115 Tracy Schroepfer and Earlise Ward

- I am an assistant professor in the School of Social Work. And I also am working on this project at the Comprehensive Cancer Center. Although I am up here today, I have quite a team of people that work with me, some of which are sitting over there in the audience. And I have doctoral students, master students, and then community partners. I'm going to skip some of this, because I feel like I think that we have the idea about the disparities. I think I just want to mention one thing and that is the Wisconsin Comprehensive Cancer Control Plan, because it is that plan that really brought this particular project that I'm going to talk about to fruition. I think that we have pretty much discussed the need for models that, or ways to approach cancer health disparities. And we've certainly had some examples this morning. When we started this project, when we thought about how do we address disparities; how can we do this, especially since we're academicians; we're not in the community. How do we make that link? 

And that's where we came up with the model that I'm going to talk to you about today, which we refer to as Partners Building Bridges. We felt like the model needed to be one where somehow we could bridge from being in this institution out into the communities. I know from having worked in communities for 20 years, that there is strengths in communities, and that often they're not recognized. And that it's really important that a model would do just that, that it would recognize, and see us more as equal partners and not as the academicians going in to help people, but rather working together and bringing both our strengths and expertise. And so this is a model that I'm going to talk about the communities today. We're working in nine diverse communities across Wisconsin. It's a model that we're looking to see and testing to see if it's replicable. Does it work across different cultures? Is it sensitive to the culture and the climate of each community? And does it adopt a holistic approach? 

That is, not just focusing on the physical aspects of cancer, but also the psychosocial and the spiritual. I've done hospice work for years, and what I found in working with people who are dying of cancer is that psychosocial is so crucial. That's not to say that the physical is not. It is, but I think that sometimes the psychosocial and the spiritual get lost. And so that's what we really wanted to make sure this was an integral part of this model. So, we're using CBPR, Community Based Participatory Research. This has different principles. Each one of these principles, we're really working to incorporate. So, we truly want the partnership that we've talked about, and we want it to be collaborative. We want there to be a joint involvement in the process, so it's not us doing the work, but together that we're addressing these disparities. 

As I said before, partners do contribute expertise. We share responsibility in ownership. And I'm going to talk about how we do that. And we increase understanding of the issue, not just in the communities. The communities pretty well know what the issue is. It's really us going in and understanding what the issue is in the community. And then a key component is capacity building. And that is the outcome of this model, we hope. That it builds capacity not only for the community to address disparities, but also for the academic partners, our capacity to work hand-in-hand with communities to address the disparities. And then this balance between research and action, and that's very critical to me. 

When I do research, it's applied research. I don't just want to gather information, I want to see change. And it's a critical component of social work. So, here is the model. I'm going to go through each one of these stats. But I just wanted to quickly show you that this is the model itself, steps 1-8. And all along these steps-- and I'll mention this-- we're training and mentoring community members. And we find that they're also training and mentoring us, so it truly is a back and forth relationship. So, the key part to this is the partnership building. And that's really crucial. 

Meeting with communities, talking with them, that's not enough. We've had people tell us you know, researchers never come out to the community. They call us, they email us. But you know, it's too far to come, to go up north to a tribe, you know. People want to do the research, but they don't want to make the trip. They don't want to really see the community. We make that effort. We go out to all of our communities. And we do that regularly. The community, they define the boundaries. 

So when we meet with an organization or a group in a community who wants to work with our project, that community defines what community means to them. In some, it may be-- And I'll talk in a minute about each one. But it could be that they define the community by zip code. It could be that they define it by a county. It's their definition of what they see as their community, and where they want to focus the project. We always do a Memorandum of Understanding with our communities. We sit down and together we work out the responsibilities, so that we both understand what it is that we are doing together. It's a partnership agreement. We each sign it. And that's the basis for our work together. 

In addition, our project gives funds to the community. These are grant funds. Those funds go to the communities, but we don't give them a budget. We don't say, "You must spend it on this." Communities know what to do with the money. And it's their money to do what they will. So, we give them the money. I'll talk about the different steps, and the money at the different steps. But truly, we give it to them, and they use it as they see fit, in terms of the project. Then young community members actively engage in the project, as well as I said my team is made up of students. 

