Immigrant Well-being Project: Transdisciplinary Ecological Mental Health Intervention for Mexican Immigrants

Study Overview
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Brief Summary
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The goal of this study is to test a transdisciplinary ecological approach to reducing mental health disparities among Mexican immigrants by adapting and integrating a multilevel community-based advocacy, learning, and social support intervention (Immigrant Well-being Project, IWP) into existing efforts at three community partner organizations that focus on mental health, education, legal, and civil rights issues for Mexican immigrants. This research is innovative and significant because it employs cutting edge strategies to address social-structural determinants of mental health and examines the community-engaged process of adapting and testing the impact of a multilevel intervention originally designed for refugees. The IWP intervention emphasizes a sustainable and replicable partnership model between community-based organizations and universities that involves Mexican immigrants and undergraduate advocates working together to: a) increase immigrants' abilities to navigate their communities; b) improve immigrants' access to community resources; c) enhance meaningful social roles by valuing immigrants' culture, experiences, and knowledge; d) reduce immigrants' social isolation; and e) increase communities' responsiveness to immigrants through changes in policy and practice. The IWP is administered by university students enrolled in a service learning course, and has two elements: 1) Learning Circles, which involve cultural exchange and one-on-one learning opportunities, and; 2) Advocacy, which involves collaborative efforts to mobilize community resources related to health, housing, employment, education, and legal issues. Studies of the intervention model with refugees demonstrated feasibility, appropriateness, acceptability, and evidence that the intervention decreased participants' psychological distress and increased protective factors, and impacted changes in system-wide policies and practices. After completing in-depth ethnographic interviews with 24 Mexican immigrant adults to elucidate their mental health needs, stressors, current political/economic/social context, and local solutions, and a process of community engagement and intervention adaptation, a mixed methods strategy with data collected from 90 participants at four time points over a period of 14 months will be used to test the impact of the 6-month intervention on reducing psychological distress, increasing protective factors (access to resources, English proficiency, environmental mastery, and social support), and achieving system-level changes in organizational, local, and state policies and practices that impact Mexican immigrants' well-being. Mechanisms of intervention effectiveness will be explored by testing mediating relationships between protective factors and psychological distress. Qualitative data will explore feasibility and acceptability of the intervention, participants' experiences in the intervention, and unexpected impacts; document multilevel changes and the context of implementation at each site; and inform interpretation of quantitative data. Quantitative and qualitative data on the quality of the CBPR partnerships and their relationship to multilevel outcomes will also be examined.

Detailed Description
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The goal of this research is to advance the science of community-level mental health interventions that aim to reduce social inequities and health disparities. The proposed study will adapt and integrate a successfully implemented multilevel, ecological intervention that addresses social-structural determinants of mental health into existing efforts at three community partner organizations that focus on mental health, education, legal, and civil rights issues for Mexican immigrants in New Mexico. Using a mixed methods longitudinal design, the processes and outcomes of the collaborative, community-based intervention efforts, including the impact of the quality of the community-based participatory research (CBPR) partnerships on individual, organizational, and community-level outcomes, will be illuminated. Social and structural inequities contribute significantly to increasing health disparities globally, with the increasing numbers of migrants throughout the world bearing a disproportionate burden. The immigrant share of the U.S. population has risen steadily over the past four decades, comprising 13.5% of the total population in 2015, with Mexican-born immigrants accounting for 27% of all immigrants. The social, legal, and economic context of the migration process, including increasing uncertainty, discrimination, stigma, lack of access to resources, and fear of deportation and family separation based on immigration policies and public perception of immigrants as a threat all have a critical impact on adverse mental health outcomes among Mexican immigrants in the U.S. In addition, Mexican immigrants have low utilization rates for mental healthcare, in part because of barriers that include lack of health insurance, ineligibility for governmental health programs, discrimination, lack of interpretation services and culturally appropriate care, and an anti-immigrant political and economic climate. Although evidence points to the need to address socio-structural determinants, many mental health interventions offered to Mexican immigrants have focused on individual-level predictors of mental health. Also, Mexican immigrants' health outcomes are often viewed within the Latino health paradox, and therefore are frequently overlooked in mental health research and development of appropriate interventions, despite mounting evidence of mental health disparities and disproportionate exposure to trauma. Thus, multilevel, transdisciplinary intervention approaches that address social-structural determinants of mental health, are culturally appropriate, build upon Mexican immigrants' strengths, are cost-effective and scalable, and occur in non-stigmatized settings are needed. In prior NIH-funded research, the PI and community partners developed and tested a 6-month community-based advocacy, learning, and social support intervention, which pairs paraprofessional university students with refugee adults to engage in mutual learning and social change efforts. The intervention was found to decrease participants' psychological distress, improve their quality of life, access to resources, social support, and English proficiency, and improve communities' responsiveness to refugees; and also proved to be highly acceptable, cost effective, and sustainable. The objective of this study is to: a) adapt the intervention for Mexican immigrants (Immigrant Wellbeing Project; IWP); b) integrate IWP into existing efforts at three community partner organizations; and c) elucidate new understandings of partnership and intervention processes that lead to sustainable multilevel changes and the reduction of mental health disparities and related social inequities. Aim 1. Conduct an in-depth study of the mental health needs, stressors, current political/economic/social context, and local solutions as experienced by 24 Mexican recent and non-recent immigrants and their families residing in Bernalillo County New Mexico and contextualized by staff at three community partner organizations. Aim 2. Building on the data from Aim 1, use a CBPR approach to adapt the intervention model (IWP) and integrate it within existing service delivery and social change efforts at three community partner organizations. Aim 3. Using a mixed methods longitudinal design, investigate the feasibility and acceptability of the adapted community-based mental health intervention and test the quality of the CBPR partnership and impact of the intervention on mental health problems and protective factors among 90 Mexican immigrants and on organizational and government changes in policies and practices impacting immigrant mental health. 3.1 The IWP and collaborative adaptation/integration process will be feasible and acceptable and will serve as a model for implementing and studying multilevel, community-based intervention efforts. 3.2 IWP participants' psychological distress will decrease significantly over time. 3.3 IWP participants' protective factors (access to resources, English proficiency, environmental mastery, social support) will increase significantly over time. 3.4 Lower levels of psychological distress will be mediated by the protective factors. 3.5 Qualitative data will document changes in organizational and governmental policies and practices and the context of implementation at each site, explore other impacts, and inform interpretation of quantitative data. 3.6 Quality of CBPR partnership at each site will be related to policy/practice changes and health outcomes. As one of the core research projects of the Transdisciplinary Research, Equity and Engagement Center for Advancing Behavioral Health (TREE), this study will benefit from and contribute to collaborative efforts to elucidate and address the impact of social-structural (e.g., racism, lack of access to resources) and historical (e.g., violence, trauma, colonization) determinants of mental health for immigrant and indigenous populations.

