Patient Navigation for Depressed Mothers in Head Start - An Engagement Strategy

描述(由申请人提供)：产妇抑郁对低收入和少数族裔妇女的影响不成比例，并对其子女产生重大负面影响。在这些妇女中，无数的文化、心理和后勤障碍阻碍了与精神卫生服务的接触，导致获得护理的机会不平等。2009年，医学研究所(IOM)发表了一份里程碑式的报告，《父母、育儿和儿童中的抑郁》，其中认识到参与护理是改善结果的重大障碍，并呼吁采取干预措施，将筛查工作与治疗计划联系起来，并在以社区为基础、以家庭为重点的场所进行。与这份报告一致，我们的研究小组在2010年获得了R01奖(R01MH091871)，在Head Start中进行了一项母亲抑郁症预防干预的随机试验-这是一个由联邦资助的学前项目，为全美约100万低收入家庭的儿童提供服务。在这项正在进行的研究中，Head Start母亲根据她们患上严重抑郁发作(MDE)的风险进行登记；那些在MDE中的母亲被故意排除，并被转介到更明确的护理。这项R21建议将那些被排除在预防试验之外的妇女纳入一项辅助先导研究-其主要目标是开发患者导航作为促进抑郁症护理的模型。患者导航是一种外行交付的病例管理方法，其重点是在定义的事件期间克服护理的后勤障碍，如交通、语言障碍或保险复杂性。然而，由于参与精神卫生保健需要解决额外的文化和心理障碍，我们认为传统的导航模式将不足以达到这一目的。因此，我们将培训我们的领航员参与面试，这是一种得到经验支持的技巧，面试官促进以客户为中心的生活经历探索、共同决策和目标设定，以此作为建立寻求治疗动机的一种方式。我们提出了一项双臂、60名受试者的先导研究，其中我们将：实地测试研究机制，包括在MDE中开始的母亲中随机化的可接受性；使用质量改进方法来优化干预提供；并获得研究参数的经验性估计，以指导适当的随机对照试验的规划。虽然患者导航在成年癌症患者中有新的证据表明可以促进及时使用诊断服务，但它尚未作为促进参与精神卫生保健的机制进行研究。在以儿童为中心的开端环境中学习参与提供了进一步的可能性，以了解如何利用这种以社区为基础的环境--其重点是儿童和家庭--来帮助MDE中的母亲寻求护理。这些知识将为开发干预模式的后续试验提供信息。我们的最终目标是通过Head Start在国家一级传播模式，减少获得精神卫生保健方面的差距。 公共卫生相关性：产妇抑郁对低收入和少数族裔妇女的影响不成比例，并对其子女产生重大负面影响。在这些妇女中，无数的文化、心理和后勤障碍阻碍了与精神卫生服务的接触，导致获得护理的机会不平等。这个R21应用程序建议探索患者导航作为一种机制，以促进参与Head Start中抑郁母亲的护理-这是一个由联邦资助的针对低收入家庭儿童的早期学习计划。通过在导航模型中嵌入基于理论的参与策略，我们的目标是提高心理健康服务的参与度，从而改善抑郁母亲及其子女的结果。

DESCRIPTION (provided by applicant): Maternal depression disproportionately affects low-income and minority women and has substantial negative impacts on their children. Among these women, myriad cultural, psychological and logistic barriers impede engagement with mental health services, resulting in disparities in access to care. In 2009, the Institute of Medicine (IOM) published a landmark report, Depression in Parents, Parenting, and Children, in which it recognized engagement with care to be a substantial hurdle to better outcomes, and called for interventions that link screening efforts to treatment plans, and that take place in community-based, family-focused venues. Consistent with this report, our research group obtained an R01 award (R01MH091871) in 2010 to conduct a randomized trial of a maternal depression prevention intervention in Head Start - a federally funded preschool program that provides services for ~1 million children of low-income families across the US. In this ongoing study, Head Start mothers are enrolled based on their risk for developing major depressive episode (MDE); those in MDE are deliberately excluded and referred to more definitive care. This R21 proposes to enroll those women excluded from the prevention trial in an adjunct pilot study - the principal goal of which is to develop Patient Navigation as a model to promote engagement with depression care. Patient Navigation is a lay-delivered case management approach that focuses on overcoming logistical hurdles to care, such as transportation, language barriers or insurance complexities, during a defined episode. However, because engaging with mental health care requires addressing additional cultural and psychological barriers, we believe that traditional Navigation models will be insufficient for this purpose. We will thus train our navigators in the 'Engagement Interview,' an empirically-supported technique, in which interviewers facilitate client-focused exploration of life experiences, shared decision making, and goal setting as a way to build motivation to seek treatment. We propose a two-arm, 60-subject pilot study, within which we will: field test study mechanics, including the acceptabiliy of randomization among Head Start mothers in MDE; use quality improvement methods to optimize intervention delivery; and obtain empiric estimates of study parameters to inform the planning of an appropriately powered RCT. Although Patient Navigation has emerging evidence among adult cancer patients for promoting timely use of diagnostic services, it has yet to be studied as a mechanism to promote engagement with mental health care. Studying engagement in the child-focused Head Start setting offers the further possibility of learning how such a community-based setting - with its emphasis on children and family - can be leveraged to help mothers in MDE seek care. Such knowledge will inform the development of a subsequent trial of the intervention model. Our ultimate goal is model dissemination at the national level through Head Start and a reduction in disparities in access to mental health care. PUBLIC HEALTH RELEVANCE: Maternal depression disproportionately affects low-income and minority women and has substantial negative impacts on their children. Among these women, myriad cultural, psychological and logistic barriers impede engagement with mental health services, resulting in disparities in access to care. This R21 application proposes to explore Patient Navigation as a mechanism to promote engagement with care for depressed mothers in Head Start - a federally funded early learning program for children of low-income families. By embedding theory-based engagement strategies in the navigation model, we aim to improve engagement with mental health services, and thereby improve outcomes for both depressed mothers and their children.