The American Academy of Nursing has identified the development of healthy families, particularly those that are underserved, as one of its priorities. This is a broad mandate that focuses on physical and mental health promotion, maintenance, and treatment, recognizing that physical and mental health is intertwined. Mental health status is particularly precarious in families living in poverty and those confronted with chronic health problems, limited access to care, and the stigma associated with mental health problems. This brief focuses on fostering mental health in diverse and underserved families.
Background
Underserved populations from diverse cultural and racial backgrounds across the life span experience higher rates of exposure to factors that put them at risk for poor mental health. The U.S. Surgeon General's Report on Mental Health identified that “even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services. These disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender” (
U.S. Department of Health and Human Services, 1999
, p. vi).U.S. Department of Health and Human Services. Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
The World Health Organization identified mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community” (
World Health Organization, 2007
, p. 1). In the United States, underserved racial and ethnic groups experience numerous disparities in health and health care that adversely influence their mental health. This includes higher illness risks, diminished access to care, and lower-quality treatment (World Health Organization. (2007). What Is Mental Health? Online Q7A. Retrieved from http://www.who.int/features/qa/62/en/index.html.
Smedley et al., 2004
). Disparities in mental health care are even more pronounced in underserved racial and ethnic groups and residents of rural communities. These disparities in care result in poor engagement and, ultimately, poor health outcomes.Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2004). The healthcare environment and its relation to disparities (pp. 80-124). In B. D. Smedley, Stith, A. Y., & Nelson, A. R. (Eds.). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, D.C.: National Academy Press.
Engagement is seen as pivotal to reducing mental health disparities and improving mental health (
Interian et al., 2013
). Engagement has been defined as occurring on a continuum, beginning with the decision to seek care and followed by a series of decisions about remaining involved in care. The process of obtaining mental health services is complex and includes many “linked steps: encouraging treatment seeking when there is a need, continuity in various aspects of care (including visit participation), treatment retention, and medication adherence” (- Interian A.
- Lewis-Fernandez R.
- Dixon L.B.
Improving treatment engagement of underserved U.S. racial-ethnic groups: A review of recent interventions.
Psychiatric Services. 2013; 64 (Retrieved from)https://doi.org/10.1176/appi.ps.201100136
Interian et al., 2013
, p. 212). Engagement is facilitated when there is comfort with the health care provider and a belief that the provider is sensitive to and flexible with culturally diverse, vulnerable, and underserved individuals.- Interian A.
- Lewis-Fernandez R.
- Dixon L.B.
Improving treatment engagement of underserved U.S. racial-ethnic groups: A review of recent interventions.
Psychiatric Services. 2013; 64 (Retrieved from)https://doi.org/10.1176/appi.ps.201100136
The Mental Health Parity and Addiction Equity Act (2008) entitles Americans to a full range of mental health and substance use disorder services on a par with physical and medical health care. Implementation of the Affordable Care Act dramatically improves access to care pathways. Yet, the issue of engagement is more complex and involves the willingness of individuals and families to actively participate in care and maintain a relationship with the health care provider.
Nursing is in a pivotal position for leadership in the movement toward mental health parity. Nurses at both the generalist and specialty levels of practice understand the nuances of the engagement process, which involves getting underserved families to health care services and then supporting them to remain involved in their care.
Individuals and families often seek treatment for a mental health issue that could have been addressed much earlier, before a worsening crisis, with targeted prevention of more serious problems. With improved accessibility of services, the challenge will be in engaging patients, fostering trust, and ensuring that patients believe they are being heard and cared for in a respectful, nonjudgmental manner. Psychiatric/mental health nursing specialists can be the drivers of mental health services integrated into primary care and embedded in the care provided by nurse generalists and other health professionals in a variety of settings. Nurses have also developed innovative models of care that integrate primary care and behavioral health services for the severely mentally ill (e.g., Integrated Health Care of the University of Illinois School of Nursing). Nursing is well positioned for leadership in fostering patient engagement, addressing the treatment needs for diverse and underserved populations, driving the treatment process, and reducing the harm of unmet mental health needs.
The following recommendations for mental health plans, programs, and research will foster resilience and health for vulnerable families:
- 1.The Administration should convene a multisectoral task force to develop a national action plan for promoting mental health that will encompass approaches that address the strengths and vulnerabilities of individuals, families, and communities; target access to mental health services that are integrated into primary care; and focus on patient engagement. An updated Surgeon General's Report on Mental Health can serve as the foundation for the development of this action plan.
