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Abstract
Introduction Severe inequities in depression and its diagnosis and treatment among rural-dwelling, racial-minority and ethnic-minority older adults compared with their urban white counterparts result in cognitive impairment, comorbidities and increased mortality, presenting a growing public health concern as the United States (US) population ages. These inequities are often attributable to social and environmental factors, including economic insecurity, histories of trauma, gaps in transportation and safety-net services, and disparities in access to policy-making processes rooted in colonialism. This constellation of factors renders racial-minority and ethnic-minority older adults ‘structurally vulnerable’ to mental ill health. Fewer data exist on protective factors associated with social and environmental contexts, such as social support, community attachment and a meaningful sense of place. Scholarship on the social determinants of health widely recognises the importance of such place-based factors. However, little research has examined how they shape disparities in depression and treatment specifically, limiting the development of practical approaches addressing these factors and their effects on mental well-being for rural minority populations.
Methods and analysis This community-driven mixed-method study uses quantitative surveys, qualitative interviews and ecological network research with 125 rural American Indian and Latinx older adults in New Mexico and 28 professional and non-professional social supporters to elucidate how place-based vulnerabilities and protective factors shape experiences of depression among older adults. Data will serve as the foundation of a community-driven plan for a multisystem intervention focused on the place-based causes of disparities in depression. Intervention Mapping will guide the intervention development process.
Ethics and dissemination This study has been reviewed and approved by the University of New Mexico Health Sciences Center Institutional Review Board. All participants will provide informed consent. Study results will be disseminated within the community of study through community meetings and presentations, as well as broadly via peer-reviewed journals, conference presentations and social media.
- Aging
- Community-Based Participatory Research
- Health Equity
- MENTAL HEALTH
- PUBLIC HEALTH
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study’s use of qualitative, quantitative and ecological methods will yield a holistic, multidimensional understanding of how social and environmental characteristics of rural places influence older adults’ experiences of depression and help-seeking.
Intervention Mapping, a participatory approach to planning health interventions, will ensure that the resulting intervention plan is pragmatic, community driven and contextually relevant.
The study sample is composed of residents from a single community with substantial internal heterogeneity, which may limit generalisability of findings and intervention materials to other sociocultural contexts.
Introduction
Inequities in depression and its diagnosis and treatment are severe among racial-minority and ethnic-minority older adults in the USA. These older adults have higher rates of depression and lower rates of diagnosis and treatment than non-minorities across treatment settings and insurance status.1–3 These inequities are exacerbated in rural areas, where the ageing population is high and increases with remoteness.4 This compounded disparity in depression diagnosis and treatment among rural-dwelling minority older adults presents a growing public health concern as the nation’s population ages.5 Inequities are due to a concurrence of interlocking vulnerabilities often tied to place (ie, physical and social environment). Key vulnerabilities include economic insecurity,6 histories of trauma,7 8 chronic gaps in transportation and safety-net services (eg, food assistance, healthcare)6 and dense networks of acquaintanceship that may stigmatise mental illness and seeking help.9 However, health-promotive mechanisms of protection and resilience are also linked to place. Such mechanisms may include proximity to supportive relationships10 11 and cultural and environmental practices (eg, gardening, ceremony)10 12 that enhance mental well-being through meaningful social roles, senses of place and connections to community and cultural history.13–15 The influence of place on mental health only increases in importance as people age and are less able to relocate.14 The importance of place-based factors in shaping health is well recognised, yet little research has examined how such factors shape disparities in depression and treatment for racial-minority and ethnic-minority older adults.16 Studies are also needed to develop effective place-based interventions, which are complex by nature, involving a multiplicity of contextual particularities, diverse stakeholders and levels of influence.16 17
