Archives of Psychiatric Nursing 29 (2015) 1418

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Review Article

Addressing Gaps in Mental Health Needs of Diverse, At-Risk,

Underserved, and Disenfranchised Populations: A Call for Nursing Action
Geraldine S. Pearson a,, Vicki P. Hines-Martin b, Lois K. Evans c, Janet A. York d, Catherine F. Kane e, Edilma L. Yearwood f
a

University of Connecticut School of Medicine, Farmington, CT

University of Louisville School of Nursing
University of Pennsylvania School of Nursing
d
Medical University of South Carolina
e
University of Virginia School of Nursing
f
Georgetown University School of Nursing & Health Studies
b
c

a b s t r a c t
Psychiatric nurses have an essential role in meeting the mental health needs of diverse, at-risk, underserved, and
disenfranchised populations across the lifespan. This paper summarizes the needs of individuals especially at-risk
for mental health disorders, acknowledging that such vulnerability is contextual, age-specic, and inuenced by biological, behavioral, socio-demographic and cultural factors. With its longstanding commitment to cultural sensitivity and social justice, its pivotal role in healthcare, and its broad educational base, psychiatric nursing is wellpositioned for leadership in addressing the gaps in mental health prevention and treatment services for vulnerable
and underserved populations. This paper describes these issues, presents psychiatric nursing exemplars that address
the problems, and makes strong recommendations to psychiatric nurse leaders, policy makers and mental health advocates to help achieve change.
2014 Elsevier Inc. All rights reserved.

Psychiatric nurses practice in a variety of health settings caring for individuals from conception through late life who are highly vulnerable and
at-risk for mental health disorders. Even with a growing body of
literature about the importance of mental health, risk factors for mental illness and mental health-related disparities, the focus on mental health promotion and disease prevention continues to be minimalized or ignored
(Calloway, 2007). A social justice perspective (Hoy, 2005) strongly supports the inherent human right to primary, secondary, and tertiary medical
and mental health care resources (Pearson, 2012). With its longstanding
commitment to cultural competence and social justice, its pivotal role in
healthcare, and its broad educational base, psychiatric nursing is well positioned for leadership in addressing the gaps in mental health prevention
and treatment services for vulnerable and underserved populations. Facilitating nursing's leadership in this area will require a sustained policy focus
on psychiatric nursing and interprofessional research, practice, and educational models that enhance and expand existing roles and allow psychiatric nurses to practice fully within their scope.
BACKGROUND OF THE PROBLEM
The World Health Organization (WHO) identies mental health as the
absence of illness and, more broadly and signicantly, as a state of wellbeing in which an individual realizes his or her own abilities, can cope with
Corresponding Author: G.S. Pearson, PhD, PMHCNS, BC, FAAN, University of Connecticut
School of Medicine, Farmington, CT.
E-mail address: gpearson@uchc.edu (G.S. Pearson).
http://dx.doi.org/10.1016/j.apnu.2014.09.004
0883-9417/ 2014 Elsevier Inc. All rights reserved.

the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the
foundation for individual well-being and the effective functioning of a community (WHO, 2007, p. 1). Throughout the lifespan, mental health is the wellspring of thinking and communication skills, learning, resilience and
positive self-esteem. Mental health conditions have a profound effect on
the quality of life and productivity for individuals and families across the
lifespan and around the globe. Complex, interactive, and cumulative risk
factors exert adverse effects over the course of a lifetime (WHO, 2001).
Many of these risk factors or determinants of mental health and illness
are contextual, found within the demographic, socio-cultural and environmental contexts in which people grow, develop and live out their lives. In
addition to these social determinants, co-morbid health conditions such as
cardiovascular disease, hypertension, diabetes and substance use are interactive and potentiate increased risk for negative mental health outcomes.
SOCIAL DETERMINANTS OF HEALTH AND DISPARITY
There are signicant differences in social, economic and educational
contexts among many population groups which subsequently place
them at greater risk for poor mental health. The U.S. Surgeon General's
Report on Mental Health identies that even more than other areas of
health and medicine, the mental health eld is plagued by disparities in
the availability of and access to its services. These disparities are viewed
readily through the lenses of racial and cultural diversity, age, and gender
in the seminal publication on mental health (DHHS, 1999, p.vi). More
recently, the social determinants of health (SDH) literature added that