- 2.Nursing's participation in all aspects of developing and implementing the action plan, formulating additional policies, and redesigning mental health services is essential. State government boards, commissions, and councils must include nursing leadership in policy decisions influencing mental health services. The American Academy of Nursing will work with other national nursing organizations to assist the administration and others in identifying nurses with expertise in mental health care who can lend their important perspectives to this work.
- 3.The National Institutes of Health, the Patient-Centered Outcomes Research Institute, and the Substance Abuse and Mental Health Services Administration, along with relevant nongovernmental organizations, should prioritize research that addresses access, patient engagement, and mental health interventions within the context of cultural and ethnic differences in populations across the life span.
- 4.Federal and nongovernmental agencies that develop research guidelines and provide funding should emphasize community-based participatory research methods for studies of mental health care.
- 5.The federal and state governments should partner with payers and providers to develop mental health promotion programs that build on intrinsic community and family strengths such as spirituality, identity, values, educational attainment, and local leadership.
- 6.The Academy will engage nursing and other key stakeholders in raising public awareness of and supporting multisectoral initiatives that address the broad range of conditions in communities that can undermine the mental health of individuals and families, such as joblessness, poverty, violence, and racism. The Academy will also work with the American Organization of Nurse Executives and other leading nursing organizations to encourage chief nursing officers and other nurse leaders in nonprofit hospitals to integrate this focus into their institutions' community benefit assessment and improvement plans.
- 7.Congress must appropriate funding for the expansion of nurse-managed clinics, as authorized under the Affordable Care Act, that integrate behavioral health services and focus on individual, family, and social network strengths to mediate risks to mental health while supporting resilience.
- 8.The Department of Health and Human Services, Health Resources and Services Administration, should prioritize funding nursing and other health professions' educational programs that will build the capacity of the nursing and health care workforce to integrate mental health care into primary care, school health, and other health care services. Health Resources and Services Administration initiatives should seek to ensure that generalist nurses are trained to provide mental health screening and nursing interventions to diverse and underserved families across the life span and within multiple treatment settings.
- 9.Organizations and agencies that approve and accredit nursing schools and programs should include standards to ensure that these include opportunities for students to develop the evidence-based knowledge and skills that they will need to be able to address the mental health concerns of underserved and diverse populations.
- 10.National nursing specialty organizations should take the lead to encourage the development of and provide a model of collaborative practices and practice agreements between advanced practice generalist and specialty nurses.
- 11.Increased funding must be secured for advanced psychiatric and mental health education by academic nursing programs in order to (1) ensure that nurses have the evidence-based skills to address mental health issues in underserved and diverse populations and to (2) expand the supply of advanced practice nurses with a specialty in child, adolescent, family, and adult mental health.
- 12.The Centers for Disease Control and Prevention should collaborate with the Surgeon General's Office to develop an initiative for promoting public awareness of mental health across the life span and across cultures and ethnic/racial groups as a way of moving the nation forward on the Healthy People 2020 goals and reducing the stigma associated with mental illness. This initiative should include engaging consumers; local, state, and national entities; and health care providers to collaborate on improving print literature, online resources, and social media that focus on mental health messaging.
- 13.The Department of Health and Human Services, Center for Medicare and Medicaid Innovation, should develop a grant program for exploring models of care that effectively use primary care providers as the first line of mental health assessment for all populations followed by a support network of mental health providers who can offer more intensive psychiatric interventions. This program could encourage the development of primary care/mental health residencies to increase the number of cost-effective providers who are proficient in such collaborations.
- 14.Advocacy groups such as the National Alliance on Mental Illness and other consumer-focused organizations and health care providers should collaborate on developing a model of consumer empowerment and patient- and family-centered mental health care.
Acknowledgments
This policy brief was developed by the Psychiatric Nursing and Substance Use Disorders Expert Panel for the American Academy of Nursing. The authors wish to thank Mary D. Moller, DNP, APRN, PNHCNS-BC, CPRP, FAAN for her editorial assistance.
References
- Improving treatment engagement of underserved U.S. racial-ethnic groups: A review of recent interventions.Psychiatric Services. 2013; 64 (Retrieved from)https://doi.org/10.1176/appi.ps.201100136
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2004). The healthcare environment and its relation to disparities (pp. 80-124). In B. D. Smedley, Stith, A. Y., & Nelson, A. R. (Eds.). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, D.C.: National Academy Press.
U.S. Department of Health and Human Services. Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
World Health Organization. (2007). What Is Mental Health? Online Q7A. Retrieved from http://www.who.int/features/qa/62/en/index.html.