American Indian and Latina, Latinx, and Latino (hereafter, Latinx) older adults are two populations who experience mental health inequities. Although depression can be difficult to measure definitively among older American Indians because of cultural differences in concepts and manifestations of mental illness,18 some studies estimate that as many as 9% of American Indian older adults meet the criteria of major depressive disorder,19 compared with 1%–5% in other samples of older adults.20 Rates of depression among Latinx older adults tend to be roughly equal to or greater than those among their non-Hispanic white counterparts.21 In both populations, the risk of depression is increased by other common factors, such as lifetime stress.19 21 Minority older adults are also more likely than whites to encounter structural barriers to care (eg, financial insecurity, unsafe home environments) and other factors that discourage help seeking and reduce trust in healthcare providers (eg, lack of knowledge regarding mental health, discrimination).1 22 Among American Indian older adults who live in rural or reservation areas, access to healthcare remains difficult despite their right to access health services through the Indian Health Service (IHS).23 24 Their mental health is also affected by histories of violence, discrimination and social marginalisation8 and the common burden of caring for children and grandchildren.25 Similarly, ageing Latinx adults are likely to experience negative health effects from lifetime histories of adversity,7 along with the daily stress of discrimination,26 which may be compounded by social isolation and a lack of geographic mobility for many rural residents.27
Although older adults in rural areas encounter similar obstacles, their experiences remain understudied.6 28 Common characteristics of rurality, such as geographical isolation, social and demographic change, and insular community and family networks, increase the risk of depression for many older adults, especially those with poor health or who live alone.29 These challenges have major health consequences, as untreated depression is associated with increased mortality,30 cognitive impairment31 and multiple comorbidities, especially with other chronic illnesses, such as diabetes, heart disease and stroke.32 The imperative to address mental health disparities is pressing as more than one in five US adults age 65 and older are rural-dwelling.4 Census estimates indicate that the population of American Indian older adults will increase by 40% by 2060 while the population of Latinx older adults will increase by more than 150%.5 33 34
Interventions to increase mental wellness and diagnosis and treatment of depression in minority ageing populations largely focus on individual-level approaches like medication management and health system navigation.35–38 However, efforts to influence place-specific factors, such as community environments and resources (eg, affordable housing), can effectively prevent and treat chronic illnesses and social ills.39 In racial-minority and ethnic-minority settings, community-driven interventions have increased health equity in physical health outcomes and social well-being.39 Although community-level and multilevel interventions are more complex to implement, there is a need for such approaches to consider the broad historical, social and environmental determinants that define and shape experiences of wellness.39 40 Moreover, community-level healing approaches are indispensable in addressing the root causes of mental distress for marginalised populations, such as American Indian and Latinx people, because they are culturally relevant and effective in increasing the well-being of both groups.41–43 This study draws on such approaches to (1) elucidate the relationships between social and environmental influences and mental health disparities, which scholars identify as vital to advance the science of health disparities16 38 and (2) develop new place-based intervention strategies to influence the multiple systems (eg, physical environment, social context, healthcare system) within which such disparities are reproduced for American Indian and Latinx older adults.
Conceptual frameworks
This study draws on structural vulnerability and social-ecological theories. Stemming from the recognition of social structural forces (eg, racial and socioeconomic hierarchies, institutional policies) that shape health, the concept of structural vulnerability draws attention to how social inequality produces health disparities for some by increasing their exposure to health risks and barriers to treatment.44 45 Structural vulnerability theory is in keeping with a social-ecological model of health46 47 that describes influences on health as occurring at personal, interpersonal, community and policy levels, with the healthcare system as an additional level.48 This model accentuates the importance of cultural and community context in defining and shaping experiences of illness and health and prioritises efforts to support cultural and community assets in the interest of long-term, sustainable change.40 49 50 The current study emphasises the social and physical environment as a crucial but understudied domain of influence.14 48
This study uses an adapted version of Winterton et al’s14 community ecological model of wellness for rural older adults (figure 1). This model conceptualises the sociocultural and physical or built environment as consisting of interrelated sets of influences—sociodemographic characteristics (eg, race and ethnicity, education) and quality and availability of resources (eg, natural spaces, healthcare). Winterton et al predict that these influences affect rural older adults’ mental wellness via (1) their opportunities and capabilities, which shape their ability to achieve goals; (2) their perceptions of their environment and (3) their health (measured both objectively and subjectively). The present study hypothesises that while minority status and lack of access to high-quality resources will correlate with fewer opportunities and capabilities and poorer mental health (as predicted by the model), these effects will be modified by strong community attachment and sense of place (ie, historical and/or cultural rootedness in place, positive perceptions of the environment).