It is really important that we build capacity for this type of research. And I think Dr. Underwood did a great job of explaining that really, it's students. I mean, if we can really begin to really train our young pre-professionals, and it's not just the community, but also the students here at the university that I work with, so they're learning as they work with pre-professionals as well out in the communities. Now, our communities. We're working with nine what's termed "medically underserved communities" in the state of Wisconsin. One is the Sankofa Project. Actually, Dr. Underwood is on the board of the Sankofa Project under the American Cancer Society. And it's African Americans, really at a community level, addressing cancer health disparities. 

Wisconsin Coalition and Mutual Assistance Association, Hmong population. And let me say on Sankofa, they define their community as three zip codes. So we're working in those three zip codes. The Hmong community defined it as the state. The clans are so, they said that there is really no way to say this is our community, because the clans work so closely together. Latino Health Council of Dane County. Dane County is their community. Gerald Ignace Health Center of Milwaukee. This is an urban American-Indian health center. They define theirs as anyone who walks in the door to receive services and those who are enrolled tribal members. 

But they can be enrolled from any of the tribes. Scenic Bluffs Community Health Clinics. Cashton is west Wisconsin, and it's a very rural area. We're working in two counties there: Vernon and Monroe. So that's the rule. And these are the new communities, though they're no longer new, because they've actually already finished one of the big assessments. That is Lac Courte Oreilles Band. And that's northwest Wisconsin. Bad River, Red Cliff. Those are both tribes at the tip of Wisconsin. 

And the 16th Street Community, that's a community health center in Milwaukee. And they serve, about 95% of their population are Latino. And they define theirs as three zip codes, as well. And the reservations, it's the reservation itself. And then we're working with the Amish community, not necessarily on the model. We're really working on partnership building. And we've had some. I'll hopefully have time to say a little about that, because we've actually had some discussions and gone out to the community. Dr. Jim Cleary from Palliative Care at the Cancer Center went out with us. 

The Bishop invited people from the district, and we sat in the Bishop's house and discussed the issues of cancer disparity, and what they felt they needed. So, we're slowly kind of building that partnership. So step one is the partnership building. I can't say enough about that. And it's not just step one, it's all throughout. It's really continuing to develop that partnership. Step two has been completed in all the communities except 16th Street. And this one is the assessing of community readiness. So here what we've done, is we're doing, actually, two assessments. Rather than just assessing at the individual level, we're assessing at the community level. 

So, we interview. We have the community choose their leaders that they want us to interview. And we interview those leaders regarding resources, leadership, the climate, culture in terms of values and beliefs regarding cancer. It's to get an idea of how the leaders see what resources, what strengths and what challenges they have in the community context to deal with cancer. And then those leaders are interviewed by pre-professionals in the community. We train them on interviewing skills. And they actually conduct the interviews themselves. After the leaders have been interviewed, then we analyze the data and then report it back to the community. We ask the community leaders. We give it back to the leaders and ask the leaders to read through it to see if we have captured their words accurately. 

Because we know we're not members of the community, so it's very easy for us to make a mistake. I've already mentioned this. So, the community readiness, it does do, in terms of the qualitative, it really is very rich. The leaders give us lots of information that will help us when we get to the intervention phase of this model. But I just wanted to say also, there is a scoring that goes with this and you can actually score a community's readiness to address cancer health disparities. All the way from a community that gets a one, of no awareness at all, all the way to a high level of community ownership. The score in and of itself is a score. But it does give you an idea of where a community is. You know, if a community is higher up, in terms of stabilization, well you don't want to go in just with pamphlets. You know, some communities-- We're finding that we have one community in particular that is really doing a lot. 

Sankofa, and actually we have two communities. And so it's really important to understand what's already going on in the community, so that we don't replicate, but we build on. Now, as I said, we basically, in terms of the update. The nine communities. We've got the professionals out there. They're trained. They've conducted the interviews. And we, at this point, have gone back to two of the communities with the results. But we are still analyzing the other seven communities. But what we found is that basically, the communities are scoring lower on their level of readiness, except for the two that I mentioned. 

And cultural beliefs and values play a critical role, and that any intervention that we develop will have to take that component into consideration. We also know that we're going to have to think out of the box with interventions. It can't just be a standard, "We're going to bring in this program and we're going to do this." But how do we utilize the community and hopefully bring in not just the community, but the resources in the community, the local businesses, etc. People that are in the community actively working, as well as people in the Cancer Center, etc., who want to go out and do programs. How do we make those connections? Step four is our individual assessment. It's called, "Assessing the Quality of Cancer Care." This we developed. 

