We assessed the role of promotoras—briefly trained community health workers—in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention’s impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention’s implementation, involving infrastructure at the health centers, boundaries of the promotoras’ roles, and “turf” issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.
The question of "how" occupies center stage in the explanatory efforts of developmental science and establishes the study of process as the field's defining mission. In line with this mission, recent decades have witnessed a new wave of focus on taking seriously issues of time, variability, and context in the study of development. For many in the field, however, fully espousing a process orientation for developmental science requires an abandonment of the structural explanation in which the field is historically steeped-for example, the organizational sequencing and directionality established in the "grand theories" of classic developmental accounts. Metatheoretically, the idea that a process orientation actively conflicts with a structural orientation rests on the conceptual conflation of different kinds of structural explanation. Such conceptual conflation, in turn, derives from the adoption of an ontological framework that reduces all explanation to mechanistic antecedent-consequent relations. The purpose of this article is to frame developmental science's pursuit of the question of "how" within the broader context of metatheoretical division that characterizes the field's approach to explanation itself.
Psychological sequelae of war and genocide can potentially persist into adulthood for child survivors of such tragedies. However, few studies have investigated child survivors’ particular experiences with such sequelae in adulthood, and fewer still distinguish between orphaned and nonorphaned child survivors’ experiences. The present study examined the experiences of posttraumatic distress and psychological growth among a sample of adults ( N = 40) who, as children, survived Guatemala’s 36-year civil war and genocide. We compared the experiences of orphaned survivors raised at a particular permanent residential home for much of their childhoods ( n = 20) with those of their childhood peers raised by family ( n = 20), all from the same rural mountain town. Findings reveal that both groups report similar long-term posttraumatic distress, yet the orphaned group reported significantly higher posttraumatic psychological growth than their peers. Implications for reconsidering institutional care for child survivors of war and genocide are discussed.
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