Margarita Alegria - US grants

The proposed study aims to understand what differentiates mental health care needers non utilizers of mental health services from mental health care utilizers. Under what circumstances utilizers entered the mental health care services and what barriers keep needers non utilizers cut of the treatment population. Two independent samples will be drawn: a sample of 300 recipients of Community Mental Health Centers and another of 500 needers of said services. Mental health needers non utilizers will be followed up six months after the interview to detect under what circumstances they have change the status of needers non utilizers of mental health services to utilizers. Data will be collected through an in-depth interview. Multiple regression, which permits analysis of both direct and interacting effect of a variable will be the basic analytic technique. In delineating the barriers that keep mental health care needers out of the treatment population, we anticipate such research will have an impact on planning and development of mental health care policy, treatment programs, and research related to patterns of mental health services utilization.

We propose a continuing competing research project of the ongoing study, Mental Health Care Utilization among Puerto Ricans (ROI MH42655) that will allow us to understand the mental health utilization process over time. A goal of this continuation study is to examine a model of mental health services utilization for the poor with prospective data. Building on previous research, the proposed research has the following specific aims: 1) to identify if there are changes in the use of mental health services over the three data collection periods; 2) to determine the extent to which factors identified in the decision making model reduce or increase the likelihood of seeking mental health services over time; 3) to identify among utilizers of mental health services the factors associated with the decision to change, cease, or continue receiving mental health care; 4) to determine whether changes in need, as assessed by multiple measures, predict prospective use of mental health services; and 5) to compare our findings to similar studies conducted in the U.S. with different ethnic groups, to enhance our understanding of the use of mental health services by the poor. Data will be collected by two follow up interviews of the original sample initially interviewed in 1988. This sample was selected by a stratified design that divides the enumeration districts by income substrata. A probability islandwide community sample of 1,777 respondents living in poor areas was successfully interviewed, yielding a completion rate of 91.8%. To examine specific hypothesis, we will augment this sample by increasing the number of households to be interviewed in each segment of our original sampling frame. Collection of data in three points will facilitate the assessment of changes in the patterns of use of mental health services. The decision making model of the help seeking process will be tested by estimating three logistic regression models. The mental health care utilization process will also be Assessed through the development of Markov chains as a way of understanding the transitions within the health care system to deal with mental health problems.

We propose a continuing competing research project of the ongoing study, Mental Health Care Utilization among Puerto Ricans (ROI MH42655) that will allow us to understand the mental health utilization process over time. A goal of this continuation study is to examine a model of mental health services utilization for the poor with prospective data. Building on previous research, the proposed research has the following specific aims: 1) to identify if there are changes in the use of mental health services over the three data collection periods; 2) to determine the extent to which factors identified in the decision making model reduce or increase the likelihood of seeking mental health services over time; 3) to identify among utilizers of mental health services the factors associated with the decision to change, cease, or continue receiving mental health care; 4) to determine whether changes in need, as assessed by multiple measures, predict prospective use of mental health services; and 5) to compare our findings to similar studies conducted in the U.S. with different ethnic groups, to enhance our understanding of the use of mental health services by the poor. Data will be collected by two follow up interviews of the original sample initially interviewed in 1988. This sample was selected by a stratified design that divides the enumeration districts by income substrata. A probability islandwide community sample of 1,777 respondents living in poor areas was successfully interviewed, yielding a completion rate of 91.8%. To examine specific hypothesis, we will augment this sample by increasing the number of households to be interviewed in each segment of our original sampling frame. Collection of data in three points will facilitate the assessment of changes in the patterns of use of mental health services. The decision making model of the help seeking process will be tested by estimating three logistic regression models. The mental health care utilization process will also be Assessed through the development of Markov chains as a way of understanding the transitions within the health care system to deal with mental health problems.