And this, we actually interview people who have had cancer, who currently have cancer, and they may or may not be receiving treatment, and people who are dying of cancer. And we, in addition have now developed a caregiver survey because as previously noted about lung cancer in some of our communities, particularly the tribes up north, we have yet to be able to interview anyone with lung cancer, because people die so quickly from lung cancer. So, in order to capture the information about people who have died from lung cancer, we have the caregiver survey. And what this survey does, so we have kind of the contextual piece from the community readiness assessment. We kind of have an idea of what the leadership is in cancer, the resources, etc. Now what we want to do is we want to hear from people who are actually taking this journey in this community with the resources that they have. And you know what have been the things that have gone really well for them? What have been challenges? And so that is where we interview 75 people and we really look at across the cancer journey. As I said before, all the way from screening, diagnosis, treatment, to those people who die. 

And we assess areas. It's very much a mixed method, because we didn't just want to have quantitative. We really wanted to have the voices and allow people just to tell their story. We gather information in all of these areas. And the instruments-- I basically mentioned the caregiver survey. But we've had to develop instruments. We have "A", which is basically surveys asked of all respondents. It captures basic demographic information that would be the same across for anyone. But we had to develop, then, three surveys. "A" kind of tells the interviewer where to go next. 

Survey "B" is the one that asks questions about whether you are currently receiving treatment. Survey "C" is for those people who have cancer, but for whatever reason, they've never received treatment. And survey "D", they are not currently receiving treatment, but have in the past. We now have translated the surveys into Hmong and into Spanish. The next thing is the development of the referral sources. This has become a very integral process but I think it's a key component of this model. When we go into a community, we ask the leaders about, how do we get referrals, these 75 referrals. Where would we get them from? An example is our rural community. And our rural community we're working with Gunderson Lutheran, St. 

Joseph's Hospital, Vernon Memorial Hospital, Vernon Memorial Hospice, Hope, which is an organization. It's a community-based organization. And then the Community Health Center of Scenic Bluffs. Referrals are coming from all of those sources. These are competing healthcare systems that have come together, set down at the table to do this because the one thing that cuts across is they want to deal with cancer health disparities. Same thing Sankofa. The same thing has happened. We're working with multiple healthcare systems. And we even found a hospice where 25% of their patients are African-American. And that's very rare. 

So the communities are really pulling together. And I think that's one of things that we're seeing that's really effective about this model is getting people, even if you're competing with each other, how can we work together. So, again with the AQCC, kind of our update. We have the five communities. Already, we've gotten our IRB approvals. We're out in three communities doing this individual assessment. So, Sankofa community, the rural community and Latino Health Council community. So, we've moved to that. Now our next steps. That's as far as we've gotten at this point. 

But our next steps are that we will analyze this individual data. We'll take that data, again, we'll go back to the communities. We'll ask the communities, and we'll also go back to different respondents. We'll randomly select respondents to go back to and make sure that what we have interpreted of the qualitative of their story is accurate. But that data will be compiled. It'll take it back the leaders again of the community. And then, once that data has been approved, we'll combine that with the community contextual data. And then we'll sit down at the table with our community partners, and whoever they want to bring to the table, and then set priorities. And the priorities will be set by the community based on what we've collected. Then, an intervention will be developed, implemented and tested. 

And with that, I don't know that our team will do the intervention. I think that what we're seeing is that there is so much going on already in these communities. They already have programs that are going on. They have people who are very involved, very knowledgeable. And I know that there have been so many people from this campus who have contacted me saying, you know, "If a community would like to do this, I have this grant, I have this project. I will go in. I will do it no cost. I would like to work with the communities. I just don't know how to approach them. I don't have the connection." 

So we're hoping that in setting these priorities and developing the intervention that what we can do then is create more bridges between additional partners. And that's really our hope. And this is not anything short-term. We don't see it as, okay when we're done we're done, but rather then what we hope is that we will have good enough relationships with the communities, worked as partners, that we can continue to do it in other areas. Because I truly believe the only way we're going to eliminate disparities is if we all work together. The reason I really got into this research is that first-hand in the south, of seeing what poverty, what racism can do. That's where I was born, that's where I was raised. My father was Potowatomie. I've seen in terms of American Indians what happens in terms of healthcare, and what people are not given. That touches really close to me, and it's very important. 

