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Congratulations to the NNED-a-thon winner, Team 2—Changemakers!  Twelve teams of NNEDLearn 2018 participants competed in a fast-paced interactive challenge to brainstorm strategies on the use of networks, including the NNED, to assist with eliminating disparities in behavioral health.  Teams comprised of individuals from different organizations and representative of all five NNEDLearn 2018 training tracks examined strategies for establishing and reinforcing partnerships to promote community health and well-being.  The NNED-a-thon was an opportunity for NNEDLearn 2018 participants to interact with other participants not in their assigned training track and expand the potential for peer-to-peer learning. 

Modeled after hack-a-thons that are commonly used by technology innovators to problem-solve, the NNED-a-thon teams had four minutes to present their strategies for enhancing the NNED based on two assigned attributes of a healthy network.  Changemakers presented their two attributes—“value” and “capacity to tap the network assets”—and identified concrete strategies for applying each of the attributes to the NNED.  The team described multiple values of the NNED, including collaboration, shared learning, acceptance, and skill development.  The capacity for NNED members to tap the network assets through utilization of the online discussion forum which allows for continuing conversation with other NNED organizations was emphasized during the team’s presentation.  Understanding that multiple doors of entry are needed to maximize the potential to tap the network’s assets, Changemakers highlighted multiple entry points within the NNED for members to access information and connect with each other. 

Moving forward, the Changemakers expressed the need to increase clarity of communication across the network.  Showcasing the shared values and unique talents of NNED members was proposed to help motivate members to connect with each other.  Changemakers reminded everyone that leveraging social media to connect NNED partners and networks is key. The team suggested creating a NNED mobile app, using a single-sign on, social media format to access all features in the website, and marking content with hashtags to make it easier to connect with NNED partners.  

We look forward to implementing the feedback as best possible. Thank you to all NNEDLearn 2018 participants for their great work in the 2018 NNED-a-thon!

Find out how you can get involved in the NNED-a-thons and NNEDLearn!

The following article was written by and from the perspective of David Danto, the Program Head of Psychology at the University of Guelph-Humber.

In northern Ontario, surrounding James Bay and Hudson Bay, lie six remote First Nations communities.

They range in size from several hundred members to several thousand. They have no road access linking them to other communities in the region, and with varying degrees of ease, they can be reached by rail, air, boat or winter ice road. Many of these communities struggle with a host of mental health issues including high rates of suicide, substance abuse, and depression.

One community stands out, by virtue of its low rates of suicide and mental health services utilization. This community shares a history of oppression, victimization, and suffering with its sister communities. It also endured the relatively recent trauma of a natural disaster.

How is it that this one community has produced what appear to be more positive mental health outcomes?

To investigate this question, I developed a research project in collaboration with Dr. Russ Walsh of Duquesne University. We interviewed community leaders and resident mental health service providers about the strengths of their community with respect to mental health. As non-Indigenous psychologists, we used a culturally sensitive method that focused on listening and that privileged the perspectives of participants.

We avoid mentioning any communities by name, to protect the confidentiality of participants. There are relatively few communities in the James and Hudson Bay region and populations are relatively small. Our research participants included community leaders and elders. Even limited information about these communities would risk identifying individuals.

The strength of community members’ connection to the land emerged as the most striking finding. Participants spoke of this connection as woven through mental, physical, spiritual and emotional dimensions of the self. They described it as foundational to their faith, uniting those with otherwise differing spiritual beliefs and possibly stabilizing the community in the face of other differences.

“Back to the land,” said one community member. “When you’re there, it’s like your spirit, your mind, and your physical well-being — everything improves when you’re out there; it’s like you rejuvenate while you’re out there.”

“We have a belief,” said another community member. “I’m not going to give it a word of religion or culture. No, it’s a way of life, you know. It always was in the beginning, and it is today.”

The medicine wheel

A challenge for this study, as for the bulk of research within Indigenous communities, was the “outsider” status of the researchers themselves. Despite our interest in, and concern for, the well-being of Indigenous communities, we remain unavoidably non-Indigenous Western psychologists. This “from the outside in” orientation runs the risk of further oppression and colonization in the name of scientific truth.

