fio

s

iverofe-somse,

nwork productively and is able tomake a contri-nity. In this positive sense, mental health is thell-being and the effective functioning of a commu-roughout the lifespan,mental health is thewell-mmunication skills, learning, resilience and

ental health outcomes.

Archives of Psychiatric Nursing 29 (2015) 1418

Contents lists available at ScienceDirect

Archives of Psych

.e lBACKGROUND OF THE PROBLEM There are signicant differences in social, economic and educationalcontexts among many population groups which subsequently place

them at greater risk for poor mental health. The U.S. Surgeon General'sric nurses to practice fully within their scope. SOCIAL DETERMINANTS OF HEALTH AND DISPARITYon psychiatric nursing and interprofessional research, practice, and educa-tional models that enhance and expand existing roles and allow psychiat-

active and potentiate increased risk for negative mmotion and disease prevention continues to be minimalized or ignored(Calloway, 2007). A social justice perspective (Hoy, 2005) strongly sup-ports the inherent human right to primary, secondary, and tertiarymedicaland mental health care resources (Pearson, 2012). With its longstandingcommitment to cultural competence and social justice, its pivotal role inhealthcare, and its broad educational base, psychiatric nursing iswell posi-tioned for leadership in addressing the gaps in mental health preventionand treatment services for vulnerable and underserved populations. Facil-itating nursing's leadership in this areawill require a sustainedpolicy focus

positive self-esteem. Mental health conditions have a profound effect onthe quality of life and productivity for individuals and families across thelifespan and around the globe. Complex, interactive, and cumulative riskfactors exert adverse effects over the course of a lifetime (WHO, 2001).Many of these risk factors or determinants of mental health and illnessare contextual, foundwithin the demographic, socio-cultural and environ-mental contexts in which people grow, develop and live out their lives. Inaddition to these social determinants, co-morbid health conditions such ascardiovascular disease, hypertension, diabetes and substance use are inter-positioned for leadership in addressing the gaps in mental health prevention and treatment services for vulnerableandunderserved populations. This paper describes these issues, presents psychiatric nursing exemplars that addresstheproblems, andmakes strong recommendations to psychiatric nurse leaders, policymakers andmental health ad-vocates to help achieve change.

2014 Elsevier Inc. All rights reserved.

Psychiatric nurses practice in a variety of health settings caring for indi-viduals from conception through late life who are highly vulnerable andat-risk for mental health disorders. Even with a growing body ofliterature about the importance ofmental health, risk factors formental ill-ness andmental health-related disparities, the focus onmental health pro-

the normal stresses of life, cabution to his or her commufoundation for individualwenity (WHO, 2007, p. 1). Thspring of thinking and coReview Article

Addressing Gaps in Mental Health Needs oUnderserved, and Disenfranchised Populat

Geraldine S. Pearson a,, Vicki P. Hines-Martin b, Lois K. Evana University of Connecticut School of Medicine, Farmington, CTb University of Louisville School of Nursingc University of Pennsylvania School of Nursingd Medical University of South Carolinae University of Virginia School of Nursingf Georgetown University School of Nursing & Health Studies

a b s t r a c t

Psychiatric nurses have an essential role in meeting the mental health needs of ddisenfranchised populations across the lifespan. This paper summarizes the needsfor mental health disorders, acknowledging that such vulnerability is contextual, agological, behavioral, socio-demographic and cultural factors.With its longstanding city and social justice, its pivotal role in healthcare, and its broad educational ba

j ourna l homepage: wwwTheWorld Health Organization (WHO) identies mental health as theabsence of illness and, more broadly and signicantly, as a state of well-being in which an individual realizes his or her own abilities, can cope with

Corresponding Author: G.S. Pearson, PhD, PMHCNS, BC, FAAN, University of ConnecticutSchool of Medicine, Farmington, CT.