In response to Program Announcement #PA 93-059, a longitudinal four year research project of drug and non drug using inner city Puerto Rican women is proposed. While ultimately seeking to help inform the development of community level drug prevention and intervention programs, the present research examines more specifically individual, social, institutional and cultural factors whose influence on drug use among women has been acknowledged but is only partially explicated. A better understanding of the interrelationship between drug use and problem behaviors is also sought. The specific aims of the study are to: 1) Identify concomitant (individual, social, cultural and institutional) factors that are associated with female drug use behaviors at baseline and examine changes in drug use and its correlates over time; 2) Assess the relationships over time between problem behaviors (criminal activity, high risk sexual activity and partner violence) and drug use among inner city drug and non drug using women; 3) Examine the impact of drug use on physical health outcomes (STDs/HIV infection, functional impairment) among drug and non drug using women over time; 4) Develop an empirical model for inner city women examining the influence of individual, social and cultural factors on subsequent problem behaviors. The following factors will be considered as mediators: drug use behaviors, social support, institutional support, and incarceration; 5) Evaluate the degree of participation of female drug users in drug treatment programs and examine the role of treatment on changing drug use and/or subsequent problem behaviors; and 6) Assess the relationship between participation in human service programs and female drug use behaviors over time. To accomplish these aims, two groups of women will be studied: a sample of 400 crack/cocaine or injecting drug using women recruited from drug copping areas and a sample of 400 community women with no drug use residing in the same neighborhood. Women, aged 18-34, will be interviewed at baseline and at two follow-ups, with twelve months between data collection periods. The location of copping areas in metropolitan San Juan has been previously identified and is updated on a monthly basis. Based on the targeted sampling strategy, copping areas will be randomly selected. Recruitment at each copping area will occur at random periods. The community sample will be selected from a random household enumeration of women residing in census blocks where the copping areas are located. Special emphasis will be placed in establishing a relationship with the community and gaining acceptance by members of the drug copping areas. Information on drug use will be assessed by self reported drug use and urine and hair screen tests for crack/cocaine and heroin. Blood samples will be tested for antibodies against HIV and syphilis. Our analytic strategies include the use of canonical correlation analysis, covariance structure analysis, log linear analysis, multivariate logistic regression and structural equation modeling.

The overall goal of the proposed application continues to be the examination of the help seeking process for mental health services of poor Puerto Ricans. However reform in the organization of the public health care system in Puerto Rico with the adoption of privatized managed health care provides a unique opportunity to examine how variations in the health care system might impact the process of seeking care for mental health problems. The two major aims of the proposed study are: 1) to determine the impact of managed care on help seeking for ental health problems among poor Puerto Ricans. Specifically, we will examine if there are changes in the probability of use, patterns of provider and continuity and extent of treatment under managed and non-managed health care; and 2) to identify the factors that predict changes over time in the use of services, provider patterns, and continuity and extent of treatment for a mental health problem (help-seeking). Special emphasis will be placed examining of predictors of help-seeking vary for individuals under managed and non- managed care. Our study population consists of an islandwide community- based sample of 3,507 adults previously interviewed over two data collection periods one year apart. Health care reform in Puerto Rico is being implement stepwise, by taking one region at a time. Throughout most of 1996, puerto Rico will virtually have one half of the island under reform (under managed care) while in the remaining half, health services for the indigent will continue to be provided through public facilities (without managed care). This allows us the unique opportunity to use our earlier collected data as a baseline, and to study the influence of managed mental health care relative to help-seeking in a pre/post quasi- experimental control group design. This study design will permit comparisons of the help-seeking process between individuals living in regions with and without managed health care, as well as, comparisons of the same individual's help seeking behavior before and after health care reform. To examine specific hypotheses the analyses encompass the use of multivariate logit or multinomial regressions and a variety of random- effects regression models that make full use of the longitudinal aspects of the data. The results of the study will provide information of relevance for health service planners and providers.