G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418

mental health disparities are also driven by social, environmental and

economic structures such as stigma, discrimination, social exclusion,
poverty, low educational attainment and the overall health of our living,
working and playing environments (WHO, 2014).
Contextually, health disparities are discrepancies in health status,
health services, or health outcomes based on social inequalities among distinct segments of the population. These differences occur based on gender,
race or ethnicity, education or income, disability, environment, or social
condition. Health equity is the promotion and achievement of the highest
level of health for all people and the absence over time of persistent health
differences between racial, ethnic, vulnerable, and underserved groups.
Health equity entails focused societal efforts to address avoidable inequalities, both by equalizing the conditions supporting health for all groups and
also by assuring the provision of minority health services, especially for
those who have experienced socioeconomic disadvantage or historical injustices. Health equity is achieved when there is a distribution of disease,
disability, death, and health service availability that does not create a disproportionate burden on one population.
The National Association of Community Health Centers (NACHC, 2007)
identies access as the critical factor when designating a population as
disenfranchised. NACHC also asserts that the disenfranchised constitute a
subset of the underserved population and include those that face multiple
and compounding barriers to care, including lack of insurance, nancial
difculty, differences in language and culture, lack of transportation [and]
the lack of providers present or willing to treat them (p.1). Mental Health
America (MHA, 2008) has also described signicant barriers to mental and
physical health care access and quality of services for people with mental
health conditions and other marginalized groups who are, as a result,
largely disenfranchised. Unfortunately, there continues to be a societal
devaluation of any sustained emphasis on mental wellness.
It is imperative that mental illness and resulting disenfranchisement
be reframed as a public health issue on par with other major health
conditions (DHHS, 1999, 2001). All individuals and families are at risk
for stress and situational psychological distress; not all individuals and
families, however, have the necessary resources to adequately manage
distress. All people need the opportunity to develop selfunderstanding,
mental health literacy, coping skills, and effective use of social supports
as well as have access to mental health and mental wellness counseling
and support to promote resilience and reduce the risk of mental illness.

Social Determinants of Health

Individuals' overall health suffers because of the social conditions in
which they live (Marmot, 2006). Social determinants of health have
been dened as the full set of social characteristics within which living
takes place (Baum, 2008) or, more specically, characteristics of the
physical and social environments that shape human experience and
offer or limit opportunities for health (Anderson, Scrimshaw, Fullilove,
Fielding, & Task Force on Community Preventive Services, 2003).
There is a distinction between underlying determinants of health
inequities and more immediate determinants of individual health
(Commission on Social Determinants of Health [CSDH], 2007). The
Task Force on Community Preventive Services examined broad
determinants of health from an etiological perspective, recognizing
connections between health and sustainable human, cultural, economic
and social activities (Anderson et al., 2003). They concluded that
patterns of health or disease depend on a combination of biological
traits, personal behaviors, and characteristics of social and physical
environments that shape experiences and provide health opportunities.
Recently, the Surgeon General and the National Prevention Council
identied four recommendations to promote mental and emotional
well-being. They included a focus on positive early childhood development supported by positive parenting and violence free environments;
promotion of social connectedness and community engagement; access
to and adequate resources to support mental well-being in individuals