Official Title
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Addressing the Social-Structural Determinants of Mental Health Through Adaptation of a Transdisciplinary Ecological Intervention Model for Mexican Immigrants

Conditions
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Mental Health

Intervention / Treatment
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* Behavioral: Immigrant Well-Being Project


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Mexican immigrant Residing in Bernalillo County, New Mexico Exclusion Criteria: Severe cognitive functioning problems Imminent suicide risk Mental illness that is so severe as to impede participation in a group and that warrants immediate individual treatment

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Interventional Model Description: This is a pilot study of an intervention with a within-group longitudinal design. All participants will participate in the intervention.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Immigrant Well-being Project Intervention<br>Intervention | Behavioral: Immigrant Well-Being Project<br>* The IWP intervention emphasizes a sustainable and replicable partnership model between community-based organizations and universities that involves Mexican immigrants and undergraduate advocates working together to: a) increase immigrants' abilities to navigate their communities; b) improve immigrants' access to community resources; c) enhance meaningful social roles by valuing immigrants' culture, experiences, and knowledge; d) reduce immigrants' social isolation; and e) increase communities' responsiveness to immigrants through changes in policy and practice. The IWP is administered by university students enrolled in a service learning course, and has two elements: 1) Learning Circles, which involve cultural exchange and one-on-one learning opportunities, and; 2) Advocacy, which involves collaborative efforts to mobilize community resources related to health, housing, employment, education, and legal issues.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hopkins Symptom Checklist-25: Depression/Anxiety symptoms | Overall Distress Scale obtained as mean of all 25 items, range is 1-4 Depression symptom subscale is mean of 15 items (11-25), range is 1-4 Anxiety symptom subscale is mean of 10 items (1-10), range is 1-4 Higher scores indicate more depression/anxiety symptoms (worse outcome) | 14 months | 
| PTSD Symptom Checklist (Civilian Version) | Overall Symptom Severity is total of all 17 items; range is 17-85; higher score indicates more PTSD symptoms (worse outcome) | 14 months | 
| Abbreviated Hispanic Stress Inventory Scale - Culturally-Specific Distress | Overall Stress is mean of 25 items; range is 0-3; higher score indicates more distress/stress (worse outcome) | 14 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Multi-Sector Social Support Inventory | Three subscales, each with 7 parallel items: Family Social Support, Ethnic Group Social Support, Non-Ethnic Community Social Support; each subscale is calculated as the mean of the relevant 7 items; range 0-4; higher scores indicate more social support (better outcome) | 14 months | 
| Satisfaction with Resources Scale | Mean of 12 items assessing satisfaction with resources in different life areas; range 0-6; higher score indicates greater satisfaction (better outcome) | 14 months | 
| Difficulty Accessing Resources Scale | Mean of 12 items assessing difficulty accessing resources in different life areas; range 1-4; higher score indicates more difficulty (worse outcome) | 14 months | 
| World Health Organization Quality of Life assessment | Total of 26 items; range 26-130; higher score indicates better quality of life (better outcome) | 14 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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pilot study, mental health, immigrant, within-group longitudinal design