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Building of Project Wings, a Multi-Component Mental Health

Promotion Intervention: Funding, Findings, and Future Steps

Carolyn M. Garcia, Ph.D.Assistant Professor

garcia@umn.edu

OVERVIEW

• Significance• Need• Potential impact

• Innovation• Methodological advancements• Theoretical advancements

• Approach• Collaborators• Preliminary studies• Plan of work

• Funding history• Strategizing future research

SIGNIFICANCE

From Center for Scientific Review (for reviewers):

Does the project address an important problem or critical barrier to progress in the field?

If the aims of the project are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved?

How will successful completion of the aims change the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field?

SIGNIFICANCE: NEED

1. Magnitude of the problem

2. Malleable risk and protective factors

3. Evidence for health promotion intervention models

GAPS, GAPS, GAPS, GAPS, GAPS

SIGNIFICANCE- Magnitude of Problem

Demographics- Projected increase of Latino youth in US by 60% (compared to 8% overall)

Mental health and risk behaviors- Twice as many Latina girls report depressive symptoms (40%) compared to other girls

- Disproportionately high rates of anxiety, suicidal ideation, suicidal attempts

- High rates of related problems, including multiple risk-taking behaviors, substance use, delinquency, pregnancy

The implications of poor mental health in adolescence extend into life and health trajectories…

SIGNIFICANCE- Risk/Protective Factors

Individual-level- Physical development

- Cultural identity, acculturation

- Coping skills, outlook on life have influence on stress impact, which affects health trajectory, depressive symptoms, etc.

Social-level- Family factors: values, immigration/reunification, mother/father connectedness

- School factors: connectedness, caring adults, achievement

Our research intervenes on the two most important sources of potential protection and social support for Latina

adolescents, namely school and family.

SIGNIFICANCE- Intervention Evidence

Attributes of successful interventions with Latino youth- Tiered approach

- Group-based formats

- Culturally-relevant and respectful to parents

Support for sex-specific interventions- Demonstrated need for and benefits of girls’ only interventions

- Girls’ only intervention can incorporate unique developmental needs and learning styles of girls

Our study advances the field by implementing a school-based, family-involved mental health promotion intervention for

Latina girls.

SIGNIFICANCE: POTENTIAL IMPACT

Health promotion field needs additional effective, realistic sustainable interventions

Study findings might yield knowledge about what works in promoting the mental health of Latino girls

Study findings might provide insights useful for mental health promotion with other adolescent populations

INNOVATION

From Center for Scientific Review (for reviewers):

Does application challenge/seek to shift current research or clinical practice paradigms by utilizing novel theoretical concepts, approaches or methodologies, instrumentation, or interventions?

Concepts, approaches or methodologies, instrumentation, or interventions novel to one field of research or novel in a broad sense?

Refinement, improvement, or new application of theoretical concepts, approaches or methodologies, instrumentation, or interventions proposed?

INNOVATION: METHODOLOGICAL ADVANCEMENTS

Data Collection Strategies- Mother-daughter dyad communication task

- Ecological momentary assessment via text messaging

Intervention Components- School-based and family-involved

- Photovoice

- Home visits and groups

Our research seeks to inform mental health promotion paradigms by testing the intervention

with varied data sources to render unique trajectory insights.

INNOVATION: ECO-RESILIENCE THEORY & COMPLEXITY THEORY

Macro-level EnvironmentPolitical RealitiesYouth Laws/PoliciesMacro-level EconomicsHistorical EventsImmigration ReformCultural Values

Eco-Resilience Microsystems

Community Environment

• poverty• household make-up• age of migration• neighborhood climate• access to care barriers• school resources• transportation options• access to tobacco, alcohol, drugs, firearms

• school quality/options• cultural consistencies• culturally relevant services• employment rates of adults• informal support systems• religious institutions• access to role models

Macro-level Environment

Risk Protection

Family

• familial separation• family mental illness• maternal stress• acculturative differences• overcrowding• poverty• documentation issues• risky health behaviors• authoritarian parenting style• exposure to family violence• parental work demands