Community ecology of wellness for rural older adults: levels of influence and associated variables/analyses.
Intervention Mapping (IM) will inform data collection instruments and the community-based intervention model to be developed as part of this study. The IM model is an empirical and theory-based approach to planning health promotive programmes using six steps: (1) undertaking a needs assessment; (2) creating a model of change; (3) selecting theory-based and evidence-based strategies that describe how an intervention will result in intended outcomes; (4) developing and testing intervention materials; (5) designing an implementation plan and (6) preparing an evaluation plan.51 The study aims will map onto the IM steps as described below. The final product is a contextually and culturally appropriate plan for a place-focused intervention to improve depression, diagnosis and treatment among rural minority older adults.
Project aims
This study will elucidate how place-based vulnerabilities and protective factors influence experiences of depression and access to diagnosis and treatment among rural American Indian and Latinx older adults in New Mexico. Data will contribute to a plan for a community-driven intervention addressing the place-based causes of disparities in depression and its diagnosis and treatment. This plan will form the basis of a subsequent study to implement and evaluate the intervention. The focus on American Indian and Latinx older adults will facilitate comparisons of characteristics specific to each group, such as their sociocultural history and access to different health systems, including the IHS and federally funded non-profit health facilities for medically underserved populations, known as Federally Qualified Health Centres (FQHCs). This focus will also enable an analysis of how common place-based factors (eg, cultural and environmental practices, geographical remoteness) affect both groups. The aims of the study are to:
Describe the range of social and environmental vulnerabilities and protective factors associated with depression and access to and use of mental health services for rural minority older adults using in-depth, semistructured qualitative interviews with older adults and their social and professional supporters.
Identify relationships between social and environmental factors and depression symptoms for rural minority older adults and compare how they vary across axes of difference (eg, race and ethnicity, age, gender, access to health systems) using quantitative surveys and ecological network analysis.
Engage older adults and their social supporters in IM to develop a community-driven protocol for a place-focused intervention that will influence the social and environmental factors influencing depression.
Methods and analysis
This study uses a ‘convergent parallel’ mixed-method research design, meaning that qualitative and quantitative data will be collected and analysed simultaneously, with both sources complementing and expanding on the other.52 The research team will use quantitative data to test a sequence of hypotheses regarding the main effects of minority status and limited resources on mental health (ie, depression) and effect modification through either mediation or moderation by the level of community attachment. We will use qualitative data collected from in-depth interviews to generate a detailed description of place-based protective factors and vulnerabilities and their influence on participants’ perceptions and experiences of mental health and help seeking. Triangulation of both sets of findings will yield a holistic, richly descriptive and geographically grounded account of how place shapes mental wellness, experiences of depression and access to depression diagnosis and treatment for American Indian and Latinx older adults. Using both types of data will thus create a deeper understanding of these relationships than would be gained from a single type of data.52 Figure 2 outlines the study components.
Procedural diagram of study components.
Research setting
This research centres on the ageing residents of New Mexico’s Española Valley, a US Health Resources and Services Administration-designated rural and health professional shortage area53 that encompasses parts of Rio Arriba and Santa Fe Counties, including two American Indian Pueblo tribes. The Valley’s population of 24 660 inhabitants is spread over an area of 20.1 square miles, approximately 10 000 of whom live in the town of Española.54 People over age 65 make up about 17% of the population, comparable to the rest of the nation. Nine per cent of residents are American Indian and more than three-quarters (80%) identify as Hispanic.54 Residents have long experienced structural and health inequities rooted in a history of colonisation by the Spanish and US governments. In Rio Arriba county, the US Census describes 18.1% of residents as living in poverty.55 Valley residents experience higher mortality rates from mental health and substance use problems, including suicide, drug overdose and alcohol-related problems, as well as chronic illness associated with depression, such as stroke and diabetes, compared with the state average.56 The behavioural health safety net for the region was decimated in 2013 when many longtime community providers were forced to shut down under unsubstantiated allegations of Medicaid fraud.57 Popular and scholarly accounts have tied these challenges to the place and culture of the Española Valley, often stigmatising American Indian and Latinx residents as criminal, poor and trapped within intergenerational patterns of substance abuse and ill health.58 59 Yet, Valley residents maintain material, intergenerational and cultural connections to place that figure significantly in their own assessments of individual and communal well-being.10 12 Research describing how place-based factors create risks for such populations and that elucidates their protective potential is scarce. The Española Valley thus provides an ideal location to examine the relationship between place and mental wellness across race and ethnicity, gender, relative age and access to health and social services.
