Intervention IP-055: Community Engagement and Planning (CEP) to Address Depression Disparities
Summary
This intervention compares the effectiveness of Community Engagement and Planning (CEP) versus Resources for Services (RS) to implement depression care to improve mental health-related quality of life and services. Researchers used programs from health, social and other service sectors to implement depression quality improvement toolkits to under-resourced communities over a 12-month period. The findings show that CEP was more effective than RS at improving mental health-related quality of life (HRQL), physical activity, homelessness, health hospitalization and medication visits.
Overview
Compare the effectiveness of Community Engagement and Planning (agency collaboration) versus Resources for Services (individual agency support), to implement evidence-based depression collaborative care, to improve clients’ mental health quality of life and services use.
Research-Tested — Interventions with strong methodological rigor that have demonstrated short-term or long-term positive effects on one or more targeted health outcomes to improve minority health and/or health disparities through quantitative measures; Studies have a control or comparison group and are published in a peer-review journal; No pilot, demonstration or feasibility studies.
Intervention Details
Both Community and Academic/Clinical Researchers
Citations:
-
Wells KB, Jones L, Chung B, Dixon EL, Tang L, Gilmore J, Sherbourne C, Ngo VK, Ong MK, Stockdale S, Ramos E, Belin TR, Miranda J. Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities. Journal of general internal medicine. 2013 Oct;28(10):1268-78. Epub 2013 May 7. PubMed
PubMed Central DOI
Relevance: Main Intervention -
Chung B, Ong M, Ettner SL, Jones F, Gilmore J, McCreary M, Sherbourne C, Ngo V, Koegel P, Tang L, Dixon E, Miranda J, Belin TR, Wells KB. 12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial. Annals of internal medicine. 2014 Nov 18;161(10 Suppl):S23-34. PubMed PubMed Central DOI
Relevance: Post-Intervention Outcomes
Yes
Collaborative care for depression based on Partners in Care, including Cognitive Behavioral Therapy tailored to under-resourced groups
Collaborative care and Cognitive Behavioral Therapy, Kenneth Wells (kwells@mednet.ucla.edu), Jurgen Unutzer (unutzer@uw.edu) and Jeanne Miranda (jmmiranda@mednet.ucla.edu) for CBT
Collaborative care AIMS center: https://aims.uw.edu/CBT for minorities: https://www.rand.org/content/dam/rand/pubs/monograph_reports/2005/MR1198.6.pdfhttps://www.rand.org/health-care/projects/pic.html#:~:text=Partners%20in%20Care%20(PIC)%20consists,socioeconomically%20and%20ethnically%20diverse%20populations.
Citations:
-
Miranda J, Schoenbaum M, Sherbourne C, Duan N, Wells K. Effects of primary care depression treatment on minority patients' clinical status and employment. Archives of general psychiatry. 2004 Aug;61(8):827-34. PubMed DOI
-
Unützer J, Rubenstein L, Katon WJ, Tang L, Duan N, Lagomasino IT, Wells KB. Two-year effects of quality improvement programs on medication management for depression. Archives of general psychiatry. 2001 Oct;58(10):935-42. PubMed DOI
Yes
Contact Information
Kenneth B Wells
UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785665/https://communitypartnersincare.org/
kwells@mednet.ucla.edu
310-794-3728
Results
Improve minority health or the health of other populations with health disparities (e.g. rural populations, populations with low SES, and sexual and gender minorities)
Mental health-related quality of life (HRQL) and depressive disorder
At various months: physical activity, employment, homelessness risk, behavioral health hospitalizations, use of health/community services, medications and visits for depression, community-defined remission, first remission and periods in remission
6-month follow-up: Community Engagement and Planning (CEP) was more effective than Resources for Services (RS) at improving mental health-related quality of life (MHRQL) (OR=0.74, 95% CI=0.57 to 0.95), increased physical activity, and reduced homelessness risk factors and behavioral health hospitalizations12-month sample: CEP compared to RS decreased odds of having reduced MHRQL (OR=0.77, CI=0.61 to 0.97 36-month follow-up: CEP relative RS improved physical health quality of life (PCS-12), between group difference=0.2, CI=0.2 to 2.2), reduced behavioral health hospitalization nights, and increased use of faith-based and community depression services48-month follow-up: CEP was more effective than RS in improving depression remission (OR=1.73, CI: 1.00, 2.99) and community-defined outcome remission (OR=2.43, CI: 1.17, 5.02). CEP relative to RS improved secondary outcomes
All analyses accounted for clustering (clients within programs), weighting, and multiple imputation. Significance of comparisons by intervention status was based on regression coefficients. Results of linear regression models are presented as between group difference, logistic regression as odds ratios (OR), log-linear regression as rate ratios (RR), and Cox proportional hazard regression as hazards ratios (HR) with 95% confidence intervals.