15

and families, and early identication of mental health needs (National

Prevention Council, 2011, p. 4849).
The impact of environments is a signicant factor. One important
environmental aspect that affects mental health disparity is rurality.
Research indicates that there is less use of mental health services in
rural areas even when availability, accessibility, demographics and need
factors are considered. Residents of rural environments with low population density obtained less mental health treatment than did residents of
metropolitan areas, leading to the conclusion that rural residency disadvantages all rural occupants with respect to mental health treatment
(Petterson, Williams, Hauenstein, Rovnyak, & Merwin, 2009). While
rural residents generally describe their health status as good, racial/ethnic
minorities residing in predominantly Caucasian rural areas are found to
experience more mental health problems, such as anxiety and depression
that are risk factors for chronic disease (Bonnar & McCarthy, 2012). Additionally, when a lack of mental health providers exist, rural residents are
more likely to receive mental health services within the primary care system, thus, excluding them from specialty mental health care. An even
more profound disparity is found, however, when gender is considered.
Rural women are less likely to receive mental health treatment in either
primary care or specialty mental health settings when compared to
urban women (Hauenstein et al., 2006).
Conversely, an urban environment contributes to poor mental health as
a result of the complex and chaotic conditions that may exist within urban
neighborhoods. Issues of overcrowded living spaces, lack of clean and green
areas, limited parks and recreation facilities, poor housing conditions, lack of
employment opportunities, poorly performing and unsafe schools, and
crime exposure and victimization are all contributing factors (Lorenc
et al., 2012; Redwood et al., 2010). In data from a self-report survey on perceived neighborhood stressors in young adults, Snedker and Hooven
(2013) found a positive correlation between perceived lack of safety, lack
of social support, poverty, neighborhood instability and neighborhood dissatisfaction with depressed mood, anger and sense of hopelessness in
study respondents. These perceptions expressed by participants in the
study reect decits in key elements required for emotional well-being.
A decade ago, the New Freedom Commission on Mental Health (2003)
proposed a transformed mental health system where all Americans would
share equally in the best available services regardless of race, gender, ethnicity or geographic location. Achieving this transformation necessitates
improved access to quality care that is culturally informed and improved
access to quality care across geographic areas. Limited progress has been
made toward that transformation. Implementation of strategies that are
evidence-based are still needed in underserved areas: professional training
to construct and provide culturally tailored services, development of an
ethnically diverse workforce, creating consumer-centered systems, using
technologies in tele-mental health, training community stakeholders,
and ensuring that those being served have a voice are among the gaps
that continue to exist.
Based on educational preparation and clinical expertise, psychiatricmental health nurses are in a unique position to help actualize the unachieved goals identied in the Surgeon General's Reports of 1999 and
2001 and the 2003 New Freedom Commission developed during the
Bush administration. Psychiatric nurses practice in all at-risk geographic
areas and with all at-risk populations. They have broad preparation in
the social and biological sciences and in culturally relevant consumer
driven care, including education of patients, families, communities,
and indigenous workers. These skills make them ideally suited to assist
underserved populations of all ages [Grossman (York) et al., 2007].
VULNERABILITY ACROSS THE LIFESPAN
It is evident that mental health vulnerabilities exist across the
lifespan. Several risk factors common to childhood/adolescence may
occur with higher frequency among disadvantaged or vulnerable
populations. In children these risk factors include prenatal damage
from substance exposure; low birth weight; external risk factors like

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G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418

poverty, deprivation, abuse and neglect; poor parentinfant attachment; parental mental health disorder, and exposure to traumatic
events. The social environment for children is especially important in
the development of skills and attributes that are protective of mental
health for each successive phase of maturation. Adolescents, on the
other hand, are exposed to risk factors that include bullying and other
forms of violence, social exclusion, stress associated with academic performance and demands, enticements to engage in substance use, and
vulnerability associated with the prevalence of several psychiatric disorders that emerge during the adolescent years. In adulthood, exposure
to stressful life events may challenge otherwise adequate coping skills.
These stressful events include: divorce or loss of intimate relationships,
death of a family member or close friend, economic hardship/loss of employment, immigration, role conict or overload, experience of racism
or discrimination, poor health, accidental or intentional assaults on personal safety including military combat and domestic violence, incarceration and past trauma exposure. Finally, while older adults bring a
plethora of wisdom, experience and resilience to the tasks of late life,
they, too, encounter certain stressful events with greater frequency.
These include higher incidence of death of signicant others, residential
relocation, loss of role and social status, and loss of health and autonomy. Coping with multiple stressors at a time when capacity may be declining stretches reserve and may result in troubling psychiatric
symptoms or disorders. Identication of, and attention to, age-specic
factors and vulnerabilities is critical to the success of any prevention
program and to the provision of acceptable services that reduce overall
disparities (DHHS, 2001).
The development and enhancement of resilience enable people to
withstand stressful insults during periods of risk, and this is best observed in the presence of supportive social networks, sufcient resources to meet basic needs and access to resources. Thus, preventive
programs that strengthen these factors from pre-birth through late life
have the greatest potential for helping people stay emotionally healthy
and productive throughout their lives.