Community advisory board
Critical approaches to research with Indigenous and other racially and socioeconomically marginalised groups emphasise community engagement and empowerment at all stages.60 61 This study employs an 8–10 member community advisory board (CAB) of American Indian and Latinx older adults and allies, such as healthcare and social service providers with backgrounds in elder care. The CAB will include 4–5 members from the Seasons of Care CAB, a group that has been meeting bimonthly since 2015 to oversee a study of American Indian Elders’ healthcare access and utilisation.62 The remaining members will consist of individuals identified and invited with input from the existing CAB members, with an emphasis on Latinx older adults and allies. The CAB will meet bimonthly throughout the study to cocreate and review research instruments and protocols (as described below), help with recruitment and provide feedback on the interpretation and dissemination of data.
Quantitative survey
Participants and recruitment
To achieve IM steps 1 and 2 (conducting a needs assessment and creating a model of change), we will use a variety of recruitment activities and a purposive sampling strategy to recruit a total of 125 American Indian and Latinx older adults to participate in the quantitative survey. These approaches are appropriate in the absence of an accurate sample frame for all population members. We will begin recruitment using multiple strategies successfully deployed in our previous research with minority older adults.62 We will conduct regular visits to senior centres, community health fairs and meetings of older adult-serving community groups and organisations, such as the American Association of Retired Persons and the New Mexico Indian Council on Aging, in the Española Valley and surrounding communities to present study information and answer questions, screen interested candidates and conduct surveys and interviews. We will distribute study information and business cards to staff and providers in local health facilities (eg, IHS facilities, FQHCs) and social service offices (eg, Social Security Administration (SSA) offices, Supplemental Nutrition Assistance Programme (SNAP) offices and family resource centres) to share with eligible patients and clients. We will post study information and distribute cards to share with eligible individuals in community settings (eg, grocery stores, libraries, social justice organisations, volunteer programmes and community gardens) that older adults commonly frequent. Finally, we will advertise the study information in community newsletters and public service announcements on local radio channels serving the state’s American Indian and Latinx populations. All advertisements will encourage candidates to call the study phone number for eligibility screening and to set up an appointment.
In addition to these approaches, we will use a respondent-driven sampling strategy, an approach that is appropriate for ‘hidden’ populations that are otherwise difficult to reach due to distrust of, or lack of familiarity with, research processes.63 After each survey and interview, we will ask participants to suggest peers who may be interested in participating. To ensure variation in mental health status, we will ask participants to suggest individuals they perceive to be ‘doing well’ and those who may be ‘struggling’ without revealing which is which. We will ask participants to provide contact information or contact their suggested peers on our behalf if they are comfortable doing so; otherwise, we will give them study business cards to pass along to their peers. This strategy will be less stigmatising and more culturally acceptable than identifying candidates by mental health status (eg, via interactions with mental health providers). If necessary, we will deliberately oversample or undersample certain groups so that the final sample includes roughly equal numbers of males and females, American Indian and Latinx individuals, and older adults who are in ‘early’ (eg, age 55–64) and ‘later’ (eg, age 65+) stages of old age.
