The Use of Community Assessment Data to Prioritize
the Need for Mental Health Services within a Community Health Center

Kristi L. Lewis
Ann Myers
Kathryn A. Janousek
James Madison University

M. Andrée Gitchell
Rockingham Memorial Hospital

Introduction

     Understanding quality of life within a community is essential in planning and providing services to community members. A growing need within many communities is enhanced mental health and substance abuse services and support for caregivers. The common method used to assess quality of life among community members is called community-based participatory research (CBPR). CBPR is defined as research emphasizing the active involvement of community members or organizations throughout the entire process of data collection (Savage, Xu, Lee, Rose, Kappesser, & Anthony, 2006; Westfall & Stevenson, 2007 ). As the methods of CBPR have evolved, communities and researchers have partnered to tackle the assessment of community members who may be in need of mental health care and substance-abuse treatment. The goal of CBPR is to improve medical care, enable better access to care, and educate community members in order to promote social change. Although such strategies have become more popular in assessing quality of life indicators, few studies of quality life in communities have included mental health assessment items (Chene, et al 2005). This article describes the process and results of a community-based assessment using mental health as an indicator of quality of life. The indicators used to assess mental health within the community are 1) psychological distress, 2) substance abuse, 3) caregiving, and 4) social support. Data obtained through the 2006 HCC assessment will be used to justify the need for mental health services in a community health center currently being planned in the community. 

Background

     Mental disorders, alcohol abuse, and correlating poor health status are common in the United States. According to the National Institute of Mental Health, approximately 26.2 percent of Americans ages 18 and older suffer from a diagnosable mental disorder in a given year (NIMH, 2007). Despite the high prevalence, mental illness is often underdiagnosed and poorly treated, especially among low-income, indigent populations (Mims, 2006). High prevalence of substance-abuse disorders have also been identified by national mental health epidemiological research (Stecker, Curran, Han, & Booth, 2007). Another important component of mental health is psychological distress. One contributing factor to stress which has been documented is the effect of caregiving. An estimated 52 million people in the United States are primary caregivers for a loved one who is ill or disabled (Mind, Mood, & Memory, 2007; Gopalan & Brannon, 2006). Fortunately, social support networks are known to improve the mental health of community members as well as decrease stress levels for caregivers. Enhancing social support ties is a common goal of behavioral health treatment, with overwhelming evidence supporting the connection between strong social networks and mental health (Savage & Russell, 2005).
     In response to the need to assess mental health in communities, academic researchers have conducted community-based participatory research that includes areas of assessment of mental health. One such partnership is the Healthy Community Council (HCC) of Harrisonburg, Virginia. The HCC is composed of nearly 160 stakeholders representing both public and private organizations within the community. The mission of the HCC has been to conduct assessments to measure quality of life within the community, identify assets, and prioritize community needs. While many factors contribute to quality of life within a community, mental health surfaced as one of eight categories used to measure community-specific quality of life within the HCC community.  Indicators for the mental health section of the assessment included 1) psychological distress, 2) substance abuse, 3) caregiving, and 4) social support.

Methods

     The HCC developed and implemented community-specific assessments in 1996, 2001, and most recently in 2006 to measure quality of life within the community.  The 2001 assessment instrument and the assessment process for implementing and disseminating the assessment were analyzed prior to the initiation of the 2006 HCC assessment.  Assessments conducted in other communities were also surveyed for specifics such as instrument design and assessment methodology.  After extensive review, community assessments conducted in Jacksonville, Florida and Marin County, California served as models for the 2006 HCC assessment. Additionally, state and national surveys such as the National Health Interview Survey (NHIS), and national health goals outlined in Healthy People 2010 were reviewed.
A 56-item instrument for the 2006 HCC Assessment was developed. There were five questions that related to psychological distress, seven questions on substance abuse and six questions on caregiving.  Institutional Review Board (IRB) approval was obtained from a local university.
     A random sample of community members was purchased from Survey Sampling International, Inc.  Each individual on the list was contacted via telephone to request participation in the assessment.  Individuals who agreed to participate were mailed an assessment packet, which included the assessment instrument, a cover letter explaining the assessment including informed consent parameters, and a self-addressed stamped envelope.  A packet with a modified cover letter was sent to individuals who could not be reached via telephone after two attempts.  The cover letter explained that attempts were made to contact the individual by phone to explain the assessment and the importance of conducting a community assessment in planning and developing community-specific services. A response rate of 42% with a sampling error of 3.8% was obtained. Stratified random sampling techniques were used to ensure that the sample who completed the assessments were representative of the entire population within the community.  The sample was stratified by geographic location within the community with the county being divided into four distinct regions and the city composing the fifth area. The completed assessments mirrored the proportion of individuals residing in each of the five regions of the community. Assessments were scanned into a spreadsheet and then downloaded into SPSS 14.0 for analysis.  Data analysis included frequencies and cross-tabulations based on gender and age. 

Results
Mental Health Status and Desire for Help

     Demographics of survey participants are found in Table 1. Responses indicate that seniors, ages 65 plus, reported lower instances of serious psychological distress during the past 30 days than adults, ages 18-64. However, between 2001 and 2006 there was a reported increase in adult symptoms of serious psychological distress, and a decrease in symptoms for seniors. When compared to national data established by the 2004 NHIS, the overall percentage of adults who experienced serious psychological distress was 11.3% compared to NHIS levels of 6.6%. (Table 1)
     It is essential to assess the need for mental health services within the community so that services may be developed and tailored for individuals in need of help.  In assessing treatment for mental illness, 15% of adults and 14% of older adults reported taking prescription medication for depression and/or anxiety.  In assessing utilization of mental health services within the community, 12% of adults and 5% of older adults reported receiving care by a mental health professional for an emotional or mental health concern (Figure 1). For those who had received care, 97% of adults and 100% of older adults stated that they had received mental health care within a timely manner.  