SUBPROJECT ABSTRACT NOT AVAILABLE

The University of Puerto Rico (UPR) seeks support for a Latino Research Program Project (LRPP) which will conduct research also to improve the mental health care for Latino populations. The University of Puerto Rico (UPR) is poised to take a leadership role by pulling together three island research units (successful in psychiatric epidemiology, mental health services, and clinical interventions) with investigators in five partner research sites (San Antonio, Galveston, Los Angeles, San Diego, and New Jersey). The LRPP is conceptually oriented by the Socio-cultural Framework for Mental Health Effectiveness Research, which incorporates the overarching influence of culture in the process and outcomes of mental health care. The four proposed pilot projects will provide critical data required to propel state-of-the-art RO1 research proposals to NIMH. The LRPP proposes the following specific aims: 1) Establish an administrative structure that builds a synergistic core of researchers through shared resources, leadership, and expertise from the island and mainland; 2) Provide a structure for methodological and statistical support to assist in our proposed pilot and exploratory work, as well as to develop appropriate analytic protocols for future research; 3) Formulate and conduct an interdisciplinary mental health services research program with particular emphasis on: Development and Adaptation of Culturally Sensitive Outcome Measures; Entry and Retention of Latinos in Mental Health Services; Effectiveness of Interventions for the Treatment of Depression; and the Impact of Managed Care on Latino's Access to Care; 4) Develop a mentorship program without walls for junior investigators; and 5) Disseminate the product of these research efforts to inform policy decisions and practice, to contribute to stakeholders' knowledge, as well as to encourage future research in Latino communities. The LRPP can constitute an effective mechanism to further research that will allow us to understand the problems faced by Latinos in obtaining quality mental health care. Our goal is to have the LRPP evolve into a national research for research and policy development regarding mental health services for Latinos.

Latino and Asian American populations are expanding at a rate far outstripping the development of the research capacity necessary to understand the nature of their risks for psychiatric disorders and respond to their service needs. This dramatic demographic shift raises questions whether mental health systems are ready to address the needs of these rapidly growing populations. This application seeks support to estimate prevalence and correlates of psychiatric disorders and mental health service use with nationwide Latino and Asian American samples. We propose to conduct a study, concomitantly with the National Comorbidity Survey Replication (NCSR) and the National Survey of African Americans, with 4,000 Latino respondents (1,500 Mexican Americans, 1,500 Puerto Ricans, and 1,000 Cubans), and 3,000 Asian Americans (1,500 Chinese and 1,500 Filipinos). The proposed study seeks to better understand the intra and inter group ethnic and racial differences linked to psychiatric disorders and service use. The study aims are: l) to estimate intra- and inter-group ethnic differences in the prevalence of specific psychiatric disorders, and in help seeking and utilization of mental health services in nationwide representative samples of Latinos and Asian Americans, 2) to explore the intra- and inter-group ethnic differences in the correlates of psychiatric disorders and the factors associated with help seeking and utilization of mental health services, 3) to compare the prevalence of specific psychiatric disorders, help seeking and utilization of mental health services of Latinos, Asian Americans, non Latino Whites, and African Americans; and 4) to generate nationally representative data for Latinos and Asian Americans in the United States in the year 2000 that will be used as part of the World Health Organization's (WHO) Mental Health 2000. Experience with the previous National Comorbidity Survey makes clear that the NCSR will not yield samples large enough to pursue the aims set out in this proposal. The desired target populations include US household residents ages 15-74. Two multistage probability samples, one for Latinos and one for Asian Americans will be developed. We anticipate that a significant number of Latino and Asian Americans selected for the sample will be non-English speakers. This combined study of Latino and Asian Americans will use identical survey methods and measures to compare the prevalence of mental disorders and the use of mental health services among ethnic subgroups. The proposed investigation intends to pool the resources and expertise of researchers familiar with Latinos and Asian Americans into a single comprehensive study team under the IRPG mechanism.

