Building interdisciplinary/intersectoral research partnerships for community-based mental health research with older minority adults.(ORIGINAL PAPER)

Since the 1960s, when the outspoken statements of once-marginalized communities of African Americans, Latinos, gay and lesbian adults, and women compelled scholarly disciplines to examine their values and methodologies, social scientists have sought ways of using research to engage with communities and address community needs. Some early efforts took the form of rebellion against the constraints of academic research, situating research in the hands of community organizations (Schensul & Schensul, 1978); other efforts moved toward exploring different forms of partnerships between university-based researchers and community agencies and organizations (Berkowitz, 2000; Cheadle et al., 2002; Strand, Marullo, Cutforth, Stoecker, & Donohue, 2003), resulting in research-based forms of service learning and the university-community partnership movement (Schensul & Berg, 2004; Simonelli & Roberts, 1998). In recent years, community organizations themselves have expressed an interest in conducting or controlling their own research activities (Miller & Kelly, 2002). And finally, some researchers have developed their own independent organizations based on strong commitments to conduct research of community benefit, with community partners (Schensul, Weeks, & Singer, 1999).

Scholarly disciplines have claimed their own "space" in translating their research activities into practical use. Given the hegemony of individual research disciplines, however, interdisciplinary research poses multiple challenges as researchers struggle to overcome the received rules of science in their own disciplines, and to negotiate research priorities with others. Our case study illustrates that interdisciplinary struggle can be tempered when the goal of the research involves working with communities to promote structural transformations that reduce disparities and all parties agree on how the issues are to be addressed. Where there is political will to arrive at research consensus, our own experience has shown that stakeholders are more likely to use scarce time and resources to seek the best approaches to research that can achieve these goals rather than trying to promote approaches they believe will further their disciplines or their own disciplinary standing.

Mental illness continues to be a sensitive topic among older adults in general, and minority adults specifically, because emotional distress is not always perceived or interpreted as a mental health problem. Research conducted by anthropologists and cross-cultural psychiatrists shows that older adults, especially those of Latino, Caribbean/Puerto Rican and African-American backgrounds, tend to define emotional problems somatically and do not have the expected emotional vocabularies that signal mental health literacy and mental health problems to mainstream professionally trained clinicians (Bok & Candales, 1985; Borowsky, 2000; Comas-Diaz, 1989;Cuellar & Stanford, 1984;De La Cancela & Guzman, 1991). For many of these elders, having a mental health problem is associated with "being crazy (loco)," or out of control (Schensul, 1992). Further, sadness and loss are considered to be part of the normal course of aging and there are few helping resources available to assist older adults to differentiate between what is "normal" and what is "not normal" in this regard, or when to seek professional help.

Anthropologically derived theories and ethnographic methods that explore meaning associated with mental and physical distress and well-being can add to and strengthen correlational epidemiologic and psychological research and psychiatric case descriptions, enabling improved explanations as well as accurate predictions of trends and patterns. Further, a careful ethnographic consideration of coping strategies, barriers to care, and challenges in help seeking is necessary to ensure that the standard questions about social supports and help seeking included in most psychosocial and health services studies of barriers and facilitators to accessing mental health treatment, are supplemented with the perspectives of the help seekers themselves. To conduct these studies in an ethical manner calls for establishment of an adequate and appropriate crisis intervention system, and advocacy for policy change related to improvements in service delivery, requiring an intersectoral approach.

The interdisciplinary/intersectoral community-based mental health partnership study we describe here combined the "ethnography of emotions" (Guarnaccia, De La Cancela, & Carrillo, 1989; Heurtin-Roberts, Snowden, & Miller, 1997; Kauffman, 1995) and social suffering (Kleinman, Das, & Lock, 1997), and the application of ethnographic methods to the meaning of depression (Schensul & LeCompte, 1999), with epidemiologic and psychosocial survey research and psychiatric screening. The study also depended on anthropological expertise to identify the critical elements of culturally responsive treatment and access improvement as well as the conditions under which treatment may not be necessary. It utilized cross-cultural psychological expertise to identify the best screening and diagnostic tools to be used in an epidemiologic survey designed to obtain the prevalence of depression in a multiethnic population. It utilized psychosocial expertise, derived both from the psychologists and the anthropologists on the team to identify primary predictors of depression. A cross-cultural psychiatrist identified which symptom sets indicate psychosis and suicidality, and which were normal cultural or situational expressions of sadness, grief, loss and psychosocial stress. Finally, to ensure appropriate crisis response and to address issues of service quality and advocacy, as well as entry and study support, the study also included agency and mental health clinic staffs, managers and older adults from the study population. Below we discuss the problems and challenges of interdisciplinary/intersectoral work in this research setting with a special focus on the integration of theoretical and methodological approaches drawn from the disciplines of anthropology, cross-cultural psychology and psychiatry.