Data collection
Participants will be asked a set of fixed-response questions covering demographics, basic health status, access to and utilisation of mental healthcare, health insurance and social support. Pertinent questions will be drawn from the Behavioural Risk Factor Surveillance System,64 the Medicare Current Beneficiary Survey65 and the National Health Interview Survey66 to facilitate comparisons with other populations. In addition to these descriptive measures, the survey will assess emotional and mental wellness using the Hopkins Symptom Checklist67 68 and the WHO Quality of Life measure.69 While wellness measures are not intended to diagnose depression, they will furnish data on symptoms related to depression (eg, enjoyment of daily activities) among older adults who may be reluctant to identify themselves as needing mental health treatment. Additional questions to examine culturally specific health indicators will be discussed and adapted in consultation with the CAB.70 71 An additional set of measures will evaluate the presence or absence of meaningful, protective connections to place that are known to correlate with mental well-being.15 72 73 These measures will be cocreated with the CAB to capture historically and culturally specific experiences of attachment to place and community. Potential questions will be adapted from Cramm and Nieboer’s74 scales of neighbourhood-level social cohesion and belonging among older adults and the Sense of Place module of the Hamilton Household Quality of Life Survey, which asks about the meaning and significance that individuals attribute to the place they live, including rootedness, sentiment, neighbours and environment/health.75
Finally, following a method described by Browning and Soller,50 76 all participants will be asked a set of ecological network questions intended to elicit information about the routine places they visit throughout their community and the extent to which those places overlap, with greater extensity of overlap significantly and positively correlating with community attachment and support.50 Participants will review a list of community locations generated in consultation with the CAB (eg, libraries, stores and restaurants) and indicate whether they have visited those locations in the previous 30 days. Participants can also suggest new locations, which will be recorded with as much geographical specificity as possible (eg, cross streets). Participants will also be asked to provide a physical location for themselves that they are comfortable disclosing (eg, home address, cross streets and nearby landmark).
Data analysis
We will use the quantitative data to summarise and compare participant characteristics and test hypotheses. First, responses to the ecological network questions will be coded and constructed into two-mode networks. To calculate the extensity of networks, a one-mode matrix will be derived from these networks to indicate the number of shared locations between any two participants, which can then be summed to indicate an individual’s number of shared locations with all other participants. Second, multiple regression will be used to test the hypothesis that mental wellness is positively associated with measures of community attachment, sense of place and ecological network extensity. Because these relationships are likely to be confounded, we will control for demographic characteristics, overall health status and access to and utilisation of healthcare. Independent sample t-tests will be used to explore additional relationships between variables (eg, community attachment, sense of place) and groups (eg, men and women, American Indian and Latinx older adults). We will use demographic and healthcare access and utilisation data to summarise and compare characteristics of older adult participants and to triangulate these characteristics with their experiences of place. Using questions from national surveys will allow us to compare findings with samples of other populations (eg, urban and non-minority older adults) to examine the specific disparities experienced by this sample of rural minority older adults.
Third, the location provided by participants will be used to attach a variety of contextual information to the survey responses. In addition to basic sociodemographic information from the US Census, we will calculate each participant’s distance to a variety of different community resources (eg, medical facilities, green spaces), defined in consultation with the CAB. This contextual information will be combined with the geocoded subject-level data to estimate multilevel and spatial autocorrelation regression models to identify dimensions of the sociospatial and resource environment that may be predictive of poor mental health and healthcare access and utilisation.
Semistructured interviews
Participants and recruitment
Qualitative interviews will be conducted with a subset of 24 older adults selected from the larger sample, along with 14 non-professional social supporters (eg, family members, non-elderly friends) and 14 professionals who work with older adults, including providers of healthcare (eg, primary care and behavioural health providers, community health representatives), social services (eg, benefits enrollment counsellors, SSA and SNAP office staff) and community services (eg, librarians, senior centre volunteers). These sample sizes are based on agreement among qualitative researchers that 12–26 individuals within a group are sufficient to achieve saturation of data.77 78 Interview participants will be recruited using qualitative sampling strategies to elicit a deep and broad array of knowledge, viewpoints and experiences.79 First, we will select the subset of older adults using maximum variation sampling, including equal numbers of American Indian and Latinx people. After the quantitative survey, we will invite the first six survey participants to take part in the qualitative interview. If a participant declines, we will invite the next survey participants until we have completed six qualitative interviews. We will then invite subsequent participants who reflect a variety of sociodemographic characteristics (ie, race and ethnicity, age), recruitment settings (ie, senior centres, SNAP offices) and mental health statuses and levels of community attachment, as represented by survey responses. Social supporters and service providers will be recruited to take part in a qualitative interview using the same respondent-driven and maximum variation sampling procedures described above.