• connectedness - mother - father• parental presence• parental values - towards school - toward risk taking• two parents• family cohesion• authoritative parenting style

Community Environment

Macro-level Environment

Eco-Resilience Microsystems

Risk Protection

• prejudice from peers

• perception of threat

• social isolation• participation in

deviant culture

• being treated fairly by peers

• achievement goals• peers with pro-

social norms

Eco-Resilience Microsystems

Family

Community Environment

Macro-level Environment

PeersRisk Protection

• size of school• absenteeism• suspension• # of schools

attended

• connectedness • academic performance• school policies• school values• school resources• family involvement

Eco-Resilience Microsystems

Family

Community Environment

Macro-level Environment

PeersSchoolRisk Protection

• biological vulnerability• impulsivity• stress reactivity• acculturative stress• isolation• lack caring adult

• healthy coping • hope• spirituality/religiosity• social skills• positive self-image• positive self-efficacy• parental connectedness

Eco-Resilience Individual-level

Risk ProtectionIndividual

School

Community Environment

Macro-level Environment

Family

Individual

Peers

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Eco-Resilience…when risks rule…

Mental Health Risk Behaviors and Outcomes- Substance use- Isolation- Gang involvement- Sexual risk-taking- Pregnancy- School drop-out- Limited employment options

- Depressive symptoms- Suicidal ideation- Suicidal attempts- Hopelessness- Anxiety- Stress

School

Community Environment

Macro-level Environment

Family

Individual

Peers

ECO-RESILIENCE IN THIS STUDY

COMPLEXITY THEORY

INNOVATION SUMMARY

Our proposed research will use established and novel approaches to assess Project Wings’ trajectory impacts

and advance theoretical understanding.

Project Wings/Proyecto Alas, collaboratively named with input from Latino teens and parents…

…is informed by initial complexity discoveries of weather shifting as a result of simple flapping wings,

…and reflects wings as protection/asset and wings as growth and opportunity.

APPROACH

Are the overall strategy, methodology, and analyses well-reasoned and appropriate to accomplish the specific aims of the project?

Are potential problems, alternative strategies, and benchmarks for success presented?

If the project is in the early stages of development, will the strategy establish feasibility and will particularly risky aspects be managed?

If the project involves clinical research, are the plans for 1) protection of human subjects from research risks, and 2) inclusion of minorities and members of both sexes/genders, as well as the inclusion of children, justified in terms of the scientific goals and research strategy proposed?

APPROACH: COLLABORATORS

1. School-based staff- academic counselors, advisors

- educators, including educational assistants

- nurses, social workers

2. Community-based agencies- clinics

- public health

3. University-based colleagues/centers- Mentors, centers

APPROACH: COLLABORATORS Example collaborative effort for one pilot study

APPROACH: PRELIMINARY STUDIES

1. Formative Survey and Focus Groups

2. Project Wings Girls’ Group Pilot

3. Project Wings Randomized Controlled Pilot

4. Project Wings Mother-Daughter Photovoice

5. Project Wings Home Visits Pilot

APPROACH- Formative Survey and Focus Groups (2006-2007)

234 Latino adults and adolescents completed a survey about mental health perceptions and resources.

Survey results supported attention toward urban Latina adolescents, with observed differences between urban and rural adolescents in terms of mental health problems and risks.

Focus groups were conducted separately with Latino mothers, fathers, adolescent boys, and girls (8 groups) in urban setting.

Our focus group study explored Latino parents’ and adolescents’ perceptions of mental health and intervention strategies, and yielded support for a school-based, parent-involved approach.

APPROACH- Project Wings Girls’ Group Pilot (2007-2008)

Twenty-one Latina adolescents, conveniently recruited from two high schools, participated in a 16-session weekly program to promote coping knowledge and skills, and social support, using sharing circles, relaxation strategies, and life skills lessons.

Feasibility and satisfaction were demonstrated, in addition to ability to recruit and engage urban Latina adolescents at our targeted levels.

