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1.  Promotoras as Mental Health Practitioners in Primary Care: A Multi-Method Study of an Intervention to Address Contextual Sources of Depression 
Journal of community health  2011;36(2):316-331.
We assessed the role of promotoras—briefly trained community health workers—in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention’s impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention’s implementation, involving infrastructure at the health centers, boundaries of the promotoras’ roles, and “turf” issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.
doi:10.1007/s10900-010-9313-y
PMCID: PMC3051073  PMID: 20882400
Mental health; Health services accessibility; Primary health care; Community health aides; Community health centers
2.  DEPRESSIVE SYMPTOMS AND THEIR SOCIAL CONTEXTS: A QUALITATIVE SYSTEMATIC LITERATURE REVIEW OF CONTEXTUAL INTERVENTIONS 
Background
Numerous observational studies demonstrate associations between social context and depressive symptoms, yet few intervention trials exist in this arena.
Aims
This review examines intervention trials that explore the impact of contextual change on depressive symptoms.
Methods
Electronic literature databases of PubMed and PsycINFO, bibliographies of retrieved articles and the publicly available internet were searched for English-language articles published between 1997 and 2008. Peer-reviewed studies were eligible for inclusion if they reported contextual interventions and depressive symptoms measures in adult populations without other significant underlying medical or psychological illness. In total, 2,128 studies met search term criteria. Of these, 13 studies meeting inclusion criteria were classified by type of intervention. Qualitative synthesis was used to interpret the mental health impact of contextual interventions.
Results
The interventions focused on employment, housing, poverty, parenting and violence. Eight of these studies reported a decrease in depressive symptoms and/or psychological distress in intervention groups. Interventions varied in focus, length of follow-up and measures of depressive symptoms.
Conclusions
Contextual interventions for the prevention and treatment of depressive symptoms and psychological distress can be effective, though very limited data exist in this field. Policy implications include a greater emphasis on improving context to decrease depression and other mental disorders.
doi:10.1177/0020764010362863
PMCID: PMC3030674  PMID: 20354067
mental health; depression; social context; contextual interventions; housing; economics; violence; employment
3.  Caring for Active Duty Military Personnel in the Civilian Sector 
Due to the wars in Iraq and Afghanistan, the unmet medical and psychological needs of military personnel are creating major challenges. Increasingly, active duty military personnel are seeking physical and mental health services from civilian professionals. The Civilian Medical Resources Network attempts to address these unmet needs. Participants in the Network include primary care and mental health practitioners in all regions of the country. Network professionals provide independent assessments, clinical interventions in acute situations, and documentation that assists GIs in obtaining reassignment or discharge. Most clients who use Network services come from low-income backgrounds and manifest psychological rather than physical disorders. Qualitative themes in professional-client encounters have focused on ethical conflicts, the impact of violence without meaning (especially violence against civilians), and perceived problems in military health and mental health policies. Unmet needs of active duty military personnel deserve more concerted attention from medical professionals and policy makers.
PMCID: PMC3041942  PMID: 21339846
behavioral medicine; health policy; health policy research; mental health; social factors in health and health care; injury; violence
4.  Mentoring Partnerships for Minority Faculty and Graduate Students in Mental Health Services Research 
Objective
The authors developed mentorship programs to train minority junior faculty and advanced graduate students in mental health services research.
Method
The programs target “mentees” in the Southwest United States and offer long-term mentoring, seminars, group supervision, seed funding for peer reviewed research proposals, peer interaction, and weeklong institutes that feature presentations and mentoring by recognized experts.
Results
Evaluations suggest that these programs have influenced participants’ career development. Most mentees have continued to evolve in their research careers, submitted research grant applications, and obtained postdoctoral fellowships, and/or have advanced in faculty positions. Some mentees have expressed an opinion that without the support network that these programs provided, they would have abandoned their academic careers.
Conclusions
Future training efforts should take into account a series of challenges and tensions that affect mentees’ careers and personal lives, including the emotional legacy of discrimination and historical trauma.
doi:10.1176/appi.ap.30.3.205
PMCID: PMC2965353  PMID: 16728767
5.  Multinational Corporations and Health Care in the United States and Latin America: Strategies, Actions, and Effects* 
Journal of health and social behavior  2004;45(Suppl):136-157.
In this article we analyze the corporate dominance of health care in the United States and the dynamics that have motivated the international expansion of multinational health care corporations, especially to Latin America. We identify the strategies, actions, and effects of multinational corporations in health care delivery and public health policies. Our methods have included systematic bibliographical research and in-depth interviews in the United States, Mexico, and Brazil. Influenced by public policy makers in the United States, such organizations as the World Bank, International Monetary Fund, and World Trade Organization have advocated policies that encourage reduction and privatization of health care and public health services previously provided in the public sector. Multinational managed care organizations have entered managed care markets in several Latin American countries at the same time as they were withdrawing from managed care activities in Medicaid and Medicare within the United States. Corporate strategies have culminated in a marked expansion of corporations’ access to social security and related public sector funds for the support of privatized health services. International financial institutions and multinational corporations have influenced reforms that, while favorable to corporate interests, have worsened access to needed services and have strained the remaining public sector institutions. A theoretical approach to these problems emphasizes the falling rate of profit as an economic motivation of corporate actions, silent reform, and the subordination of polity to economy. Praxis to address these problems involves opposition to policies that enhance corporate interests while reducing public sector services, as well as alternative models that emphasize a strengthened public sector.