And I find that the people who are working on disparities, my students, the people in the communities. I thought Dr. Underwood really captured that piece of it. That these are real people and that we need to-- if we're ever going to bridge racism and discrimination that lead to disparities, then we also have to bridge these different institutions, the competing partners. We need to make those bridges as well. And that, I think, will be how we eventually eliminate disparities. So, quickly to conclude, I just want to say that I think disparities-- it's not just that they're scientific, or medical, or economic challenge. They're really an ethical challenge, you know. So being raised American Indian I always have a hard time with even the idea of immigration, because how do you own land? How do you say who can come into a country and who can't. 

The way we draw communities you look on a map with the borders, that's not the way. That's very frustrating. It leads to discrimination, racism, and these ethical challenges that we need to address. It's a long-term commitment. We've got to stop just going in, doing our research, and coming back out. But rather really truly bridge. And, you know, working with the communities is a first step. I just want to thank again. None of my research team could be here today, because they are working. But I would say that my students are wonderful, and the students that we're working with in the communities are wonderful. 

They've written IRBs. They're doing interviews. They've helped us construct the surveys. It's not just my students, but it's those pre-professionals in the community that I also wish could be here today because they've really done an amazing job. Thank you. 
(applause)
 
- A sense of what I will be covering in the next 25 minutes, or so. We're going to focus specifically on mental health disparities. I'm going to talk about national trends, trends in the state of Wisconsin. 

I will talk very briefly about my research as an attempt to begin to address these issues in the state of Wisconsin. And then I will end by providing some practical recommendations as to how we can go about addressing these issues which I like to call a road map. As I begin, I'd like to quote from the former Surgeon General David Satcher in his groundbreaking report focusing on mental health and culture, race, and ethnicity. He stated that, "Health disparities exist for racial and ethnic minorities, and as a result, mental illnesses have a greater impact on the overall health, as well as the productivity of racial and ethnic minorities." I'm very visual, and so I assume that everybody else is very visual. So I wanted to present just a visual image of what health disparities look like. And this was a cartoon that I retrieved off of the Internet. So, you can see that health is conceptualized as a staircase. At the bottom of the staircase we have minority groups. At the top of the staircase, we have white individuals. 

Now, I want us to be mindful that this model is very simplistic, because it doesn't take into consideration socio-economic status. So we do have white individuals not all white individuals are at the top of the staircase because of these issues. Along the stairwell, you can see several systemic issues that are implicated in health disparities. I also wanted to bring this closer to home by talking about an experience I had with a woman on a public bus in Madison that I think in a lot of ways really hones in on mental health disparities in our state. The slide is a little busy, so I'm going to walk you through this slide. I was on my way to work several years ago. I was a student at the time, I sat next to an African-American woman on the bus. The woman immediately started a conversation with me. She said, "What are you studying?" I responded, "I am studying counseling psychology." 

She then said "Good, is there an area in psychology that you're particularly interested in?" And I responded, "Yes, I'm particularly interested in cultural issues in counseling." The woman responded, "That's good, we really need people like you to study that stuff." And then she launched into a conversation with me and started saying, "Girl, let me tell you what happened to me recently..." She was standing, and I think her hand went on her hip, and she was kind of rocking back to tell me about her experience. She said, "Sometimes I have mood swings, you know. When the weather gets cold, I sometimes get depressed, and I'm unhappy, you know. Part of my unhappiness is related to being a black woman living in a white city. Anyway, I decided to tell my doctor about my mood swings. He recommended counseling. 

At first I did not want to go, because you know how us black folks think about counseling. Plus, I didn't want anyone to think I was crazy. Well, finally I got the courage to go to counseling. I thought it might be helpful. During the first 30 minutes, the counselor tells me I need to see a psychiatrist for medication. What's wrong with that damn counselor? He didn't even spend any time getting to know me. He immediately started talking about medication. I just needed somebody to talk to, but instead, he's talking about medication. Well, girl, I never went back to see his..." 

And you can finish the sentence. Now I'm going to focus on national trends. And again using information from the Surgeon General's report, he stated that, "Racial and ethnic minorities have less access to and availability to mental health care, and they tend to receive poor quality mental health services." In another report that was published recently, it was actually a physician paper in the Annals of Internal Medicine that was published two years ago. The research has indicated that even after adjusting for insurance status and income, racial and ethnic minorities tend to have less access to healthcare, and lower quality healthcare than whites. And as I focus on national trends in mental health disparities, I'm going to focus on three areas. I'm going to focus on: accessibility or access to mental health services, availability of mental health services, and quality of care. And as you can see from the slide, the major barrier is lack of health insurance. In this country today we have 45 million Americans who do not have health insurance, and in that group, African-Americans make up almost 20%, American Indians 24%, Asian Americans 16.8% or 17% Latinos make up the highest group 32.7%, almost 33%, and Caucasians 11.3%. I think we can all agree that these numbers are high even for Caucasian individuals. 