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DESCRIPTIONS (provided by applicant): Center Core. There are pervasive ethnic and racial disparities in mental health service utilization and in mental health status yet the underlying causes of these disparities are poorly understood. This application seeks to establish an Advanced Center for Latino and Mental Health Systems Research (Advanced Latino Disparities Center) that focuses on understanding the factors affecting mental health service disparities in Latinos and generating research and knowledge to eliminate them. This Center will be part of the Cambridge Health Alliance (CHA), Center for Multicultural Mental Health Research (CMMHR) and is built on the strengths and learning experiences of our ongoing NIMH-funded Latino Research Program Project (LRPP). The proposed Center is a five-year project, structured around two large (R01) and two smaller (pilot) projects. We support the research with an Administrative and Methods Core led by experienced, multidisciplinary investigators, build on the collaborative partnerships that characterize our past work, and mentor and develop junior investigators to become new experts in health disparities research. The overall aims of the Advanced Latino Disparities Center are to: (1) Establish an administrative structure that supports a synergistic core of researchers to conduct mental health service disparities research;(2) Institute a methodological and statistical component as an integral part of the proposed program;(3) Formulate and conduct an interdisciplinary mental health services disparity research program with a focus on four program areas: (a) Improving Clinical Assessment of Diagnosis for Latinos;(b) Identifying Sources Linked to Differential Assertive Community Treatment (ACT) Outcomes for Latinos;(c) Ethnic Differences in Perceived Impairment and Need for Care;and (d) Dialog with the Latino Community and Healthcare System Stakeholders for Identifying Quality Improvements;(4) Continue developing a cadre of young investigators committed to mental health service disparities research with Latino populations;and (5) Disseminate the research findings to inform policy decisions and practice, contribute to stakeholders'knowledge, and encourage future disparities research in Latino communities. Project 1: Improving Clinical Assessment of Diagnosis for Latinos. The goal of this project is to develop and test a mixed methods approach to helping clinicians in public health psychiatric settings decrease clinical uncertainty by more accurately diagnosing patients with diverse cultural backgrounds and improving the matching of clinical services to the needs of Latinos. Our approach combines methods from cultural anthropology with statistical methods and psychiatric epidemiology. The specific aims of this study focus on generating improved cultural formulations and diagnostic accuracy using information from qualitative and quantitative perspectives, iterating between the methods in a complementary fashion. The specific aims are to: Aim 1: Identify the information about symptoms and cultural and social context gathered in the initial diagnostic interview, that clinicians use to make determinations about three disorders: major depression, drug abuse and alcohol abuse;Aim 2: Use data from an epidemiological survey to assess the potential sensitivity and specificity of the clinical determinations identified in Aim1 in detecting the underlying diagnosis. We will test the hypothesis that clinical diagnosis is less accurate for Latino than non-Latino white patients;Aim 3: Assess clinician and patient reactions to the recommended improvements to diagnostic assessments developed in Aim 2. Using focus groups and consensus panels, prioritize the kinds of information to be collected to improve diagnostic determinations in safety net settings. Aim 4: Apply the findings of Aim 3 to make concrete recommendations to improve the efficiency and fairness of diagnostic decisions for Latino and non-Latino white population groups. Project 2: Identifying Sources Linked to Differential Assertive Community Treatment (ACT) Outcomes for Latinos. In this research we propose to conduct statistical analyses of data from a large quasi-experimental project (ACCESS) and a 2-stage modified Delphi technique to generate recommendations for the modification of assertive community treatment (ACT) when applied to Latino and other severely mentally ill homeless (SMIH) minority populations. The ACCESS study compared the outcome effects of "augmented" ACT (i.e., ACT + quality improvement intervention) and standard ACT, and found no evidence of differences. Utilizing a disparities framework, advanced statistical methods, and a 2-stage Delphi method, we propose to conduct service and outcomes disparities research aimed at generating information with clinical or programmatic utility for Latinos. The proposed analyses will generate new evidence on service use and outcomes for Latino SMIH persons treated with ACT, and will broaden our understanding of the effects of quality improvement interventions for Latinos. Findings will be integrated with expert opinion to generate recommendations regarding ACT for Latino SMIH persons. The study has four aims: 1. To test for disparities in service use for Latino and African American as compared to white SMIH persons served by standard and augmented ACT 2. To test for outcome disparities for Latino and African American as compared to white SMIH persons served by standard and augmented ACT 3. To estimate the impact of observed service disparities on observed outcome disparities for Latino and African American as compared to white SMIH persons 4. To integrate results from analyses of service and outcome disparities for Latinos, a literature review, and expert opinion, and generate recommendations to improve ACT for Latino SMIH persons. Pilot 1: Ethnic Differences in Perceived Impairment and Need for Care. Parental belief that the child needs mental health care has been found to be the most significant factor associated with service use in non-minority populations. The results of several studies suggest that Latino parents are less likely than European Americans to recognize and/or label their children's behavior as a mental health problem requiring intervention. It is not clear which factors explain this lower recognition of mental health problems by Latino parents, and consequently the lower utilization of mental health services by this group. Differences between providers and parents in their views of children's impairments and/or the kind of problems that require treatment may also explain some of the lower utilization of mental health services among Latino children. There is some evidence that providers from different cultures differ in their impairment ratings of children. However, there is no research that examines whether non-Latino white providers as compared to Latino providers are more likely to rate the same children as impaired, nor is there any research that assesses the extent to which parents and providers from different cultures differ in their ratings of children's impairment. This pilot aims to investigate parental and provider beliefs about what is impaired behavior, the severity of the behavior, and the need for treatment in a sample of Mexican Americans, island Puerto Rican and non-Latino providers and parents. We will examine the ratings of providers and parents from the three ethnic groups using case vignettes of children with different levels of impairment and internalizing and externalizing symptoms. Vignettes will be developed utilizing information obtained through secondary analyses of two clinical data sets. We will test the hypothesis that Puerto Rican and Mexican American parents and providers rate the children described in the vignettes as less impaired as compared to non-Latino white parents and providers. We further hypothesize that greater acculturation in Mexican American parents will be associated with less variation between Mexican American and non- Latino white parents in their impairment ratings of the vignettes. We also expect greater congruence in the impairment ratings and perceptions of need for services among parents and providers within the same ethnic group. Pilot 2: Dialogue with the Latino Community and Healthcare System Stakeholders for Identifying Quality Improvements. A disproportionate number of Latinos rely on free or reduced price care making them more vulnerable to the impact of shrinking resources on the quality of care at safety net healthcare systems. The main goal of this pilot is to identify quality improvements by increasing the Latino community voice in a safety net mental healthcare system. We will explore system concerns (disproportionate impact of economic constraints on quality of care and low levels of participation in mental health services among Latinos) by including members of the Latino community in a participatory research process together with representatives of a healthcare system (i.e., psychiatrists, nurses, social workers, senior hospital administrators, clinic coordinators). In addition, this resulting collaborative stakeholder group will jointly identify leverage points in the community and health care system to launch quality improvements. The aims of the pilot are to: 1. Consult multiple stakeholders to identify community, client, administrative, provider and mental health care system barriers to access and quality mental health services for Latino patients. 2. Selecting barriers identified from Aim 1, conduct policy implementation analyses that ground the participatory process in a clear, shared understanding of the legal, administrative and fiscal constraints on efforts aimed at quality improvements. 3. Use the information generated in Aims 1 and 2 to launch a participatory process with multiple stakeholders to identify leverage points for mental health care system change. As part of this research, we will generate hypotheses to be tested in the context of community and/or systems interventions and their prospective evaluation in R01 applications. We intend to use qualitative methods and policy implementation analysis to address these aims. We will build a collaborative, multidisciplinary community and mental health systems advisory group to assist in the identification and design of these quality improvements. By the end of this pilot, we will have a sustainable group of advisors who will work together in the future implementation of the quality improvements identified through this pilot work. Center Core:

DESCRIPTION (provided by applicant): This continuation application requests three-years of support to investigate differences in the correlates of psychiatric illness and mental health service disparities among Asian Americans and Latinos as compared to non-Latino Whites. We will use recently collected data from the National Latino and Asian American Study (NLAAS), a national psychiatric epidemiologic study conducted to measure psychiatric disorders and mental health service usage in a representative sample of Asians and Latinos, and the National Comorbidity Study Replication (NCS-R). The combined NLAAS/NCS-R data are the best available to address critical questions regarding the level of service disparities, and the identification of service disparities "hot spots." In this resubmission, we apply an innovative conceptual framework to organize correlates for psychiatric illness, mental health service use and mental health service disparities, giving attention to health system and contextual factors in addition to traditional individual level factors. Specifically, our aims are to: (1) Use combined data from the NLAAS and the NCS-R to: compare prevalence of psychiatric disorders and mental health service use among Latinos, Asian, and non-Latino Whites; investigate hypotheses related to differences in the correlates of illness and mental health services; and assess bias in disorder prevalence and service use, (2) Apply the IOM definition of disparities to quantify disparities in services utilization and identify potential mechanisms underlying services disparities, and (3) Apply methods from spatial epidemiology to identify "hot spots" of mental health service disparities at the MSA level, and investigate health care system factors associated with high and low performing MSAs. This study will provide national baseline data on which to define the progress and measurable targets for mental health service disparity improvements for Latinos and Asian Americans as compared to non-Latino Whites. In addition, it will identify health system factors measured at the community and individual level that mediate disparities and can be targeted by policymakers. Finally, it will provide policymakers with information regarding where in the US mental health service disparities are unusually high. These findings can be used to target resources, develop coherent public policies, and inform guidelines aimed at making mental health prevention and treatment services more responsive and sensitive to the needs of ethnic/racial minorities.