Data collection
Interviews will be conducted in English or Spanish. Although American Indian older adults in this community are predominantly fluent in English, participants wishing to speak their Native language can elect to have the interview conducted by one of a group of American Indian Elders fluent in their language who were trained in data collection and human subjects protections as part of our previous study of American Indian Elder health. In these cases, interviews will be documented with field notes. This approach is appropriate for the linguistic diversity of the region where access to written and recorded texts in Pueblo languages may be restricted to tribal members.80 A similar approach was well-received by American Indian Elder participants in our prior work.62
Per Winterton et al’s community ecological model,14 we will develop interview guides for each group to inquire into perceptions of the social and physical characteristics of their community and the resources available, including built, natural and service environments (ie, healthcare, social services). Additional questions for older adults and their non-professional social supporters will focus on their subjective evaluations of their emotional and mental well-being, and factors influencing their access to and utilisation of mental healthcare, such as trust in social services and healthcare providers. A complimentary interview guide for professionals will include questions on work roles and responsibilities related to older adults; knowledge of mental health issues and diagnosis and treatment; and perceptions of social and environmental factors affecting older adults’ mental wellness. Using the guides will increase the comparability of responses and allow discretion to follow-up on new or unexpected information. Each interview will last approximately 60 min and be digitally recorded, professionally transcribed, checked for accuracy and imported as text into a secure database.
Data analysis
Interview transcripts will be analysed using both rapid and iterative techniques. The rapid analysis will prepare findings for use in aim 3 (described below). The rapid analysis will be conducted using the RADaR technique for applied research.81 In this technique, interview transcripts are placed into a series of data tables organised by question and response, which are condensed and reorganised into a logic model of place-specific social and environmental determinants (ie, vulnerabilities and protective factors) of depression symptoms, diagnosis and treatment for this population of older adults. This model will be presented to the CAB for review and refinement, with the final model representing step 2 (creating a model of change) in the IM process.
Second, interview data will undergo a more exhaustive, iterative analysis process to identify key themes and issues. We will assign codes to segments of text based on topics and questions in the interview guides. We will then engage in open and focused coding to locate new themes and issues and determine which themes represent recurring or unusual concerns.82 Codes with similar content or meaning will be grouped into broader themes linked to the interview text.82 A key product will be a comprehensive inventory of place-based vulnerabilities and protective factors described in participants’ own words that provides insight into older adults’ experiences of depressive symptoms and the likelihood and ability to seek help. We will triangulate these findings across several dimensions (eg, gender, race and ethnicity) and create matrices detailing vulnerabilities and protective factors. Comparison of perspectives across these dimensions and from different types of participants will elucidate points of convergence and divergence.
Merging of quantitative and qualitative data
Merging of datasets in the analysis phase will use joint display analysis83 to iteratively define convergences and divergences in qualitative, quantitative and spatial data to enhance the rigour of results and generate a holistic understanding of the relationships between (a) older adults’ mental wellness and access to and utilisation of mental health services; (b) their ecological networks, experiences of community attachment and senses of place and (c) availability, proximity and use of supportive resources. We will examine convergence (eg, Do results provide the same answer to the same question?); expansion (eg, Are findings of one dataset explained by another?) and complementarity (eg, Does one set of results contextualise the other?). We will generate matrices detailing: (1) how social and environmental factors influence the resources available to older adults (qualitative and spatial); (2) how perceptions and experiences of place and available resources (quantitative, qualitative and spatial) relate to mental wellness and willingness or ability to seek help (quantitative and qualitative); (3) how these relationships are shared across older adults and how they differ according to race and ethnicity, gender, relative age, access to different resources and physical location (quantitative and spatial); (4) how extensity of ecological networks (quantitative) relate to mental wellness, help seeking, and perceptions and experiences of place (quantitative and qualitative) and (5) how place-specific vulnerabilities and protective factors (qualitative) are situated within ecological networks (quantitative) and physical space (spatial).