NURSE EXEMPLARS OF EVIDENCE-BASED PRACTICE THAT ADDRESS

DISPARITIES
While many nurse researchers have developed and implemented
programs of mental health-related research with diverse populations
across the lifespan, ve exemplars will be highlighted here to illustrate
some of nursing's relevant long-standing and ongoing work in the areas
of behavioral and psychological health. Each exemplar program involves populations with identied health disparities and a high risk of
disenfranchisement that could restrict health care access. The evidence
based nursing interventions developed by each nurse researcher has
implications for improved health and applicability to populations in international settings.
The rst includes a program that involves training home health
nurses to assess for depression in older adults. This evidence-based
TRIAD program for home health care provides workers with the
knowledge, skills, motivation and tools to adequately screen this population, to communicate with health care providers and (more recently)
to develop a tailored patient-centered intervention to address positive
depression screens (Brown, Raue, Roos, Sheeran, & Bruce, 2010;
Brown et al., 2010). The success of the program was acknowledged by
the American Academy of Nursing when it awarded the program Edge
Runner status in 2011.
The second exemplar targets culturally and economically diverse
children through a parentchild interaction therapy model to reduce
behavior problems in children by teaching and strengthening parenting
skills. The program has been widely disseminated and implemented in
day care centers, Head Start and other early childhood intervention
programs. Financial support to develop, test and disseminate the
intervention was supported by the Robert Wood Johnson Foundation

and the National Institutes of Health (Breitenstein et al., 2012; Gross

et al., 2009, 2014).
The third exemplar is of a culturally congruent health promotion and
disease prevention behavioral health intervention to reduce sexual risk
behaviors in African American and Latino adolescents. This research
received federal funding from sources such as the National Institutes
of Health and the Centers for Disease Control (CDC). The resulting
evidence-based curriculum has been adopted by the CDC and is currently being implemented internationally in Africa and Jamaica (Jemmott,
Jemmott, & Fong, 2010; Jemmott, Jemmott, Hutchinson, Cederbaum, &
OLeary, 2008; Kerr et al., 2013).
Lastly, the Incredible Years Program is an intervention that aims to
prevent problems in conduct among at-risk and high-risk youngsters by
promoting social and emotional competence and school readiness skills
(Hurlburt, Nguyen, Reid, Webster-Stratton, & Zhang, 2013; WebsterStratton, Jamila, & Stoolmiller, 2008). The program has undergone numerous randomized controlled trials to test and rene the intervention.
The program has been translated into many languages and is used globally in over fteen countries. Funding to support this work was obtained
by Head Start and the National Institutes of Health.
PSYCHIATRIC NURSING'S CALL TO ACTION
Psychiatric nurses are well poised to lead the action needed to effect
a positive change in the mental health of individuals, groups and
communities. Nursing has historically focused on making a difference
through professional education, clinical practice and research. The
time is now to more clearly advocate for and achieve change through
work in and with various organizations and by taking advantage of
existing leadership roles to inuence policy in multiple areas that will affect the populations described in this paper. In a prior paper we offered
recommendations for macro-level activities for research, policy and
practice changes to promote resilience and health/mental health in vulnerable families (Pearson et al., 2014).
Here we propose policy recommendations in four areas: support for
individual/family/community strengths in any action plan; development
of collaborative partnerships for prevention and treatment; enhancement
of public and professional education and awareness, and advocacy for
research on mental health promotion, treatment and translation. Each exemplar program described here has embedded these four policy recommendations in the development of the model. They show that psychiatric
nurses engaged in various levels of practice and across different practice
sites can make a difference in mental health care, treatment, research and
policy. The following recommendations provide some guidance.
POLICY RECOMMENDATIONS
I. Support community, family and individual strengths and target
vulnerabilities in any action plan, understanding key drivers of
health, disparities, and health equity as crucial to developing
road maps or action plans to improve mental health.
Ia Promote mental health and prevent mental illness on a macro
and micro level.
Ib Macro levels include advocacy, policy and political action.
Micro levels focus on addressing the needs of families and
individuals who are identied as at high risk due to situational
or developmental circumstances.
Ic Address chronic social conditions such as poverty, violence,
racism, voicelessness and discrimination/oppression that
lead to adverse mental health conditions.
Id Build on intrinsic community or population strengths such as
spirituality, identity, values, educational attainment, and
local leadership. Develop programs founded on individual,
family, and social network strengths to mediate risk and
support resilience.