We find that there are high rates of unemployment among this population that are uninsured. We know that most people get health insurance through their employer. These individuals also have low-paying jobs, in which they are unable to afford health insurance. And also because of immigration status as well, for the Latino and Asian population. Now there are public health programs for individuals that are poor or live in a certain level of the poverty line, but the issue with those programs is that the enrollment process is pretty complicated. And then, if English is not your first language, then you have some added complications in trying to access those services, but then there is also the issue of limited knowledge about those programs. In addition to these factors, we also have the issue of stigma, and as we think about mental illness. And in the African-American community, and in other minority communities, I would say even in Caucasian communities as well, when we hear that people have a mental illness problem, we think of them as "crazy." That's the language that we use. And so seeking mental health services is simply a confirmation that you are indeed "crazy." 

Then there is also the issue of spirituality. We know that in the minority community that high numbers of these individuals are using religious coping. The problem with religious coping is that it then delays seeking treatment. And so when these individuals do seek treatment, the mental issues that they're dealing with are quite severe at that point. And then there is the issue of availability of services. And availability is dependent on area of residence. We know that a large number of African-Americans live in rural south, where they have limited access to mental health services. American Indians, again, are living reservations with limited mental health services. This is also an issue for poor white individuals that are also living in rural communities and have limited access to mental health services. Now, interestingly, mental health providers are concentrated in urban areas, and although we have large numbers of minorities living in urban areas, they tend to concentrate in poor communities where we don't have mental health services available. 

So we've got some interesting dynamics going on there. Then, we also have practitioners that may not accept Medicaid or Medical Assistance. And I actually had a private practice here in Madison. And my co-workers, very well intentioned said to me "Earlise, be careful about how many Medical Assistance clients you have on your case load because they require more time." And that is indeed the case. They certainly require more time. I had a client that I worked with, I would get calls at different times of the day and night regarding pretty severe issues that was happening within the home. And then there are also community mental health centers our very own Dane County Mental Health Center that provide services to low-income individuals. Well, there is a long wait list at the mental health center. I heard that right now the wait list is anywhere between 8-11 months. 

And we know that when these individuals call for services, they're needing services right away. In fact, they're needing it yesterday, maybe a month before. So having to wait 8-11 months before you get your first appointment is really unacceptable. Quality of care. So in a study conducted by -- colleagues, they found that older African-Americans who were diagnosed with depression were twice as likely not to receive anti-depressant medications compared to white individuals. In the former Surgeon General's report, he also indicated that, "African-Americans compared to Caucasians, were less likely to receive anti-depressants when first diagnosed with a mental health problem." And in a study that was recently conducted by Malphy and colleagues, they found that African-Americans are more likely to be prescribed older, less tolerable and less safe tricyclic anti-depressant medications while Caucasians were significantly more likely to receive newer, safer, and more tolerable SSRIs. And there is some recent research coming out as well indicating that African-Americans experience high rates of side effects on tricyclic anti-depressant medication, but yet they are being prescribed that medication. Looking at the Latino population in quality of care. In a study conducted by Skellar and colleagues, they found that Latinos were 50% less likely to receive either a diagnosis of depression or anti-depressant medication compared to Caucasians. 

Another study conducted by Sleet found that Caucasian physicians were more likely to provide information about anti-depressants to Caucasian patients compared to Latino patients. In another study that was done by Barovski and colleagues looking at primary care services, they found that Latinos and African-Americans were less likely to be detected of having major depression compared to Caucasians. And as you've noticed, I haven't really talked much about Asian-American or Pacific Islanders and Native Americans. And that is because we don't have large epidemiological studies focusing on care and access in these populations to be able to provide any sort of information about these groups, so certainly an area of concern. Now, I'd like to bring the issues closer to home and focus on Wisconsin, our Badger State if you will. The information that I'm going to present was compiled by the Wisconsin Minority Health Program, and the information that I'm going to present is primarily based on inpatient care. With regards to seeking mental health services for racial and ethnic minorities, there is a low rate of seeking outpatient mental health services, but there is a high rate of inpatient care. The data that I'm going to present is based on inpatient care. So if you look at the-- You were right Tracy, that did get cut off there. If you can look on the Y-axis, what I'm trying to say there is age-adjusted depression hospitalization rates per 100,000 persons. 