Collaborative intervention development
The collaborative intervention development process will follow the remaining steps of the IM process: (3) selecting theory-based and evidence-based strategies; (4) developing and testing intervention materials; (5) designing an implementation plan and (6) preparing an evaluation plan. The goal of this process is to use participatory strategies and the data collected above to develop a detailed plan for a community-level intervention to improve depression and its diagnosis and treatment among American Indian and Latinx older adults.
Participants and recruitment
The remaining IM steps will be undertaken by a Community Action Committee (CAC) of older adults, social supporters and service providers who will meet monthly through the remainder of the study. The CAC will consist of the members of the CAB and 10–12 additional individuals with histories of sustained community involvement and a commitment to reduce mental health disparities. Members will be identified by the CAB using reputational case selection with a focus on individuals who represent key community sectors (eg, primary care, behavioural health, social services, faith communities) and who can thus provide pragmatic perspectives on the feasibility, acceptability and implementation strategies for the finalised intervention. This approach has been used successfully in place-based interventions to increase health equity for minority populations.84
Intervention development and planning
Based on the logic model of place-specific vulnerabilities and protective factors produced during the RADaR process, the members of the CAC will identify a set of change objectives that they wish to undertake to address a subset of domains of influence. Table 1 describes sample change objectives. Change objectives will articulate how proposed activities will improve depression among older adults directly or indirectly. For example, the CAC may choose to mitigate the effects of social marginalisation on mental health via (1) educating older adults and healthcare providers about social and environmental factors that make older adults structurally vulnerable to depression to increase providers’ ability to diagnose and treat depression; (2) creating community spaces for reflection about the impacts of colonialism on mental wellness to increase older adults’ awareness of depression and its causes and (3) supporting older adults to advocate for increased access to policy-making processes to influence decisions that affect their mental health (eg, local expansion of mental health treatment).
Sample change objectives organised by social-ecological level
Next, per the last IM steps, the CAC will review and select theory-based and evidence-based intervention methods to undertake the identified change objectives. These are techniques to achieve the desired changes (eg, community dialogues, policy advocacy, education) that are based on theories of change and evidence of success in similar contexts (see table 2 for sample methods). CAC members will identify any adaptations needed to tailor the intervention to mental health or the community context and brainstorm an associated set of implementation strategies (ie, systematic processes, activities and resources to integrate innovations into settings) to implement them85 For example, an intervention method that aligns local resources to improve social and environmental influences on mental health might employ the implementation strategies of cross-sector coalition building, community education meetings and engagement of intervention champions in multiple sectors (table 2).
Sample intervention methods and associated implementation strategies
Once the intervention methods and implementation strategies are identified, the CAC will oversee the development of intervention materials (eg, graphics, curricula, recruitment materials), which will be pretested with focus groups of older adults and social supporters. Pretesting will provide feedback on the acceptability and appropriateness of intervention materials,86 as well as their strengths, limitations and gaps to be addressed. Pretesting will also include measures of implementation feasibility of the intervention (eg, barriers and facilitators to implementing the intervention within the particular community context).86 The final product of this work will be a refined intervention protocol and materials and a detailed plan for its implementation and evaluation. The plan will detail (1) intervention users; (2) implementation strategies to support the intervention; (3) performance objectives for the implementation of the intervention and (4) process and outcome indicators for each performance objective. Process indicators will pertain to multiple socioecological levels, such as the number of individuals reached by intervention materials, new groups or networks formed or policy-makers recruited to advocate for changes to physical or social environments. Outcome indicators will assess changes in older adults’ health outcomes and behaviours (ie, depressive symptoms, engagement with resources and/or treatment) and changes in community attachment, sense of place and quality of life. This plan, along with the rich mixed-method contextual data from this study, will form the basis of a subsequent study to undertake a large-scale implementation and evaluation of the intervention and its effects on depression.