Interdisciplinary, community-based research

In this paper, we follow the definition of discipline used by Miller and colleagues who refer to "formal schools of learning that have well-defined norms and rules of conduct and to professions for which such norms and rules of conduct are also well defined" (Miller, Revenson, & Schensul, 2004-5). In community settings, where problems are complex, single disciplines may be unable to offer the best and most complete theoretical and methodological tools for problem identification and solution, a situation calling for interdisciplinary teamwork. Community-based research also addresses issues of social justice, attempting to understand and confront disparities in health and access and the structural and social factors that are responsible for producing and reproducing inequities (Minkler, Blackwell, Thompson, & Tamir, 2003; Minkler & Wallerstein, 2003; Park, Brydon-Miller, Hall, & Jackson, 1993). These issues are best addressed when key stakeholders who have direct experience with disparities form partnerships with researchers in the action-research process to contribute both to science and to the improvement of community health (Minkler & Wallerstein, 2003; J. J. Schensul, 2002). We use the term "intersectoral" to refer to the inclusion of key stakeholders who represent service, policy, development and other action oriented sectors. Community-based research locates investigation in local communities rather than in controlled clinical settings and requires knowledge of and relationship with the community in question including permission to enter the study environment. Thus many interdisciplinary partnerships are also intersectoral, involving other stakeholders as well as community residents who can provide entry, add to the conceptualization of the study, support data collection and utilize the results. Most research partnerships in health focus on environmental, chronic health problems or reproductive health, STDS and HIV-related problems. Our case study adds to the very limited number of published examples of interdisciplinary/intersectoral partnerships that involve the conduct of mental health research and intervention (Belar, 1995; Lester, Cody, & Deuchar, 2002).

Study overview

In 2001, a consortium that included the Institute for Community Research, the Braceland Center for Mental Health and Aging, the North Central Area Agency on Aging, the Hartford Housing Authority, seven community mental health facilities, and senior housing managers and concerned residents identified disparities in mental health status among impoverished older adults as a central focus for research and action. This community-based consortium embarked on a study of factors associated with depression and barriers to mental health treatment among older, low-income adults of diverse ethnic backgrounds that were living in subsidized private and public senior housing.

University-based faculty and students could have conducted this study. However, we have found that universities offer inherent limitations to the ability to remain flexible to respond to the constraints and demands of community based research including the ability to hire, train and promote field researchers without advanced degrees and pay them competitive salaries. In addition, intersectoral and collaborative work have the potential for proceeding more smoothly when not constrained by the individualistic culture of many university departments that encourage researcher independence in research and publications. The ICR and the Braceland Center for Mental Health and Aging are established community and clinical health research centers that can be flexible in these areas. Though the community research partnership consortium did not include full time university faculty, the senior research staff had advanced degrees (Ph.D., M.A.) and several held university appointments

The specific goals of the study were to identify the prevalence and predictors of depression among African American, Caribbean, Latino, European origin and other older adults in senior housing, to refer for treatment participants with markers of clinical depression or anxiety, to study the barriers they encountered in seeking care, including differences in definition and meaning of depression between providers and older adults, and to use the results to promote improvements in mental health service delivery. The outcomes were to contribute to the scientific literature on depression and barriers to care in ethnic minority adults, and at the same time to reduce mental health disparities by improving access and quality of care for depression and related problems.

The study involved a number of elements that were based upon and benefited from interdisciplinary/intersectoral collaboration. These included the formation of a partnership of stakeholders, the scholarly work of research design, methods and referral approaches, the development, field testing and implementation of psychometrically rigorous and culturally appropriate measures, interdisciplinary/intersectoral project management, and identifying, training and supporting community research staff. Though we could have addressed other topics, the authors have concurred, based on experience and published literature (cf. Schensul, Weeks, & Singer, 1999; Schensul, 2005, Minkler & Wallerstein, 2003; Israel et al., 2002), that these issues were the most salient to the success of this specific project. We will address each of these in turn, using our case example involving anthropology, psychology, and psychiatry to illustrate how interdisciplinary/intersectoral partnerships enhance community-based research projects and what challenges researchers face in the process

Formation of interdisciplinary partners and the partnership process

The study's lead agency is the Institute for Community Research (ICR), an independent, nonprofit community-based research organization that includes interdisciplinary and intersectoral work in its mission statement (Schensul, 2005). ICR brought to the study long experience in ethnographic and mixed methods research methodology (Schensul, Schensul, & LeCompte, 1999; Schensul et al., 2004; Schensul, 2005; Weeks et al., 1996; Weeks, Singer, Himmelgreen, Richmond, & Romero-Daza, 1998, Weeks et al., 2001; Singer and Weeks, 2005), and a history of successful conduct of community-based interdisciplinary/intersectoral research and relationships. The study of depression…