DESCRIPTION (provided by applicant): The proposal, entitled "Reducing Ethnic and Racial Bias in Screening for Psychiatric Disorders in Adolescents" is designed to improve the effectiveness of identification, referral and screening for mental health disorders potentially associated with ethnic/racial disparities in adolescents'receipt of mental health care. For racial and ethnic minority youth, there is a great disparity in the receipt of mental health services and, as a result, these youth are more likely to experience persistent impairment from psychiatric disorders. Preliminary data on referrals for mental health treatment appear to indicate that minority children are under-identified for services by their schools and families, the two major referral sources. The research to be generated can help us achieve needed enhancement in school screening, a previously under-funded area of health services research in general, and comparative effectiveness research more specifically. This project provides the opportunity to support the analysis and dissemination of data from the National Comorbidity Survey Adolescent Supplement (NCS-A), the most comprehensive national data available to study screening and referral patterns for ethnic/racial minority children. We propose four specific aims that allow us to examine a broad range of possible causes for under- recognition and lack of treatment for ethic and racial minority youth as well as alternative methods for enhancing screening tools used to assess them. Aim 1 intends to determine whether schools are equally likely to encourage parents of ethnic/racial minority youth who have psychiatric disorders to seek services for their child as they are to encourage non-Latino white parents, and whether school, community, and family characteristics explain any disparities in referral. Aim 2 then tries to identify ethnic/racial differences in parents'assessment of youth with psychiatric disorders associated with ethnic/racial disparities in service access. Aim 3 plans to evaluate meaning and response bias in the screening questions used to assess major depression and generalized anxiety disorders in non-Latino white and racial/ethnic minority adolescents. Finally in Aim 4, we compare the accuracy of predictions of mood and anxiety disorders using screening scales specific to blacks, to Latinos or to whites, with universalistic screening scales, in order to help improve detection for ethnic and racial minorities, and to determine if the scales should be group-specific or universal. Study results will be distilled to provide basic information about biases in the identification, referral and screening process by schools, and factors that influence whether parents identify "mental health problems" and follow-up on service referrals. Findings will be disseminated through a website for teachers and school mental health service providers, via newsletters of professional organizations, and by submission to annual conventions of school- based practitioners, thus bringing critical information to those most poised to affect change. The proposed research is designed to improve the effectiveness of identification, referral and screening for mental health disorders potentially associated with ethnic/racial disparities in adolescent receipt of mental health care. Using data from the National Comorbidity Survey Adolescent Supplement (NCS-A), the most comprehensive national data available to study screening and referral patterns for ethnic/racial minority children, we propose four specific aims that allow us to examine a broad range of possible causes for under- recognition and lack of treatment for ethic and racial minority youth as well as alternative methods for enhancing screening tools used to assess them. The project intends to distill and disseminate research results to those most poised to affect change, including creating a list of basic information about biases in the identification, referral and screening process by schools, and factors that influence whether parents identify "mental health problems" and follow-up on referrals for services, thus working towards the goal of diminishing the impact of early onset disorders and preventing the development of comorbid and more serious mental health problems.