E-mail address: gpearson@uchc.edu (G.S. Pearson).

http://dx.doi.org/10.1016/j.apnu.2014.09.0040883-9417/ 2014 Elsevier Inc. All rights reserved.Diverse, At-Risk,ns: A Call for Nursing Actionc, Janet A. York d, Catherine F. Kane e, Edilma L. Yearwood f

se, at-risk, underserved, andindividuals especially at-riskpecic, and inuenced by bi-mitment to cultural sensitiv-psychiatric nursing is well-

iatric Nursing

sev ie r .com/ locate /apnuReport on Mental Health identies that even more than other areas ofhealth and medicine, the mental health eld is plagued by disparities inthe availability of and access to its services. These disparities are viewedreadily through the lenses of racial and cultural diversity, age, and genderin the seminal publication on mental health (DHHS, 1999, p.vi). Morerecently, the social determinants of health (SDH) literature added that

America (MHA, 2008) has also described signicant barriers tomental and

15G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418physical health care access and quality of services for people with mentalhealth conditions and other marginalized groups who are, as a result,largely disenfranchised. Unfortunately, there continues to be a societaldevaluation of any sustained emphasis on mental wellness.

It is imperative that mental illness and resulting disenfranchisementbe reframed as a public health issue on par with other major healthconditions (DHHS, 1999, 2001). All individuals and families are at riskfor stress and situational psychological distress; not all individuals andfamilies, however, have the necessary resources to adequately managedistress. All people need the opportunity to develop selfunderstanding,mental health literacy, coping skills, and effective use of social supportsas well as have access to mental health andmental wellness counselingand support to promote resilience and reduce the risk of mental illness.

Social Determinants of Health

Individuals' overall health suffers because of the social conditions inwhich they live (Marmot, 2006). Social determinants of health havebeen dened as the full set of social characteristics within which livingtakes place (Baum, 2008) or, more specically, characteristics of thephysical and social environments that shape human experience andoffer or limit opportunities for health (Anderson, Scrimshaw, Fullilove,Fielding, & Task Force on Community Preventive Services, 2003).

There is a distinction between underlying determinants of healthinequities and more immediate determinants of individual health(Commission on Social Determinants of Health [CSDH], 2007). TheTask Force on Community Preventive Services examined broaddeterminants of health from an etiological perspective, recognizingconnections between health and sustainable human, cultural, economicand social activities (Anderson et al., 2003). They concluded thatpatterns of health or disease depend on a combination of biologicaltraits, personal behaviors, and characteristics of social and physicalenvironments that shape experiences and provide health opportunities.

Recently, the Surgeon General and the National Prevention Councilidentied four recommendations to promote mental and emotionalwell-being. They included a focus on positive early childhood develop-ment supported by positive parenting and violence free environments;promotion of social connectedness and community engagement; accessto and adequate resources to support mental well-being in individualsmental health disparities are also driven by social, environmental andeconomic structures such as stigma, discrimination, social exclusion,poverty, low educational attainment and the overall health of our living,working and playing environments (WHO, 2014).

Contextually, health disparities are discrepancies in health status,health services, or health outcomes based on social inequalities amongdis-tinct segments of the population. These differences occur based on gender,race or ethnicity, education or income, disability, environment, or socialcondition. Health equity is the promotion and achievement of the highestlevel of health for all people and the absence over time of persistent healthdifferences between racial, ethnic, vulnerable, and underserved groups.Health equity entails focused societal efforts to address avoidable inequal-ities, both by equalizing the conditions supportinghealth for all groups andalso by assuring the provision of minority health services, especially forthose who have experienced socioeconomic disadvantage or historical in-justices. Health equity is achieved when there is a distribution of disease,disability, death, and health service availability that does not create a dis-proportionate burden on one population.

TheNational Association of CommunityHealth Centers (NACHC, 2007)identies access as the critical factor when designating a population asdisenfranchised. NACHC also asserts that the disenfranchised constitute asubset of the underservedpopulation and include those that facemultipleand compounding barriers to care, including lack of insurance, nancialdifculty, differences in language and culture, lack of transportation [and]the lack of providers present or willing to treat them (p.1). Mental Healthand families, and early identication of mental health needs (NationalPrevention Council, 2011, p. 4849).