PMCID: PMC2965354  PMID: 15779471
6.  Educating, Training, and Mentoring Minority Faculty and Other Trainees in Mental Health Services Research 
Objective
The authors describe the evolution of a novel national training program to develop minority faculty for mental health services research careers. Recruiting, training, and sustaining minority health professionals for academic research careers in mental health services research have proven challenging.
Method
Over the past 8 years the authors developed NIMH-funded programs to educate, train, and mentor minority psychiatrists and other junior faculty and graduate and post-graduate students. Their areas of academic interest focus primarily on minority mental health issues in primary care and community settings.
Results
The authors began with a program that targeted local trainees from the University of New Mexico and expanded to regional and national programs offering weeklong institutes, onsite and distance mentoring by experts, and supportive peer interactions that addressed the considerable challenges affecting trainee career decisions and paths.
Conclusions
Early outcomes support the value of these programs.
doi:10.1176/appi.ap.31.2.146
PMCID: PMC2965356  PMID: 17344457
7.  Promotoras as Mental Health Practitioners in Primary Care: A Multi-Method Study of an Intervention to Address Contextual Sources of Depression 
Journal of Community Health  2010;36(2):316-331.
We assessed the role of promotoras—briefly trained community health workers—in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention’s impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention’s implementation, involving infrastructure at the health centers, boundaries of the promotoras’ roles, and “turf” issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.
doi:10.1007/s10900-010-9313-y
PMCID: PMC3051073  PMID: 20882400
Mental health; Health services accessibility; Primary health care; Community health aides; Community health centers
8.  Prenatal Care Utilization for Mothers from Low-Income Areas of New Mexico, 1989–1999 
PLoS ONE  2010;5(9):e12809.
Background
Prenatal care is considered to be an important component of primary health care. Our study compared prenatal care utilization and rates of adverse birth outcomes for mothers from low- and higher-income areas of New Mexico between 1989 and 1999.
Methodology/Principal Findings
Prenatal care indicators included the number of prenatal care visits and the first month of prenatal care. Birth outcome indicators included low birth weight, premature birth, and births linked with death certificates. The results of our study indicated that mothers from low-income areas started their prenatal care significantly later in their pregnancies between 1989 and 1999, and had significantly fewer prenatal visits between 1989 and 1997. For the most part, there were not significant differences in birth outcome indicators between income groupings.
Conclusions/Significance
These findings suggest that while mothers from low-income areas received lower levels of prenatal care, they did not experience a higher level of adverse birth outcomes.
doi:10.1371/journal.pone.0012809
PMCID: PMC2941446  PMID: 20862298
9.  Multimethod Evaluation of Health Policy Change: An Application to Medicaid Managed Care in a Rural State 
Health Services Research  2008;43(4):1325-1347.
Objective
To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.
Data Sources/Study Setting
Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.
Study Design
Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.
Data Collection/Extraction Methods
Survey: multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.
Principal Findings
The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.
Conclusions
MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.
doi:10.1111/j.1475-6773.2008.00842.x
PMCID: PMC2517275  PMID: 18384362
Medicaid managed care; safety net; multimethod research; access; ethnography
10.  Transforming Administrative and Clinical Practice in a Public Behavioral Health System: An Ethnographic Assessment of the Context of Change 
In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services.
Methods
Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period.
Results
New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive.
Discussion
Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.
doi:10.1353/hpu.0.0177
PMCID: PMC2819110  PMID: 19648713
Behavioral health; cultural competency; evidence-based practices; rural; safety-net institutions
11.  The Impact of Changing Medicaid Enrollments on New Mexico's Immunization Program 
PLoS ONE  2008;3(12):e3953.
Background
Immunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico's immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices.
Methods and Findings
This study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment.
Conclusions
New Mexico's improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state's efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.
doi:10.1371/journal.pone.0003953
PMCID: PMC2602595  PMID: 19107189
13.  Commentary—The History and Contradictions of the Health Care Safety Net 
Health Services Research  2005;40(3):941-952.
doi:10.1111/j.1475-6773.2005.00430.x
PMCID: PMC1361178  PMID: 15960699
14.  Critical Incidents of Nonadherence with Standard Precautions Guidelines Among Community Hospital-based Health Care Workers 
OBJECTIVE
To identify, categorize, and assess critical incidents of nonadherence to standard precautions.
DESIGN
Qualitative and quantitative analysis of a written, mail-out survey.
SETTING
Community hospitals.
PARTICIPANTS
Statewide stratified random sample of community hospital-based health care workers at risk for blood exposure.