Qualitative methodology, despite its focus on the experiences of participants in their own words, still undertakes the task of organizing and interpreting participants’ accounts, and hence also entails the risk of colonizing participants’ experiences.

To minimize this risk, we decided to organize and interpret participant narratives using the medicine wheel of traditional healing. Rod McCormick, the B.C. Regional Innovation Chair in Aboriginal Health at Thompson Rivers University and a member of the Mohawk (Kahnienkehake) nation, provides the following overview of the medicine wheel:

“The Aboriginal medicine wheel is perhaps the best representation of an Aboriginal worldview related to healing. The medicine wheel describes the separate dimensions of the self — mental, physical, emotional and spiritual — as equal and as parts of a larger whole. The medicine wheel represents the balance that exists between all things. Traditional Aboriginal healing incorporates the physical, social, psychological and spiritual being.”

Indigenous Canadian healing traditionalists view the person as comprised of these integrated categories. An individual’s health and wellness result when these realms are balanced and integrated. By organizing our qualitative analysis along these lines, we sought to frame the results in culturally appropriate terms, and thereby set the stage for community conversations regarding mental health.

Through my work in northern Ontario, I have developed connections with mental health workers in the region. Over several months, Dr. Walsh and I had a series of conversations with them regarding their interest in community-oriented and strength-based research to inform their mental health interventions. The proposed study was supported by the community’s leadership.

Connection to the land

To our eyes, the most notable finding was the way in which connection to the land was interwoven throughout all aspects of the medicine wheel.

Participants’ comments regarding physical, spiritual, mental and emotional health often referred to attitudes and practices that affirmed a fundamental connection to their land:

“To know the land… you know you’re capable of things other kids aren’t, knowing where I came from, what I’m capable of.”

This connection informed individual and community efforts to maintain well-being and also seemed to provide a bridge between different spiritual beliefs. That is, community members of divergent spiritual orientations shared a belief in the land as foundational to their faith. This cohesion was evident in community activities and programs, as well as in acknowledgment of shared culture and history.

It may well be the case that members’ shared connection to the land and ready access to the land was sufficiently strong to tolerate differences that might otherwise polarize a community. And from this shared sense of connection may follow the sense of hope expressed by most of the participants:

“Everybody, even if they disagree… when it comes to a crisis and someone needs help… that’s where your strength is: The whole community comes together.”

This may hold implications for health and healing initiatives both within and beyond this community. If a sense of connection to the land is a central feature of well-being, then it may need to be a central feature of mental health interventions.

Identity and autonomy

Two other themes emerged. One was the community’s relative distance from “outside influence,” facilitating greater identity and autonomy. The other was the rather recent shared trauma of natural disaster and relocation, which required a pulling together of community resources in a way that more diffuse challenges and traumas may not.

To the degree that these factors are foundational to the strengths of this community, there may be implications for more general intervention and prevention programs. Specifically, these findings suggest that when communities can unite to face a set of problems and have a fair degree of autonomy (or freedom from outsider influence) in responding to those problems, they may be best able to draw upon their shared resilience and communal spirit. For those wishing to facilitate this resilience and spirit, the challenge is to do so in a way that affirms rather than usurps the community’s independence.

We plan to continue our investigation of these issues with a follow-up study. This will address the role of land-based interventions in promoting resilience and mental health.

Read more on TheCoversation.com.

Dr. Marjorie Mau has served as lead principal investigator of the Center for Native and Pacific Health Disparities Research since 2002, when it was established with a National Institute on Minority Health and Health Disparities (NIMHD) grant at the University of Hawai’i at Mānoa. Her experience growing up in Hawai’i and as the only Native Hawaiian in her medical school class led to a deep passion for working with Hawai’i’s communities on the health problems they care about. It also made her passionate about training people in those communities to not only volunteer in a study but also do the research.

“The word ‘collaboration’ or ‘partnership’ really doesn’t capture the form of community engagement that we use in our Center. We literally walk with our communities–and not in front of them, but beside them,” says Dr. Mau. “They’re part of just about everything the Center does.”