Substance Abuse

     While the percentage of adults who drink has almost doubled since the 2001 survey, our community remains below the national average of 68 percent. Self-reported use of alcohol among seniors increased from 11 percent in 2001 to 32 percent in 2006. Both adult and senior men reported acute drinking twice as much as women. While acute drinking was reported slightly below the national average, it was well above the Healthy People 2010 goal for adults age 18 and older. According to the 2004 Report of the VirginiaCenter for Healthy Communities, 15 percent of adults in Rockingham County and 21 percent of adults in Harrisonburg were at risk for acute drinking. Responses indicate that 57% of adults and 32% of older adults consumed alcohol during the previous month, while 19% of adults and 5% of seniors were identified as acute drinkers. Acute drinkers were defined for females as those who consume four or more drinks at the same occasion and defined as five or more drinks for males. (Figure 3)
     In assessing the desire for help with a substance abuse problem, 2% of adult and 1% of older adults reported seeking help for alcohol use.  Two percent of adults and no older adults reported wanting help with a prescription or non-prescription drug problem.  Gender and the desire for help with a substance abuse problem were also examined using 2006 HCC data.  Those who reported needing assistance with alcohol use included 3% of adult male and 1% of adult female assessment participants. (Figure 4)
     Research has shown that substance abuse affects more than the individual abuser. Assessment participants were asked if alcohol, prescription or non-prescription drug abuse caused harm to them or their family during the past two years.  Eight percent of adults and 5% of older adults reported that the use of alcohol had a harmful effect on them as an individual or on a family member within the past two years.  In addition, 6% of adults and 6% of older adults reported that the use of drugs had had a harmful effect on them as an individual or on a family member within the past two years. As compared to 2001, the 2006 survey indicates that substance use is having a greater harmful effect on families of both adults and seniors, significantly so for seniors. More adult men than women expressed a desire for help with a substance use problem. This may be because treatment is mandated more frequently for men.

Social Support and Caregiving

     Social support networks are essential for obtaining and sustaining overall health including mental health. In 2001 and in 2006, family was the primary source of social support for both adults and older adults, followed by friends and faith-based organizations.  In the 2006 Assessment, 10 percent of adults and 14 percent of older adults reported not having any support system. 
     As the aging population grows, the need for qualified caregivers within the community also increases.  In response, an increasing number of adults are taking on the role of caregiver for a loved one.  Studies have shown that caregivers are stressed with the demands of caring for dependents while also having to care for a parent, disabled child or spouse (Gopalan & Brannon, 2006). Therefore, another indicator included in the 2006 HCC Assessment within the mental health assessment category was caregiving.  Twenty-two percent of the respondents identified themselves as caregivers. Of those, the highest percentage were 45-54 year olds; however, if ages 65-84 are combined, they make up the largest group of caregivers (31%). Older adults received 75 percent of the caregiving provided. Ninety-two percent of caregivers reported receiving no assistance, paid or unpaid. In total, 35 percent of caregivers reported a disruption in employment activities. Nationally, 62 percent of caregivers had to make some adjustments to their work life, from reporting late to work to giving up work entirely. Also, 16 percent of respondents stated that they missed five to ten hours of work or other major activities per week due to caregiver responsibilities.  (Figure 2)

Discussion

     More adults 64 and younger reported symptoms of serious psychological distress compared with reports from the 2001 HCC assessment, while older adults showed a slight decline in psychological distress compared with 2001 data. Both adults and older adults were above the national level of three percent as reported by the 2006 National Health Interview Survey.
     Although more adults are experiencing psychological distress, fewer are seeking treatment in 2006 as compared to data from 2001 (Figure 1). Future research needs to focus on reasons and possible barriers to seeking mental health services within this specific community. In examining alcohol use and acute drinking within the community, alcohol consumption among adults was 18 percent, above the Healthy People 2010 target of 13 percent (Figure 3). Alcohol use and acute drinking indicates a need within the community for education as well as treatment and support services for substance abuse for all adults 18 years and older (Figure 4). In assessing social support systems utilized by community members, family and friends for both adults and older adults were most popularly cited, with faith-based organizations ranking third for both populations. The concern however, is that many adults and older adults stated not having a source of social support. This information is essential when planning, delivering, and evaluating mental health services within the community. It also shows the need for additional mental health services at the community level.

Limitations

     While alcohol abuse was above national guidelines and the impact on individuals and the family was reported to be higher than in 2001, desire for help was relatively small.  One limitation of the study was that drug use was not assessed within the community, but a desire for assistance for drug use was assessed and nearly eight percent of older adults reported a desire for help.  Another limitation was that a desire for help with a substance abuse problem was not assessed in the 2001 HCC and therefore a comparison could not be made with 2006 data.

Implications

     With mental health issues rising within communities and the lack of community-level data, this study illustrates how community based organizations can conduct a community-specific assessment so that services can be developed and disseminated to those in need. Based on the data from the 2001 HCC assessment, Generations Crossing, an adult day-care facility was developed to provide respite care for elder adults and support for caregivers. One example of how community-level assessment data can benefit those providing care giving living in communities. Through the implementation of the Generations Crossing program, many people within the community have benefited psychologically by having a place to go and caregivers to assist when needed. Based on assessment findings a subcommittee of the HCC is in the process of developing a community health center that provides care for those with mental health issues. Few community health centers provide mental health services, and therefore, it is the hope of the HCC that the center serves as a model for other communities.

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