MAIN VARIABLE
Responses to the question: “Think of an incident during the past year when you didn't adhere to universal precautions. Please describe the situation and why you didn't adhere.”
RESULTS
Reasons given for not using precautions included: belief that stopping to use standard precautions would have put the patient at risk (22%); using precautions would have interfered with patient care (20%); precautions were not warranted in a specific situation (14%); did not anticipate the potential for exposure (14%); and high job demands that had caused respondent to be in a hurry (11%). Less often, equipment was not available (7%), respondent forgot (6%), respondent thought that the patient did not pose a risk (4%), or the available equipment was not effective (3%). In terms of overall exposure rates, 34% of those who described an incident had experienced a sharps injury during the previous 3 months and 42% had experienced a mucocutaneous exposure. In terms of overall nonadherence, 44% wore gloves less than 100% of the time, while 61% washed their hands less than 100% of the time.
Needlestick injuries were lowest among those who had forgotten to use precautions, while mucocutaneous exposures were highest among those who had not anticipated potential exposure while performing the task. Failure to wear gloves routinely was highest among those who said that following precautions interfered with their ability to provide care and among those who believed a particular patient to be low risk; failure to wash hands routinely was also highest among the latter group and lowest among those who said necessary equipment was not available.
CONCLUSIONS
Using specific information about local incidents of nonadherence to standard precautions may enhance training, especially if the program identifies incidents of unanticipated exposure and helps workers plan for them in the future. Closer examination of job demands and responsibilities that interfere with standard precautions may increase the likelihood of adherence.
doi:10.1111/j.1525-1497.2004.20424.x
PMCID: PMC1492480  PMID: 15209585
blood-borne pathogens; needlestick injuries; standard precautions; inservice training
15.  The Latin American Social Medicine database 
BMC Public Health  2004;4:69.
Background
Public health practitioners and researchers for many years have been attempting to understand more clearly the links between social conditions and the health of populations. Until recently, most public health professionals in English-speaking countries were unaware that their colleagues in Latin America had developed an entire field of inquiry and practice devoted to making these links more clearly understood. The Latin American Social Medicine (LASM) database finally bridges this previous gap.
Description
This public health informatics case study describes the key features of a unique information resource intended to improve access to LASM literature and to augment understanding about the social determinants of health. This case study includes both quantitative and qualitative evaluation data. Currently the LASM database at The University of New Mexico brings important information, originally known mostly within professional networks located in Latin American countries to public health professionals worldwide via the Internet. The LASM database uses Spanish, Portuguese, and English language trilingual, structured abstracts to summarize classic and contemporary works.
Conclusion
This database provides helpful information for public health professionals on the social determinants of health and expands access to LASM.
doi:10.1186/1471-2458-4-69
PMCID: PMC544873  PMID: 15627401
16.  Increasing access to Latin American social medicine resources: a preliminary report* 
Purpose: This preliminary report describes the development and implementation of a project to improve access to literature in Latin American social medicine (LASM).
Methods: The University of New Mexico project team collaborated with participants from Argentina, Brazil, Chile, and Ecuador to identify approximately 400 articles and books in Latin American social medicine. Structured abstracts were prepared, translated into English, Spanish, and Portuguese, assigned Medical Subject Headings (MeSH), and loaded into a Web-based database for public searching. The project has initiated Web-based publication for two LASM journals. Evaluation included measures of use and content.
Results: The LASM Website (http://hsc.unm.edu/lasm) and database create access to formerly little-known literature that addresses problems relevant to current medicine and public health. This Website offers a unique resource for researchers, practitioners, and teachers who seek to understand the links between socioeconomic conditions and health. The project provides a model for collaboration between librarians and health care providers. Challenges included procurement of primary material; preparation of concise abstracts; working with trilingual translations of abstracts, metadata, and indexing; and the work processes of the multidisciplinary team.
Conclusions: The literature of Latin American social medicine has become more readily available to researchers worldwide. The LASM project serves as a collaborative model for the creation of sustainable solutions for disseminating information that is difficult to access through traditional methods.
PMCID: PMC209507  PMID: 14566372
18.  Physician-Patient Communication 
Western Journal of Medicine  1987;147(3):328.
PMCID: PMC1025872  PMID: 18750322
19.  The Return of Two-Class Medicine—III Effects of Medi-Cal Reform 
Western Journal of Medicine  1985;142(5):708-709.
California's drastic Medi-Cal reforms have created great difficulties in health care for the poor. Patients' clinical problems seldom are apparent in descriptions of changes in public insurance programs. Rapidly escalating costs of Medi-Cal led to irresistible pressures for reform, especially from the business community. The new Medi-Cal regulations provide for prospective contracts with hospitals for inpatient services, the transfer of “Medically Indigent Adults” to the responsibility of county governments and various other straightforward funding cutbacks. Confusion, disruption of services and adverse health outcomes have accompanied the Medi-Cal reforms.
PMCID: PMC1306167  PMID: 3892917

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