The Center started out by building the Ulu Network of partners at more than 60 sites across Hawaii. These partners included Native Hawaiian healthcare systems, community health centers, Native Hawaiian civic clubs and nonprofits serving Native Hawaiians, and grassroots organizations. The Network later expanded to include other Native populations in the Pacific, such as Alaska Natives and New Zealand Māori.

The Ulu Network groups’ long-standing relationship with the Center is built on trust. Representatives from the community help identify the most pressing health problems and decide how best to combat them. And if they choose to work with the Center, partners are held accountable to the joint project.

“They help us ensure that the science is going to be strong–not just scientifically–but also with strong community validity by asking, ‘How is that going to translate or transform the lives of the people it’s meant to benefit?'” says Dr. Mau.

An example of this approach is the NIMHD-funded Partnership for Improving Lifestyle Interventions (PILI) project. The Center and five community partners, located mostly in low-income urban areas of Honolulu on the island of O’ahu, decided to address obesity. They adapted an existing weight loss education program so it used local language and examples relevant to Native Hawaiian and Pacific Islander communities. The groups also added a program to help participants maintain their weight loss with the support of their family and community.

Researchers from the Center trained local staff members to collect data to find out whether the culturally adapted program worked. And it did: Six months later, participants who stuck with the program were five times more likely to have kept the weight off than were people in the control group, who followed a standard weight maintenance program.

Community training is one of the most enduring parts of the Center’s Ulu Network activities, says Dr. Mau. “All of a sudden these young kids are like, ‘Wow, I can do this. I never even thought of being a researcher.'”

Dr. Mau notes that while the PILI project went a long way to improve the health of Native Hawaiians and Pacific Islanders, participants could get even further if their doctors worked with them.

For example, in an NIMHD-funded study, Dr. Mau and the research team adapted information about diabetes for her ethnically diverse patients. But the team also went beyond that, creating short modules to teach physicians how to share decision-making with diabetic patients. Dr. Mau explains that by taking part in decisions, such as what medications to use, patients take ownership of their health.

The Center has helped counter the public’s negative viewpoints of research. “Most people think that if you participate in research, you’re a guinea pig. I think minority populations are very sensitive to that,” says Dr. Mau. But since the Center and its Ulu Network partners work toward a common goal, communities know the research will be relevant to them.

And it is equally important for researchers to be accountable to communities. Since research funded by NIH is meant to benefit everyone, Dr. Mau says it only makes sense to work with communities on the issues they care about.

Read more on NIMHD.NIH.gov.

As a child, the United States Surgeon General Jerome Adams, MD, MPH, suffered from asthma so severe that he spent months at a time in the hospital, even once being airlifted to a children’s hospital in Washington, D.C. During these stays, he was struck by the fact that he’d never encountered a black physician. That finally changed when as an undergraduate he met a prominent African-American doctor who had overcome his own significant life obstacles. Seeing another African-American making important contributions to the field of medicine inspired the young Jerome Adams to decide, “I can do that too.”

With that resolve, he embarked on a path that led to becoming an anesthesiologist and culminated in his appointment as the nation’s 20th surgeon general.  

Reflecting on his journey, Dr. Adams notes, “that’s why the efforts at the Robert Wood Johnson Foundation (RWJF) are so important. You’re providing mentorship and leadership opportunities to those who wouldn’t otherwise know how to navigate the world of public health.”

He shared these words during a visit to the Foundation where he discussed his role in building a Culture of Health with RWJF CEO Rich Besser. The conversation covered a range of issues in which Dr. Adams repeatedly stressed the role of partnerships in building healthier, resilient communities and addressing challenges such as the nation’s opioid epidemic. Here are a few takeaways from their conversation.

Intervene upstream to address the nation’s opioid epidemic.

Dr. Adams is open about his younger brother Phillip’s struggles with substance abuse. He had taken his 12- and 13-year-old sons to visit their uncle, who is currently spending 10 years in a Maryland state prison for stealing $200 to support his addiction. Phillip shared with his nephews that he suffered from untreated depression while in high school which led to self-medicating with alcohol, marijuana, and eventually other substances before he began committing crimes to support his habit.