Discussion
Public health research has focused on the disparate burden of illness and trauma affecting Latinx and American Indian populations. This is especially true in New Mexico, where historical trauma, poverty and substance use have often defined understandings of American Indian and Latinx New Mexicans.58 59 In keeping with calls to counteract framings that naturalise such disparities,40 87–89 this study balances attention to place-based vulnerabilities with a focus on protective factors available to rural minority older adults. Likewise, the ecological perspective guiding this work prioritises the identification and support of community assets and resources.90
While the preponderance of scholarship involving these populations in New Mexico largely considers them separate from one another, this study emphasises their kinship, close proximity of residence and centuries of shared community history. Highlighting this social interconnectedness will contribute to empowerment and mental wellness.87 Additionally, including both populations will enhance the rigour of findings by comparing how the same place-based influences on mental health vary between and intersect with race, ethnicity and culture. To that end, community engagement is vital in research with vulnerable populations.60 61 In this study, community-driven research procedures advance a larger goal of equity by privileging the expertise of community members. Moreover, as both American Indian and Latinx populations in this study conceptualise wellness as a collective, community characteristic rather than an individual trait, a place-centred and community-centred approach is culturally responsive and urgently needed.23 91 Finally, rather than reproducing representations of rural places as static and homogeneous, this study’s combined quantitative and qualitative approaches will also yield a holistic, multidimensional and emplaced understanding of rural places as dynamic and socially constructed, with symbolic as well as material qualities.92 93
Interventions to influence place-specific factors, such as community environments and resources (eg, affordable housing), can prevent and treat chronic diseases and social ills.39 Community-level healing approaches are also widely viewed as indispensable in addressing the root causes of mental distress for marginalised populations.42 43 This study builds on such approaches with a collaborative, culturally grounded intervention development process that responds to the need for practical approaches to enhance place-based sources of mental well-being and address place-specific vulnerabilities for rural minority older adults. The use of IM ensures that intervention objectives, methods and practical applications are grounded in the nuanced, contextually grounded expertise and life experience of participants, and that they further participants’ goals for their collective well-being.
Limitations
This study is focused on a single community with substantial internal heterogeneity, which may limit generalisability of findings and intervention materials to other sociocultural contexts. However, careful documentation of adaptations and implementation strategies will provide valuable data to translate the functions of the intervention to other populations. Because mental illness is a stigmatised topic, we may oversample participants who are more likely to access healthcare and more willing to discuss mental health. The perspectives of CAB and CAC members with substantial personal and professional experience with older adults will help to mitigate issues of under-representation. This research focuses on intervention development and will not evaluate intervention effectiveness, which will be the focus of a subsequent study.
Ethics and dissemination
This study protocol has been approved by the Institutional Review Board of the University of New Mexico Health Sciences Center. All candidates for participation in this research will be provided with an information sheet and a description of the activities involved in the research, an assurance that participation is voluntary, and the name and contact information of the principal investigator. Candidates will provide verbal consent to participate and may withdraw from the research at any time. Data will be coded in such a way that research participants cannot be identified. Findings from this study will be disseminated within the community of study through community meetings and presentations, as well as broadly via peer-reviewed journals, conference presentations and social media.
Ethics statements
Patient consent for publication
Acknowledgments
The author would like to thank Dr Cathleen Willging, Dr William Wieczorek, Dr Nina Wallerstein, Dr Jessica Goodkind and Dr Steven Verney for their guidance on the research design. She would also like to thank the Seasons of Care Community Action Board and Erik Lujan for their generous contributions to this research.
References
Footnotes
Contributors ETJ conceptualised the study design and wrote the manuscript.
Funding This work is supported by the National Institute of Minority Health and Health Disparities under award number R00MD015765.
Disclaimer The content of this manuscript is solely the responsibility of the author.
Competing interests None declared.
Patient and public involvement The research questions and methods for this study were developed by the author in collaboration with the Seasons of Care Community Action Board, a group of American Indian Elders and allies. Feedback into the research questions and design was also provided by representatives of two community organisations serving the study population. The research will be overseen by a Community Advisory Board of American Indian and Latinx older adults and will be undertaken in collaboration with older adults, healthcare providers, social supporters and advocates in the community of study.
Provenance and peer review Not commissioned; peer reviewed for ethical and funding approval prior to submission.