The impact of environments is a signicant factor. One importantenvironmental aspect that affects mental health disparity is rurality.Research indicates that there is less use of mental health services inrural areas even when availability, accessibility, demographics and needfactors are considered. Residents of rural environments with low popula-tion density obtained less mental health treatment than did residents ofmetropolitan areas, leading to the conclusion that rural residency disad-vantages all rural occupants with respect to mental health treatment(Petterson, Williams, Hauenstein, Rovnyak, & Merwin, 2009). Whilerural residents generally describe their health status as good, racial/ethnicminorities residing in predominantly Caucasian rural areas are found toexperiencemoremental health problems, such as anxiety and depressionthat are risk factors for chronic disease (Bonnar &McCarthy, 2012). Addi-tionally, when a lack of mental health providers exist, rural residents aremore likely to receivemental health serviceswithin the primary care sys-tem, thus, excluding them from specialty mental health care. An evenmore profound disparity is found, however, when gender is considered.Rural women are less likely to receive mental health treatment in eitherprimary care or specialty mental health settings when compared tourban women (Hauenstein et al., 2006).

Conversely, an urban environment contributes to poormental health asa result of the complex and chaotic conditions that may exist within urbanneighborhoods. Issues of overcrowded living spaces, lack of clean and greenareas, limitedparks and recreation facilities, poorhousing conditions, lack ofemployment opportunities, poorly performing and unsafe schools, andcrime exposure and victimization are all contributing factors (Lorencet al., 2012; Redwood et al., 2010). In data from a self-report survey on per-ceived neighborhood stressors in young adults, Snedker and Hooven(2013) found a positive correlation between perceived lack of safety, lackof social support, poverty, neighborhood instability and neighborhood dis-satisfaction with depressed mood, anger and sense of hopelessness instudy respondents. These perceptions expressed by participants in thestudy reect decits in key elements required for emotional well-being.

A decade ago, the New FreedomCommission onMental Health (2003)proposed a transformedmental health systemwhere all Americanswouldshare equally in the best available services regardless of race, gender, eth-nicity or geographic location. Achieving this transformation necessitatesimproved access to quality care that is culturally informed and improvedaccess to quality care across geographic areas. Limited progress has beenmade toward that transformation. Implementation of strategies that areevidence-based are still needed inunderserved areas: professional trainingto construct and provide culturally tailored services, development of anethnically diverse workforce, creating consumer-centered systems, usingtechnologies in tele-mental health, training community stakeholders,and ensuring that those being served have a voice are among the gapsthat continue to exist.

Based on educational preparation and clinical expertise, psychiatric-mental health nurses are in a unique position to help actualize the un-achieved goals identied in the Surgeon General's Reports of 1999 and2001 and the 2003 New Freedom Commission developed during theBush administration. Psychiatric nurses practice in all at-risk geographicareas and with all at-risk populations. They have broad preparation inthe social and biological sciences and in culturally relevant consumerdriven care, including education of patients, families, communities,and indigenous workers. These skills make them ideally suited to assistunderserved populations of all ages [Grossman (York) et al., 2007].

VULNERABILITY ACROSS THE LIFESPAN

It is evident that mental health vulnerabilities exist across thelifespan. Several risk factors common to childhood/adolescence mayoccur with higher frequency among disadvantaged or vulnerablepopulations. In children these risk factors include prenatal damagefrom substance exposure; low birth weight; external risk factors like

sources to meet basic needs and access to resources. Thus, preventive

16 G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418programs that strengthen these factors from pre-birth through late lifehave the greatest potential for helping people stay emotionally healthyand productive throughout their lives.

NURSE EXEMPLARS OF EVIDENCE-BASED PRACTICE THAT ADDRESSDISPARITIES

While many nurse researchers have developed and implementedprograms of mental health-related research with diverse populationsacross the lifespan, ve exemplars will be highlighted here to illustratesome of nursing's relevant long-standing and ongoingwork in the areasof behavioral and psychological health. Each exemplar program in-volves populations with identied health disparities and a high risk ofdisenfranchisement that could restrict health care access. The evidencebased nursing interventions developed by each nurse researcher hasimplications for improved health and applicability to populations in in-ternational settings.