Yes
Evaluations and Assessments
Yes
Process Evaluation: Administrator and Provider surveys
Demographic and Implementation Description
Depression
African American or Black, American Indian or Alaska Native, Asian, Hispanic or Latino, Native Hawaiian or other Pacific Islander, White
People with Lower Socioeconomic Status (SES), Racial and Ethnic Minority Populations
Adults
Socio-demographics / Population Characteristics
Suburban, Urban / Inner City
People with Low Education, People Who Are Homeless
Female, Male
Unspecified
California, Los Angeles
Low SES, Middle SES
Minority Health and Health Disparities Research Framework
| Levels of Influence | |||||
|---|---|---|---|---|---|
| Individual | Interpersonal | Community | Societal | ||
| Determinant Types | Biological | ||||
| Behavioral | ✔ | ✔ | ✔ | ||
| Physical / Built Environment | ✔ | ||||
| Sociocultural Environment | ✔ | ||||
| Health Care System | ✔ | ✔ | |||
Community Involvement
The community's role in different areas of the Intervention (Choices are "No Role", "Participation", and "Leadership"):
Leadership
Leadership
Leadership
Leadership
Leadership
Leadership
Leadership
Leadership
Characteristics and Implementation
Behavior Change, Patient-Clinician Communication, Physical Environmental Change, Quality Improvement or Organizational Change, community engagement and inter-agency collaboration
Secondary Prevention, Tertiary Prevention, Treatment
Clinic / Health Care Facility, Local Community (e.g. Barbershops, Beauty / Hair Salon, Laundromats, Food Markets, Community Centers), Parks and Recreation
In-person, Online/e-Health
Community Health Worker/Promoters, Health Educator, Healthcare Professional (Physician, Nurse, Technician)
Conceptual Framework
Social Cognitive / Social Learning Theory, Theories of Organization Change (e.g. Dimensions of Organizational Change, Stage Theory, Interorganization Relations Theory, Community Coalition Action Theory)
Community Organization / Community Building, Social Ecological Model
Implementation
Cluster Randomized Controlled Trial
1246
1018
2009
2011
Intervention Exposures
10-12 months
Ten webinars in 7 months, community planning over 12-18 months, and for individual participants, flexible selected between service providers and participants
7-8 Sessions
1-2 Hours
Group (e.g. Community leaders), Individual
Grade 12 or higher
Adaptations and Modifications
| Intervention Elements | Modified |
|---|---|
| Content |
Yes |
| Context |
Yes |
| Implementation |
Yes |
| Funding |
Yes |
| Organization |
Yes |
| Providers |
Yes |
| Sociopolitical |
No |
| Stages of Occurrence | Yes |
Modification Details
| Explanation | |
|---|---|
| Content | |
|
Adding Elements, Tailoring |
Community partners gave input into tailoring to local communities and in engaging communities. Agency leaders were supported in tailoring materials to their agencies and clients and adding new elements such as psychoeducation for Cognitive Behavioral Therapy and a "community clinic" for broad access across agencies in the CEP intervention -- all defined as priorities in the planning meetings. This was all done with input through a Community Partnered Participatory Research framework with community leaders as co-leads of the discussion groups. |
| Context | |
|
Format, Personnel, Setting |
In the CEP planning meetings, format was modifiable/tailored, such as adding lay person-led education in Cognitive Behavioral Therapy. This change triggered other adaptations, such as training lay personnel and changing the setting from healthcare settings to community centers or churches. |
| Implementation | |
|
Delivery, Exposure, Study Design |
With community input, the study design was modified to assure that the comparison condition (Resources for Services) included the evidence-based practices of individual agencies. The scope of agencies was expanded to include faith-based and other community-based service areas such as parks and recreation and barber shops. This also improved delivery personnel as well as collaboration across sites, and reinforcing intervention principles in healthcare and community settings broadening exposure. |
| Funding | |
|
Federal Government, Local Government |
The interventions were supported by insurance models and funding from NIMH/NIMHD and local sources such as county agencies. The study also provided a fund to CEP councils to support their innovative ideas. |
| Organization | |
|
Availability of Staffing / Technology / Space, Culture / Climate / Leadership Support, Location |
The usual scope of Collaborative Care and interventions such as Cognitive Behavioral Therapy were expanded in the CEP model, by having broader staffing collaborating in training with healthcare providers, and through the regular leadership meetings in CEP. This built a broader culture across the community for leadership support and also shifted trainings to community locations such as faith-based organizations or parks and recreation settings. |
| Providers | |
|
Training / Skills |
Providers were expanded to include individuals providing social and community services outside of health care settings, for both the CEP and comparison RS condition. |
| Stages of Occurrence | |
|
Implementation, Planning/Pre-implementation/Pilot |
The intervention was primarily modified in the planning stages prior to participant recruitment. However, the modifications added by the CEP oversight committee including their innovations for psychoeducation and community clinic, occurred as they observed the implementation phase and decided what improvements might improve outcomes. |
Impact, Lessons, Components
Yes
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 than did RS agencies. CEP participants viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. Community partners noted developing leadership skills and opportunities from participating in trainings and research. The intervention was used in other geographic areas for under-resourced or at-risk communities.