APPROACH- Project Wings RCT (2008-2009)

We recruited and randomized 42 9th and 10th grade Latina adolescents to receive the 16-session intervention or attention control programs.

APPROACH- Project Wings RCT cont.Although not statistically powered, promising trends were observed.

APPROACH- Mother-daughter Photovoice (2009 & 2010)

3 mother-daughter dyads were recruited to complete an 8-session photovoice project.

An additional ~20 dyads completed a second photovoice study, in Mexico and the U.S. in 2010, confirming feasibility.

We demonstrated ability to:(a)retain mother-daughter dyads in an 8-session weekly program despite personal/work obligations and (b)collect video-recorded communication task and 6-month follow-up data.

APPROACH- Project Wings Home Visits (2009-2010)

Twenty Latino families with students attending an urban public high school were enrolled and received an average of 6 home visits over a 6-month period.

Importantly, this pilot showed that moms will participate, and established staffing needs for home visits in the full-scale trial.

APPROACH- Pilot Study Dissemination!

Manuscripts (feasibility, methods/process, theory, results)Garcia C, Hermann D, Bartels A, Matamoros P, Dick-Olson L, Guerra de Patino J. (in press). Development of Project Wings Home Visits, a Mental Health Intervention for Latino Families using Community-Based Participatory Research (CBPR). Health Promotion Practice

Garcia C, Pintor J, Lindgren S. (2009). Feasibility and Acceptability of Project Wings, a School-based Coping Intervention for Latina Adolescents. Journal of School Nursing, 26(1), 42-52

Presentations (local, regional, national, international)

-BIRCWH Annual Meeting-Sigma Theta Tau International Research Congress-American Public Health Association-Midwest Nursing Research Society-Minnesota Association of Children’s Mental Health

APPROACH: R01…THE AIMS

Aim 1. Test the impact over time (baseline, mid-, immediate post-, 6-month post-, and 12-month post-intervention) of Project Wings, compared to an attention control condition, to increase Latina adolescent emotional well-being.

Aim 2. Assess potential moderator and modifier effects of individual-level and school-level variables on the Project Wings intervention-Latina adolescent emotional well-being relationship.

Aim 3. Assess implementation factors of Project Wings, specifically acceptability and sustainability.

APPROACH- R01…THE PLAN OF WORK

Building on the pilot study results, the following is proposed:

1.Group randomized, controlled trial involving 9th grad Latina adolescents attending 14 urban high schools

2.Two cohorts in subsequent years to maximize enrollment

3.School-level randomization to Project Wings or Attention Control

APPROACH- R01…THE RANDOMIZATION MODEL

APPROACH- R01…THE DATA

APPROACH- Study Time Line

FUNDING HISTORY2006 Sigma Theta Tau $5,0002006 Zeta Chapter, STTI $2,5002006 MNRS/STTI $2,5002007 UM Multicultural $14,0002007 UM CYFC $7,5002008 NIH/K12 $75,000 (75% salary too)2008 NIH/P20/Nursing $22,2562009 Medica Foundation $49,9992009 UM Grant-in-aid $29,1322009 Zeta Chapter, STTI $1,3332010 PIMSA (UC Berkeley) $38,0002011 ???????????????? ?,???,???

Total………….. $247,220

STRATEGIZING FUTURE RESEARCH

***R01 reviewed February 8-9, 2011 (results pending!)***

Follow-up to R01 as indicated…implement, revise/resubmit, etc.

Continue to disseminate pilot study findings.

Advance methodological expertise:- Seed grant/funding to pilot ecological momentary sampling via text messaging

Advance related content expertise:- Adaptation of evidence-based mental health promotion interventions (i.e., suicide prevention messaging/media)- Teen dating violence, runaway prevention, sexual violence

CONTACT INFORMATION

Carolyn M. Garcia, Ph.D. University of Minnesota

6-186 Weaver-Densford Hall 308 Harvard Street S.E. Minneapolis, MN 55455

Telephone: 612-624-6179 Email: garcia@umn.edu