The rst includes a program that involves training home healthnurses to assess for depression in older adults. This evidence-basedTRIAD program for home health care provides workers with theknowledge, skills, motivation and tools to adequately screen this popu-lation, to communicate with health care providers and (more recently)to develop a tailored patient-centered intervention to address positivedepression screens (Brown, Raue, Roos, Sheeran, & Bruce, 2010;Brown et al., 2010). The success of the program was acknowledged bythe American Academy of Nursing when it awarded the program EdgeRunner status in 2011.

The second exemplar targets culturally and economically diversechildren through a parentchild interaction therapy model to reducebehavior problems in children by teaching and strengthening parentingskills. The program has been widely disseminated and implemented inday care centers, Head Start and other early childhood interventionprograms. Financial support to develop, test and disseminate theintervention was supported by the Robert Wood Johnson Foundationpoverty, deprivation, abuse and neglect; poor parentinfant attach-ment; parental mental health disorder, and exposure to traumaticevents. The social environment for children is especially important inthe development of skills and attributes that are protective of mentalhealth for each successive phase of maturation. Adolescents, on theother hand, are exposed to risk factors that include bullying and otherforms of violence, social exclusion, stress associatedwith academic per-formance and demands, enticements to engage in substance use, andvulnerability associated with the prevalence of several psychiatric dis-orders that emerge during the adolescent years. In adulthood, exposureto stressful life events may challenge otherwise adequate coping skills.These stressful events include: divorce or loss of intimate relationships,death of a familymember or close friend, economic hardship/loss of em-ployment, immigration, role conict or overload, experience of racismor discrimination, poor health, accidental or intentional assaults on per-sonal safety including military combat and domestic violence, incarcer-ation and past trauma exposure. Finally, while older adults bring aplethora of wisdom, experience and resilience to the tasks of late life,they, too, encounter certain stressful events with greater frequency.These include higher incidence of death of signicant others, residentialrelocation, loss of role and social status, and loss of health and autono-my. Coping with multiple stressors at a time when capacity may be de-clining stretches reserve and may result in troubling psychiatricsymptoms or disorders. Identication of, and attention to, age-specicfactors and vulnerabilities is critical to the success of any preventionprogram and to the provision of acceptable services that reduce overalldisparities (DHHS, 2001).

The development and enhancement of resilience enable people towithstand stressful insults during periods of risk, and this is best ob-served in the presence of supportive social networks, sufcient re-and the National Institutes of Health (Breitenstein et al., 2012; Grosset al., 2009, 2014).

The third exemplar is of a culturally congruent health promotion anddisease prevention behavioral health intervention to reduce sexual riskbehaviors in African American and Latino adolescents. This researchreceived federal funding from sources such as the National Institutesof Health and the Centers for Disease Control (CDC). The resultingevidence-based curriculumhas been adopted by the CDC and is current-ly being implemented internationally in Africa and Jamaica (Jemmott,Jemmott, & Fong, 2010; Jemmott, Jemmott, Hutchinson, Cederbaum, &OLeary, 2008; Kerr et al., 2013).

Lastly, the Incredible Years Program is an intervention that aims toprevent problems in conduct among at-risk and high-risk youngsters bypromoting social and emotional competence and school readiness skills(Hurlburt, Nguyen, Reid, Webster-Stratton, & Zhang, 2013; Webster-Stratton, Jamila, & Stoolmiller, 2008). The program has undergone nu-merous randomized controlled trials to test and rene the intervention.The programhas been translated intomany languages and is used glob-ally in over fteen countries. Funding to support this workwas obtainedby Head Start and the National Institutes of Health.

PSYCHIATRIC NURSING'S CALL TO ACTION

Psychiatric nurses are well poised to lead the action needed to effecta positive change in the mental health of individuals, groups andcommunities. Nursing has historically focused on making a differencethrough professional education, clinical practice and research. Thetime is now to more clearly advocate for and achieve change throughwork in and with various organizations and by taking advantage ofexisting leadership roles to inuence policy inmultiple areas thatwill af-fect the populations described in this paper. In a prior paper we offeredrecommendations for macro-level activities for research, policy andpractice changes to promote resilience and health/mental health in vul-nerable families (Pearson et al., 2014).

