Project Background

This line of research includes efforts to address disparities in mental health and mental health care and to develop interventions that reduce barriers created by limited literacy in mental health care.  These interventions engage a number of strategies including: providing literacy support to individuals, developing reading groups within mental health outpatient settings, as well as utilizing the universal precautions approach – to reduce system level literacy barriers.

Limited literacy is an important and under-examined factor in the lives of people with SMI and is also associated with health disparities in multiple ways. The relationships among literacy and health have been well documented, with research showing that people with lower literacy skills have worse health outcomes for a variety of chronic conditions, including cancer, diabetes, and asthma (Berkman et al., 2004). Adults who report having a mental health problem have significantly lower literacy levels than adults who did not, even after controlling for education (Sentell & Shumway, 2003). In public mental health treatment settings, from 54% (Currier, Sitzman, & Trenton, 2001) to 76% (Christensen & Grace, 1999) of participants score at or below the eighth-grade level. Emerging evidence suggests literacy is also related to psychiatric symptoms and diagnoses, mental health service utilization, quality of life, and community participation for people who live with mental illness.

In keeping with the mission of IUHR and the findings of the Literacy Study (see prior projects), we are working on developing and implementing 3 separate pilot interventions.

Literacy Education for Improving Engagement in Treatment and Community Inclusion for People with Serious Mental Illness

The broad goal of this proposal is to conduct the first stage of the development of an intervention study to adapt Adult Basic Education (ABE) for use in a public, urban, mental health outpatient setting.

Multiple participants in interviews during the NIMH R01 Literacy Study, reported that a reading group tailored to meet the needs of adults living with SMI would be very helpful. In response, we have implemented the following pilot study:

Study Aims:

Aim 1: To adapt and modify ABE for use in an integrated primary care and wellness center embedded in a busy, public, urban outpatient mental health center. The adapted ABE (ABE-MH) will be service-user informed, recovery-focused, led by an ABE instructor, and supported by peer tutors.

Aim 2: To conduct a pilot study of ABE-MH to assess the feasibility and acceptability of the model

Aim 3: To inform the development of a full trial of ABE-MH in busy, public, urban clinical settings.

Ultimately the adaptation of ABE and the development of evidence-based methods to improve the reading skills of people with mental illness may have broad public health impact as seen in improvements in engagement in health and wellness activities, chronic disease management, adherence to mental health treatments and overall improvements in mental and physical health. In addition, given the stigma associated with limited literacy as well as the instrumental tasks of wellness and daily life that require reading skills, improvements in reading will facilitate access and promote community inclusion.

Drop-in Room to Provide Support to Users of Outpatient Mental Health Services to Fill Out Forms and Paperwork

Multiple participants in interviews group during the NIMH R01 Literacy Study, reported that need to have a place where they can get help with forms, paperwork, mail, and other documents they find difficult to complete. They requested that this support be offered where they receive mental health services.

The second intervention is a drop-in room to offer assistance to persons living with SMI in filling out forms related to housing, disability, or other needed services. This drop-in room intervention is being implemented in partnership with Massachusetts Mental Health Clinic, a Department of Mental Health (DMH) facility in Boston and staffed by research staff and students of the IUHR. This pilot will assess the feasibility of this model and determine effective means of expansion to not only the Department of Mental Health, but to the broader outpatient mental health centers’ communities.

Literacy Audit

Literacy audits address the universal precaution approach to literacy – where creating a space and materials that clients of all levels of literacy can access.

The final intervention is a literacy audit. Partnering with experts in the field from Brandeis University and Harvard School of Public Health, we are assessing the written communications and signage at the Fenwood Inn, the shelter at the Massachusetts Mental Health Clinic, to determine the level of literacy required to navigate care at this clinic. This audit will reveal possible areas of improvement to help clients at the clinic to understand and navigate the care they receive, despite their level of literacy. This pilot will result in a report including recommendations based on findings to increase the accessibility of mental health care for persons with SMI, as well as determine best practices for further expansion of these audits throughout MMHC, DMH, and other outpatient mental health centers.