And then if you look on the bottom here on the X-axis, you will see the different racial and cultural groups. So looking at the rate for inpatient care for depression among these populations, you find that American Indian females have the highest rate of inpatient care for depression, followed closely by African-American women. Now as you look at this data and you compare it to the Caucasian population, you see significant differences here. And the issue with the American Indian population is even more critical when you think about the size of the American Indian population in the state of Wisconsin. They make up .8% of the population, which works out to about 45,000 individuals. I'm sorry about that being cut off at the end there. It shows up on my screen just fine, so if you'll kind of bear with me and keep in mind that the Y-axis is age-adjusted hospitalization rates per 100,000 persons. Now we're looking at rates of inpatient care for Schizophrenia. Again, we find some huge disparities here. If you look at the African-American population, you find that African-American males are hospitalized at a higher rate compared to white individuals, at a rate of almost four times. 

There is some new research coming out indicating that Schizophrenia in African-American males may be over-diagnosed, as well as misdiagnosed, that African-American males who may be presenting with symptoms that meet the criteria for a mood disorder, for example, depression or bipolar disorder, are instead being diagnosed with Schizophrenia. And then, they are receiving inpatient care. When you look at the numbers for American Indians, although the numbers look the same as the Caucasian population, again, it still is an issue of concern when you think about the size of the American Indian population in the state of Wisconsin. Looking at bipolar disorder, we find the same kinds of disparities, again, between African-American men and women with Caucasian men and women. We also have the same issue here with the American Indian population. And just when you think it couldn't get any worse, well it does. When you look at the rates for inpatient care for alcohol and drug use. So, if you look here in the middle, you see the data for the American Indian population and again huge disparities when you compare those rates to Caucasian individuals, almost five times the rate. You have the same issue going on here when you look at the African-American population as well, almost three times the rates. I'd like to shift gears a little bit and focus on my research to give you a sense on how my research makes an attempt to address these issues here in the state of Wisconsin. 

My dissertation which was published two years ago in the Journal of Counseling Psychology examined African-American clients engaging in counseling at a community mental health agency. This was a qualitative study, I had a sample of 13 African-American clients that were actually receiving counseling services at the time. They were able to talk about their own experiences at the time. Without spending too much time going into all of the details, I will just present the results. What we found was that these clients reported that they engaged in an ongoing assessing process, and they assessed several factors. They assessed client-therapist match in terms of race. They also assessed their own safety in counseling, how comfortable they felt disclosing personal information in counseling, as well as concerns about how that information could be used against them. We had folks that were involved in the legal system, and so there were some concerns there about confidentiality. They were also concerned about counselor effectiveness. Is this counselor capable of connecting with me as an African-American client. 

Do they have experience working with racial and ethnic minority clients. One participant said to me, "You know, I need a therapist to treat me as a person and not based on the information that they read in text books." Interestingly, they then used this assessment data to monitor and manage the amount of self-disclosing that they engaged in. And so as you can imagine when they felt unsafe, they didn't disclose very much. Or, they disclosed on a very superficial level. It also informed decisions about whether to continue in therapy. And we did have folks that talked about leaving therapy prematurely as a result of a mismatch, if you will. Then we also had individuals that were involved with the legal system that wanted to leave therapy, but they couldn't because they were mandated to be there. And so what they did was they engaged, again, in a very superficial disclosing so they stayed very surface level. And another study that I recently published, this was actually a systematic review that was published in the Journal of the National Medical Association. 

The reference will come up in a few minutes if you're interested in getting further details. In this systematic review, we examined differential treatment effects for depression in racial and ethnic minority women. This was a systematic review, and so we reviewed randomized clinical trials that focused on depression interventions. Unfortunately, we were only able to locate ten randomized clinical trials that had a representative sample of racial and ethnic minority women. What we did find though in reviewing those ten studies is that these women seemed to prefer a wrap-around service, or what we're calling a collaborative care model. It seemed to provide optimal clinical benefit. Now, the components that are important in that model includes: having culturally competent clinicians who were trained to work with ethnic and racial minorities. They were open to the use of medication, but in this particular model that we looked at, there were also trained nurses who were providing ongoing follow up assessments, as well as support for treatment adherence to address any issues of side effects that may occur for these patients, as well as supporting them in continuing the treatment in the way that it was prescribed. They were open to individual and group counseling. They need to be educated about depression, so that they have a sense of causal factors, about triggers, and about treatment options as well. 