Here we propose policy recommendations in four areas: support forindividual/family/community strengths in any action plan; developmentof collaborative partnerships for prevention and treatment; enhancementof public and professional education and awareness, and advocacy forresearch on mental health promotion, treatment and translation. Each ex-emplar program described here has embedded these four policy recom-mendations in the development of the model. They show that psychiatricnurses engaged in various levels of practice and across different practicesites can make a difference in mental health care, treatment, research andpolicy. The following recommendations provide some guidance.

POLICY RECOMMENDATIONS

I. Support community, family and individual strengths and targetvulnerabilities in any action plan, understanding key drivers ofhealth, disparities, and health equity as crucial to developingroad maps or action plans to improve mental health.

Ia Promotemental health and prevent mental illness on amacroand micro level.

Ib Macro levels include advocacy, policy and political action.Micro levels focus on addressing the needs of families andindividualswhoare identied as at high risk due to situationalor developmental circumstances.

Ic Address chronic social conditions such as poverty, violence,racism, voicelessness and discrimination/oppression thatlead to adverse mental health conditions.

Id Build on intrinsic community or population strengths such asspirituality, identity, values, educational attainment, andlocal leadership. Develop programs founded on individual,family, and social network strengths to mediate risk andsupport resilience.

Beck, C., Buckwalter, K. C., Dudzik, P. M., & Evans, L. K. (2011). Filling the void in geriatric

17G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418Ie Decrease stigma related to the use ofmental health services inthe community through social marketing.

II. Enhance development and implementation of collaborativepartnerships to respond to prevention and treatment needs.

IIa Develop partnerships that represent systems thinking and crit-ical analysis essential for working in collaboration to addressunderlying determinants of health (York et al., 2012).

IIb Take an interprofessional approach to achieving healthequity as recommended byHealthy People 2020, recognizingthe essential role of communities, states, and national organi-zations and includingmonitoring health services trends (U.S.Department of Health and Human Services, 2012).

IIc Explicate and utilize a healthcare home concept for coordi-nated and integrated treatment for underserved populations,using holistic and lifespan approaches.

IId Include collaborative partnerships and interprofessionalpractice. An example would be integrating mental healthscreening, referral and treatment originating in primarycare (Yearwood, Pearson, & Newland, 2012).

III. Promote greater awareness ofmental health via professional andconsumer educational initiatives.

IIIa Educate nurses and consumers about mental health,disparities and related research issues includingunconsciousbiases that can profoundly inuence health care. Educationis key to changing the root causes of mental health disparityin disenfranchised populations and to develop innovativemodels of care.

IIIb Use education to facilitate elimination of the stigma associatedwithmental health issues. Shift the dialogue in nursing beyondcultural competence to achieving greater understanding ofunderservedpopulations, social justice, anddisparities throughhealth services research.

IIIc Utilize the model from the recent project of the AmericanAcademy of Nursing, the Geropsychiatric Nursing Collabora-tive, as a framework for national efforts to raise awarenessdisparities and needs in older adults (Beck, Buckwalter,Dudzik, & Evans, 2011)

IV. Advocate for inclusion of targeted research on mental healthpromotion and treatment models and disparities in healthservices research in the portfolios of the NIH and other funders.

IVa Focus on contextual factors such as how socioeconomicstatus, wealth, education, neighborhood, social support,religiosity, and spirituality relate to mental illness and,conversely, can support mental health.

IVb Address disparities in mental health outcomes and developan understanding of how factors such as acculturation,help-seeking behaviors, stigma, ethnic identity, racism, andspirituality provide protection from, or enhance risk for,mental illness in racial and ethnic minority populations(DHHS, 1999, 2001).