“What’s most frustrating to me is that despite being a doctor, I couldn’t intervene alone. None of us can face this alone,” said Dr. Adams, noting that addiction touches everyone regardless of their race, sex, age, socioeconomic status or where they live.

“We need to understand that this is a complicated problem influenced by a variety of upstream factors, including childhood trauma and community resilience. The most cost-effective and humane way to address the opioid epidemic is through prevention and partnerships. For example, since local law enforcement is the number one touch point for connecting people struggling with addiction to mental health support services, we need to partner with them and help them understand their role in connecting people to the care they need.”

Dr. Adams believes in upstream interventions that address underlying risk factors such as adverse childhood experiences (ACES) which increase the risk for addiction. He also believes in shifting away from criminalizing addicts and instead, providing treatment options to support their long-term recovery.

The power of partnerships is key to building a Culture of Health.

Dr. Adams noted the importance of engaging non-traditional partners to create healthier communities, sharing his mantra “better health through better partnerships.”

“Local conversations and finding common ground is key to building a Culture of Health. We need to consider the roles of business, education, faith, and law enforcement in building healthier communities. I also challenge everyone to consider who else is not at the table that should be and reach out to them.”

He highlighted the role of the business sector in addressing workforce shortages, absenteeism, and productivity. While the businesses may view workplace health as an insurance expense, there is a larger role for them to play in instituting workplace wellness programs and by influencing policy at the community level. “We need to create a Culture of Health in all sectors. Businesses can play an important role in lifting up the health of their communities. By doing so, they can see better health, better productivity, and better return on investments.”

He also reflected on the partnership he formed with law enforcement during his tenure as Indiana’s state health commissioner. At the time, Scott County, Ind., was facing an unprecedented spread of HIV among intravenous drug users. Through his collaboration with law enforcement, Dr. Adams was able to institute an evidence-based syringe service program in one of the most conservative areas within Indiana. Doing so halted the spread of HIV in the community.

Frame issues so others understand their role in building a Culture of Health.

There’s tremendous opportunity in framing issues to help people understand their role in prevention, as well as health equity, according to Dr. Adams. “When I talk about health equity I mention veterans, those with disabilities, and people in rural areas,” he said. “Showing others how everyone benefits from addressing inequities is more effective than using moral arguments.”

Another example Dr. Adams shared to illustrate this was noting how overworked teachers may feel burdened by having to promote a variety of programs including healthy eating and physical fitness. The fact that teachers are evaluated and paid based on test scores can be the bridge to compel them to advocate for students’ physical activity. “If we tell them we have a physical fitness program to help get test scores up, they listen.” Such an intervention was implemented in an Indiana community while he was health commissioner. When teachers witnessed the positive results, they scrambled for access to exercise rooms before their students took exams.

“It shows how we need to frame issues to help people understand how supporting health can help them achieve their goals—versus expecting them to see things from our point of view. We need to use language that resonates with those we’re talking to in order to gain their support.” 

Read more on RWJF.org.

One in five people suffer from some kind of mental health condition. That number is lower among Asian Americans — but it’s not because they are any less affected. A new study out this week shows a glaring disparity between whites and Asians when it comes to diagnosis and treatment of mental disorders.

When psychiatrist Xiaoduo Fan was working at Massachusetts General Hospital, he started to notice a pattern. “I noticed that Asian Americans rarely present to the outpatient setting to seek mental health care,” Fan said.

It was more common to see Asian Americans with mental health disorders when things got dire, like in the emergency room or among hospitalized patients. Fan wanted to know why. He and his team of researchers at UMass Medical school examined more than 360,000 MGH patient records from 2009. In their study, they found that whites were more than twice as likely to be diagnosed with mental health disorders than Asian Americans, and even among those diagnosed, whites were twice as likely to receive medication.

Fan says a couple things account for this disparity. Mental health continues to carry a deep stigma in Asian cultures. “In Asian cultures in general, when someone is talking about emotional experiences, psychological disturbances and challenges, it’s considered a character defect or personal weakness,” Fan said.

But a lack of cultural competence on the part of the healthcare providers is another part of the equation.