And with that information they then wanted the opportunity to choose a treatment of their choice. Case management was also important. Outreach to minority individuals as well as supportive services that included childcare and transportation, so that they can get to the appointment. Okay, another publication that is actually in press. I focused on recruiting older African-American women to participate in mental health research. And based on my own experiences doing this type of research, as well as what is in the literature and what is actually missing in the literature, I was able to develop a model. Now it is important to note that this model of recruitment can be useful with all minority populations, as well. And I don't have much time to go through the entire model, but the core piece that I would like you to keep in mind, looking in the middle here, is that as we try to recruit and include racial and ethnic minorities to participate in our research, we need to have a culturally competent research team, such that we need to be aware of our biases that we bring to this research. And we need to have knowledge of the populations that we intend to work with, as well as skill and strategies to work with that population. And most important, we also need to establish community partnerships, and we need to have those partnerships long before we design the research. 

And the rest of it is sort of the usual research process. And then one final study focusing on examining African-American women's beliefs about mental illness and ways of coping. This study is currently on the review. And we designed this study because of the issue of stigma regarding seeking mental health services. This was a mixed method design study. We had a sample of 185 African-American women that were all recruited here in Dane County. We had three different age groups, as you can see. I am only going to present the quantitative results. We found that the women believed that there are several factors that can cause mental illness, including family and social problems, as well as racism. They believed that mental illness is cyclical, has serious negative consequences and can be controlled by treatment and personal motivation. 

A major coping strategy included praying. They were open to seeking medical and mental healthcare, but they were more open to counseling, again because of the concerns about the side effects of medication. We found interestingly low levels of perceived stigma. And we also found some interesting age differences. Older women were more likely to use religious coping and to seek treatment compared to younger and middle aged women. As I wrap up in the four minutes that I have remaining, I would like to leave you with some practical recommendations in terms of addressing these issues, which I like to call a roadmap. I will focus on those four areas. With regards to research, we certainly need to include racial and ethnic minorities in a meaningful way. I know that NIH has various mandates, but we need to include them in a way that is relevant to health benefits, as well as in a culturally relevant way. We need to partner with racial and ethnic minority communities to increase recruitment, and we can do that by forming community advisory boards and by partnering with these groups to conduct community-based participatory research. 

We also need to collaborate with racial and ethnic minority researchers as well as students. We need to get them on board very early in their career. We need to build a culturally diverse research team. With regards to education, I believe that each department in school needs to have a required course focusing on cultural issues and diversity in healthcare. I know that there are some schools and departments that use an integrated approach, which I think is very important. But I think we actually need to have both. We also need to create research and clinical practicum and rotation so that students have the opportunity to be exposed to these populations. And in terms of our own development as professionals, as well, we need to seek out opportunities to enhance our knowledge about these issues. Clinical practice, we certainly need to have more culturally competent clinicians, as well as services. We need to use evidence-based, state-of-the-art medication and psychotherapies, and recognize if there is a conflict because we don't have enough minorities participating in research, but it certainly is an area for improvement here. 

Collaborative care model that I mentioned earlier. Patient-centered care, so that patients have an opportunity to be involved in their care. We need to partner with religious and folk healers, because we know that's where they're going first, so we need to catch them there. We also need to focus on access related issues. That includes location, hours, sliding scale fee, etc. And with regards to service, I know this is a bit of an issue because when we think about the tenure process, we know that service is sort of at the bottom. But if we're serious about reaching this population, we need to include service as well. Serve on boards in the community that are serving racial and ethnic minorities. And we also need to attend some of the cultural events in our community as well. As I end in my 50 seconds remaining, just the take home message here. 

If you don't remember anything else, I hope you remember this. Disparities in mental health care exist and is affecting the overall health status of racial and ethnic minorities, as well as white individuals in rural communities. Health disparities can be eliminated, and we all have a role to play in eliminating health disparities. I certainly encourage you to use the information that is being presented here today and let us all work together to eliminate health disparities. 
(applause)