IVc Incorporate frameworks within the context of home andcommunity where social determinants of health and illnesscan serve to inform research (Quiones et al., 2011)

IVd Facilitate sharing of collective knowledge by consumers. Thismight include lessons and strategies among cross-site inter-vention research teams to increase the speed of disseminationand to inform research planning (Department of VeteransAffairs, Health Services Research, & Development Service,2007; Pope & Davis, 2011; Quiones et al., 2011).

IVe Incorporate translational research that tailors interventionsto specic populations.mental health: The geropsychiatric nursing collaborative as a model for change.Nursing Outlook, 59(4), 236242, http://dx.doi.org/10.1016/j.outlook.2011.05.016.

Bonnar, K. K., & McCarthy, M. (2012). Health related quality of life in a rural area with lowracial/ethnic density. Journal of Community Health, 37, 96104.

Breitenstein, S., Gross, D., Fogg, L., Ridge, A., Garvey, C., Julion, W., et al. (2012). The Chica-go Parent program: Comparing 1-year outcomes for African American and Latino par-ents of young children. Research in Nursing & Health, 35, 475489.

Brown, E. L., Raue, P. J., Klimstra, S., Mlodzianowski, A. E., Greenberg, R. L., & Bruce, M. L.(2010). An intervention to improve nursephysician communication in depressioncare. American Journal of Geriatric Psychiatry, 18(6), 483490.

Brown, E. L., Raue, P. J., Roos, B. A., Sheeran, T., & Bruce, M. L. (2010). Training nursing staffto recognize depression in home healthcare. Journal of the American GeriatricsSociology, 58(1), 122128.IVf Continue to investigate differences in stress, coping, andresilience as part of the complex of factors that inuencemental health across the lifespan and within specicpopulation groups.

IVg Lay the groundwork for developing evidence-based preven-tion strategies that build upon community strengths, fosterand support mental health and lessen negative mentalhealth outcomes. Let these strategies dene the policydecisions that inuence mental health care.

SUMMARY

Mental and physical health are inextricably linked. Our increasingawareness of behavioral and mental health challenges is coupled withknowledge of the growth in vulnerable, high-risk populations and thedramatic reduction in behavioral health providers among all profession-al groups. The result is that mental health for diverse, at risk, under-served and disenfranchised populations is a major public healthproblem. Nurses comprise the largest professional health providergroup. Psychiatric nurses specically have a broad base of preparationin physical and mental health, cultural sensitivity, social justice,consumer-driven care, and consumer education for self-care. Thediverse practice areas and populations served by psychiatric nursesmake this nursing specialty ideally suited to help solve this public healthproblem for the 21st Century. Further, psychiatric nursing research hasproduced solutions for many of the mental health preventive andtreatment challenges experienced by vulnerable populations acrossthe lifespan. Greater public awareness and application of theseevidence-based solutions warrant advocacy on the part of all nursingorganizations, advocacy groups, and healthcare professionals. Wemust work toward improving mental health of the nation. Action stepsare recommended for efforts that support individual/family/communitystrengths; collaborative partnerships for prevention and treatment;public and professional education and awareness, and targeted researchon mental health promotion, treatment and translation.

Acknowledgment

The authors wish to thank Mary Moller for her review of an earlierversion of this paper.

The authors alsowish to acknowledge colleagues in the Expert Panelof the American Academy of Nursingwho provided thoughtful and crit-ical input. Please note that this manuscript was the background paperfor the following American Academy of Nursing Policy Brief:

Pearson, G. S., Evans, L. K., Hines-Martin, V. P., Yearwood, E. L., York, J. A.,& Kane, C. F. (2014). Promoting the mental health of families.Nursing Outlook, 62, 225227. Doi.org/http://dx.doi.org/10.1016/j.outlook.2014.04.003.

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Addressing Gaps in Mental Health Needs of Diverse, At-Risk,Underserved, and Disenfranchised Populations: A Call for Nursing ActionBackground of the ProblemSocial Determinants of Health and DisparitySocial Determinants of Health

Vulnerability across the lifespanNurse exemplars of evidence-based practice that address disparitiesPsychiatric nursing's call to actionPolicy recommendationsSummaryAcknowledgmentReferences