Asian Americans are the fastest-growing minority group in the country. Despite that, they are largely underrepresented in mental health professions. They’re not alone. Other research has shown similar significant disparities among Latinos and blacks. And even if care is available in the community, racial and ethnic minority groups are less likely to use it.

Fan said if providers were better able to understand this stigma and the vocabulary many Asian-American patients use to communicate emotional or mental distress­ — often through physical aches and pains, they could facilitate patients to better describe their emotional experiences.

“In Asian cultures in general, sharing feelings or psychological experience in general [is] not encouraged, so that’s why people who grow up in Asian cultures, they may not develop that vocabulary to describe their emotional experiences or feelings,” Fan said.

Susanna Yee, a 25-year-old graphic designer in Boston, can relate. Her immigrant parents juggled multiple jobs while raising her and her brother in Dorchester. Even when there was time to talk, they didn’t talk about feelings.

“I feel like anxiety was always something that was really hard to portray to my mom, so I would just say like, ‘Oh, I’m not feeling good,’ or that sort of thing. So it would really be pretty vague, if even discussed at all,” Yee said.

She said other priorities were getting food on the table and making sure bills were paid and that she and her brother got to school on time and kept up their grades.

It wasn’t until Yee was in college that she learned about counseling. It came at a time when grief and stress were mounting. Her father had died suddenly before school started. Then her grandfather passed away. She was trying to keep it together while enrolled in a rigorous graphic design program.

“I didn’t know there was a doctor there for your mental health,” said Yee. “It seemed really foreign to me but when I was talking to my classmates it’s, like, well, ‘There are some days that you’re really stressed out and having someone as a counselor is a really good way to talk about your feelings.’”

The counseling helped, and then she stopped going for a while. Shortly after college, though, Yee was dealt another tragic blow. Her mother died after battling cancer. All the losses in the span of five years left Yee reeling, but seeing her therapist regularly has given her the tools to cope. Yee only wishes more Asian Americans would feel comfortable doing the same.

“I would like for people to have more of an open conversation about it,” Yee said. “I feel like the stigma is, ‘You should only see one if you’re crazy or you’re sick.’”

Xiaoduo Fan of UMass Medical says that’s a common belief among Asian Americans. There’s also widespread skepticism of Western medicine, particularly among immigrants, who prefer personalized alternative therapies, such as acupuncture or traditional Chinese medicine.

“In Asian cultures, people don’t like to take these types of medications. They feel like these types of medications are toxic and not good for the body,” Fan said.

There may be some evidence to support that in the way some patients initially respond to treatment. The recommended dosage of psychotropic drugs is based on clinical trials made up primarily of white patients. Fan says he generally prescribes his Asian patients with dosages lower than recommended because of reports of adverse initial reactions.

There’s growing emphasis on understanding stigma and the values of other cultures in hospitals. In 2015, the American Hospital Association launched the #123forEquity campaign, an initiative to eliminate healthcare disparities. Mass General Hospital joined 1,500 hospitals in this pledge, and Joseph Betancourt of MGH’s Center for Diversity and Inclusion said MGH has ramped up its cultural competence training.

“We don’t aim to teach them the do’s and don’ts of how to take care of Asians or Blacks or Latino patients,” Betancourt explained. “But instead, we say there are a key set of cross-cultural issues that are important in different cultures, and that it’s incumbent upon you to have a radar screen to pick up what, for example, words people might use to express depression in different cultures.”

Nhi-Ha Trinh, director of MGH’s Department of Psychiatry Center for Diversity, says clinicians are now required to document a cultural and ethnic history in every new patient evaluation.

“Eventually, the goal is to include this information/consider these factors in treatment plans for every patient we see. We are planning department-wide training to further these clinical targets,” she said in an e-mail.

Meanwhile, UMass Medical School is teaching cultural competence it to its students. Xiaoduo Fan is cautiously optimistic about this growing attention but says there’s a long way to go.

“This racial disparity is real, and I’ve seen so many Asian Americans suffer from mental illness, but they remain kind of underground and remain in this dark tunnel of struggle for years or for decades or for life,” Fan said. “On the other hand, there are now treatments available in terms of medications or different types of therapy, even though there are not enough resources. But there are resources available.”

Read more on WGBHNews.org.