G.S. Pearson et al. / Archives of Psychiatric Nursing 29 (2015) 1418

Ie Decrease stigma related to the use of mental health services in

the community through social marketing.
II. Enhance development and implementation of collaborative
partnerships to respond to prevention and treatment needs.
IIa Develop partnerships that represent systems thinking and critical analysis essential for working in collaboration to address
underlying determinants of health (York et al., 2012).
IIb Take an interprofessional approach to achieving health
equity as recommended by Healthy People 2020, recognizing
the essential role of communities, states, and national organizations and including monitoring health services trends (U.S.
Department of Health and Human Services, 2012).
IIc Explicate and utilize a healthcare home concept for coordinated and integrated treatment for underserved populations,
using holistic and lifespan approaches.
IId Include collaborative partnerships and interprofessional
practice. An example would be integrating mental health
screening, referral and treatment originating in primary
care (Yearwood, Pearson, & Newland, 2012).
III. Promote greater awareness of mental health via professional and
consumer educational initiatives.
IIIa Educate nurses and consumers about mental health,
disparities and related research issues including unconscious
biases that can profoundly inuence health care. Education
is key to changing the root causes of mental health disparity
in disenfranchised populations and to develop innovative
models of care.
IIIb Use education to facilitate elimination of the stigma associated
with mental health issues. Shift the dialogue in nursing beyond
cultural competence to achieving greater understanding of
underserved populations, social justice, and disparities through
health services research.
IIIc Utilize the model from the recent project of the American
Academy of Nursing, the Geropsychiatric Nursing Collaborative, as a framework for national efforts to raise awareness
disparities and needs in older adults (Beck, Buckwalter,
Dudzik, & Evans, 2011)
IV. Advocate for inclusion of targeted research on mental health
promotion and treatment models and disparities in health
services research in the portfolios of the NIH and other funders.
IVa Focus on contextual factors such as how socioeconomic
status, wealth, education, neighborhood, social support,
religiosity, and spirituality relate to mental illness and,
conversely, can support mental health.
IVb Address disparities in mental health outcomes and develop
an understanding of how factors such as acculturation,
help-seeking behaviors, stigma, ethnic identity, racism, and
spirituality provide protection from, or enhance risk for,
mental illness in racial and ethnic minority populations
(DHHS, 1999, 2001).
IVc Incorporate frameworks within the context of home and
community where social determinants of health and illness
can serve to inform research (Quiones et al., 2011)
IVd Facilitate sharing of collective knowledge by consumers. This
might include lessons and strategies among cross-site intervention research teams to increase the speed of dissemination
and to inform research planning (Department of Veterans
Affairs, Health Services Research, & Development Service,
2007; Pope & Davis, 2011; Quiones et al., 2011).
IVe Incorporate translational research that tailors interventions
to specic populations.

17

IVf Continue to investigate differences in stress, coping, and

resilience as part of the complex of factors that inuence
mental health across the lifespan and within specic
population groups.
IVg Lay the groundwork for developing evidence-based prevention strategies that build upon community strengths, foster
and support mental health and lessen negative mental
health outcomes. Let these strategies dene the policy
decisions that inuence mental health care.
SUMMARY
Mental and physical health are inextricably linked. Our increasing
awareness of behavioral and mental health challenges is coupled with
knowledge of the growth in vulnerable, high-risk populations and the
dramatic reduction in behavioral health providers among all professional groups. The result is that mental health for diverse, at risk, underserved and disenfranchised populations is a major public health
problem. Nurses comprise the largest professional health provider
group. Psychiatric nurses specically have a broad base of preparation
in physical and mental health, cultural sensitivity, social justice,
consumer-driven care, and consumer education for self-care. The
diverse practice areas and populations served by psychiatric nurses
make this nursing specialty ideally suited to help solve this public health
problem for the 21st Century. Further, psychiatric nursing research has
produced solutions for many of the mental health preventive and
treatment challenges experienced by vulnerable populations across
the lifespan. Greater public awareness and application of these
evidence-based solutions warrant advocacy on the part of all nursing
organizations, advocacy groups, and healthcare professionals. We
must work toward improving mental health of the nation. Action steps
are recommended for efforts that support individual/family/community
strengths; collaborative partnerships for prevention and treatment;
public and professional education and awareness, and targeted research
on mental health promotion, treatment and translation.
Acknowledgment
The authors wish to thank Mary Moller for her review of an earlier
version of this paper.
The authors also wish to acknowledge colleagues in the Expert Panel
of the American Academy of Nursing who provided thoughtful and critical input. Please note that this manuscript was the background paper
for the following American Academy of Nursing Policy Brief:
Pearson, G. S., Evans, L. K., Hines-Martin, V. P., Yearwood, E. L., York, J. A.,
& Kane, C. F. (2014). Promoting the mental health of families.
Nursing Outlook, 62, 225227. Doi.org/http://dx.doi.org/10.1016/j.outlook.
2014.04.003.
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