Engagement of community partners in shared training in evidence-based practices, with adaptations for other community practice and context (health workers/peers, social determinants), coupled with joint planning for implementation adapted to community experience over time.
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 than did RS agencies. CEP participants viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. Community partners noted developing leadership skills and opportunities from participating in trainings and research. The intervention was used in other geographic areas for under-resourced or at-risk communities.
Lessons Learned
1.CPPR engages community partners in interventions.2. Planning requires time and resources for partners.3. Balance time to implement and agency need given economics/stressors.4. Clarify partner expectations and organizational support.5. Be flexible and value contribution.
Insights Gained During Implementation
| Insight Category | Insight Description |
|---|---|
| Cost of Implementing or Sustaining | Future research is needed to clarify mechanisms by exploring linkages of system and provider changes to client outcomes and examining long-term outcomes and intervention costs. |
| Logistics | Compared with RS, CEP increased program and staff training participation. CEP had a greater effect on staff training participation within social-community sectors than RS, but not within healthcare. CEP may promote staff participation in depression improvement in under-resourced communities. |
| Administrative Resources | 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. |
| Equipment / Technologies | Resources for trainings were made broadly available through hardcopy and websites for providers. With partner input, client materials included features such as cartoon/comic book descriptions and videos to be more engaging. |
| Training / Technical Assistance | 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). |
| Staffing | A broad range of staff were included in trainings for provision of case management, education and some clinical services. This included lay person psychoeducation in Cognitive Behavioral Therapy, which expanded access. |
| Recruitment | Recruitment through a combination of healthcare and community-based agencies was feasible and increased sample in under-resourced communities, and in this study. Recruitment was conducted largely by trained community members supervised by research staff to increase community trust. |
Intervention Components
Yes
No
Products, Materials, and Funding
| Used for Implementation | Needed for Sustainability | |
|---|---|---|
| Expertise | ||
|
Community mobilization, community organization/coalition building |
Yes | Yes |
|
Clinical Care |
Yes | Yes |
|
Health Education / Health Literacy |
Yes | Yes |
|
Key informants, Tribal leaders, Community gatekeepers |
Yes | Yes |
|
Patient Navigation |
Yes | Yes |
| Partnerships | ||
|
Community groups (e.g. faith-based organizations, barbershops, beauty-salons, laundromats, food markets, community centers, cultural associations, tribal groups) |
Yes | Yes |
|
Health care facilities (local clinics) |
Yes | Yes |
|
Local leaders/families |
Yes | Yes |
|
Government agencies (city/state/county health department, law enforcement/criminal justice agencies) |
Yes | Yes |
| Funding Sources | ||
|
Fee for service/billing and reimbursement |
Yes | Yes |
|
Public funding (e.g., federal, state or local government) |
Yes | Yes |
|
Private funding (e.g., foundations, corporations, institutions, facilities) |
Yes | Yes |
Product/Material/Tools
| Tailored For Language | Language(s) if other than English | Material | |
|---|---|---|---|
| Outreach/Recruitment Tools | |||
|
Informed Consent Form |
Yes |
Spanish |
https://communitypartnersincare.org/downloads/
|
|
list |
No |
https://communitypartnersincare.org/videos/
|
|
|
Publicity Materials (e.g. Posters, Flyers, Press Releases) |
Yes |
Spanish |
https://communitypartnersincare.org/about-cpic/
|
| Participant Educational Tools | |||
|
Brochures/Factsheets/Pamphlets |
Yes |
Spanish |
https://communitypartnersincare.org/depression-toolkit-resources/
|
| Measurement Tools | |||
|
Standardized Instrument/Measures |
Yes |
Spanish |
https://communitypartnersincare.org/downloads/
|
Implementation Materials and Products
| Material | |
|---|---|
| Implementation/Delivery Materials | |
|
Intervention implementation guidelines |
https://communitypartnersincare.org/community-engagement-and-planning/
|
|
Curricula |
https://communitypartnersincare.org/conference-videos/
|
|
Intervention implementation guidelines, Training/Operations manual |
https://communitypartnersincare.org/resources-for-services/
|
|
Training/Operations manual |
https://communitypartnersincare.org/collaborative-care/
|
|
Guidebooks/Workbooks/Participant Manual |
https://communitypartnersincare.org/depression-care-resources/
|
| Implementation/Output Materials | |
|
Websites (include URL/link) |
https://communitypartnersincare.org/publicationsawards/
|
|
Social/traditional media publicity/news coverage |
https://nam.edu/visualizehealthequity/#/artwork/94
|