self-esteem predicted greater emotional distress, lower positive coping, greater negative coping, and more alcohol use. Social support predicted less emotional distress and more positive coping. Chronic homelessness predicted more emotional distress, less positive coping, greater alcohol use, and IDU. Poor housing was associated with more alcohol use and IDU. Substance abuse interventions among the homeless should have a dual focus that includes attention to psychological issues and negative coping patterns while also addressing situational, environmental factors, including encouraging provision of permanent supportive housing.

Simple and robust image-based autofocusing for digital microscopy.

A simple image-based autofocusing scheme for digital microscopy is demonstrated that uses as few as two intermediate images to bring the sample into focus. The algorithm is adapted to a commercial inverted microscope and used to automate brightfield and fluorescence imaging of histopathology tissue sections.

Profile of lifetime methamphetamine use among homeless adults in Los Angeles.

Although the dramatic rise of methamphetamine use in the general population has been well-documented, little is known about methamphetamine use in the homeless population. This study examines self-reported methamphetamine use and its correlates among a sample of 664 urban homeless adults in Los Angeles. Over one-quarter of the overall sample, and 60% of whites, disclosed lifetime methamphetamine use. Less than 10% of African-Americans reported ever using methamphetamine. Approximately one-tenth of respondents reported current methamphetamine use; almost 90% of current users shared straws to snort methamphetamine and half used it daily. Logistic regression analysis in younger (18-39) and older (40+) respondents revealed that white ethnicity, polydrug use and binge drinking were independently associated with lifetime methamphetamine use, regardless of age. Injection drug use (IDU) was also an important correlate of methamphetamine use for older African-Americans. IDU was not important for the younger group. Findings suggest that there is need for greater surveillance of methamphetamine use among homeless whites and Hispanics, and methamphetamine-use prevention and reduction targeted to younger, polydrug-using, alcohol-binging homeless adults.

Generating science by training future scholars in nursing research addressing the needs of vulnerable populations.

This chapter focuses on the National Institutes of Health (NIH) T32 National Research Service Award (NRSA) funding mechanism, designed to enhance the development of nurse scientists. The general history and principles underlying NIH funding for T32s as well as the National Institute of Nursing Research's (NINR) involvement in the NRSA program is described, highlighting the University of California Los Angeles School of Nursing's T32 training program in vulnerable populations research and the program and career trajectory data from close to two-thirds of NINR-funded T32s directors. Recommendations for the improvement of NINR-funded T32 training programs are identified. Findings include the need for increased collaboration between institutions receiving T32 funding from the NINR.

Hepatitis C virus infection among homeless men referred from a community clinic.

In this study of factors related to Hepatitis C virus (HCV) infection in 104 homeless HCV-infected men and 94 uninfected homeless men, findings reveal that homeless men with HCV infection are older and more likely to be cocaine injectors than those not infected. Moreover, the sharing of needles, use of injected cocaine during the past 6 months, previous incarceration, veteran status, fair or poor health, and having multiple tattoos are also associated with HCV infection. Reports of having completed the HBV vaccination series, weekly marijuana use, and snorting cocaine or methamphetamine are negatively associated with HCV infection. Among men not reporting lifetime injection drug use, factors such as sharing toothbrushes, having multiple tattoos, being in fair or poor health, and past incarceration are associated with HCV infection. These findings may need to be considered when making screening decisions and counseling homeless male patients about HCV.

Using community-partnered participatory research to address health disparities in a Latino community.

Working in collaborative partnership with communities experiencing health disparities has been identified as a successful strategy to address population health disparities. This article illustrates a collaborative outreach program designed to address health disparities in a poor Latino community in Los Angeles County, California, by training community members to function as lay health advisors (LHAs) to provide health education to members of their own community. The study consisted of three phases, each accomplished in a collaborative partnership among researchers, community residents, community-based organizations, and health officials. In Phase 1, a community needs assessment was conducted to identify a community with demonstrated health disparities and agencies within that community willing to become partners in providing health education. In Phase 2, community members were recruited and trained to function as LHAs. Phase 3 consisted of implementation of community outreach and education activities by the LHAs in their community. This article describes how the study changed over time through responding to challenges that arose in the process of conducting the project, the participatory or collaborative methods used, and feedback received. Strategies for successful research using community partners are presented and implications discussed for future research efforts using community-partnered participatory methods for reducing health disparities.

Risk factors for hepatitis C virus infection among homeless adults.

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use. DESIGN: Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay. SETTINGS: Shelters ( N = 36) and outdoor locations in Los Angeles. PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends. RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users. CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.