The overarching goal of this methodological, data-driven study is to provide service planners and policymakers with the best available data on the magnitude and sources of racial/ethnic disparities in alcohol and drug abuse treatment services, and information about the consequences of substance disorders in ethnic and racial minority populations in the United States (US). We use four new, large, nationally representative data sets with rich diagnostic and service use information: the National Comorbidity Survey Replication (NCS-R), the National Latino and Asian American Study (NLAAS), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and the National Survey on Drug Use and Health (NSDUH). We will provide a comprehensive picture of the extent of substance disorder treatment disparities, the potential sources of intervention to remediate these disparities, and the social and economic burden associated with substance disorders in minorities. Analyses will also provide empirical evidence regarding the mechanisms underlying disparities (e.g., the extent to which disparities reflect the influence of system barriers or state policies);this information will be translated into interventions to reduce disparities.

DESCRIPTION (provided by applicant): Although minority elders represent the fastest growing segment of an aging US population, they have less access to mental health care and prevention of disability, lagging well behind non-Latino whites, and suffering significant disparities. Blacks and Latinos have the greatest risk for disability, with striking disparities in healthy aging. This includes elderly immigrants who exhibit elevated depressive and anxiety symptoms, and higher rates of disability than the native-born population; yet, they often go undiagnosed or underdiagnosed. This is a missed opportunity given that mood disorder treatment has been shown to reduce disability days and that several risk factors for disability, such as functional mobility are modifiable. Research suggests that a contributing factor may be an insufficient supply of professional providers and the inability of evidence based treatments to reach and be acceptable to minority elders. An IOM committee recently reported that the severe workforce shortages in providing mental health care to elder adults required novel approaches to resolve. To address these disparities and prevent disability among minority elders, the proposed R01 examines how to successfully build collaborative research for the provision of evidence-based mental health and disability prevention treatments in community-based settings. Promising results in a few international studies show improved access and quality of mental health outcomes and reduced disability when interventions are delivered by Community Health Workers. Yet limited and inconsistent evidence of the efficacy of CHW-led interventions in the US context remains. While the number of community-based health interventions has grown exponentially to address these service disparities, there is a lack of systematic assessment of whether they lead to increased community capacity and systems change, and whether they improve the quality of care and potentially decrease disability. Our proposed study endeavors to address this limitation. As such, the proposed R01 will be one of few efforts that simultaneously study the three components necessary for a successful intervention: efficacy, since the intervention must work, acceptability among clients, and feasibility and sustainability within the organization. It seeks to understand the role of the partnerships in increasing community capacity for a combined mental health and disability prevention intervention, and evaluating the acceptability, efficacy, feasibility and sustainability of the intervention delivere by CHWs and exercise trainers to Latino, African American and Asian elders with moderate to severe mood symptoms and at risk of disability.