MENTAL HEALTH DISPARITIES IN VULNERABLE COMMUNITIES:
IMPLEMENTATION OF AN EVIDENCE-BASED PRACTICE MENTAL
HEALTH DEPRESSION EDUCATION PROGRAM –
A PILOT STUDY

By
Claudette L. Blake-Tonge
APRN, PMHNP-BC, MSN, BSN, RN
PMHNP-BC, Rivier University, 2020
MSN, Kean University, 2012
BSN, Kean University, 2006

A DNP Research Project Submitted to Pennsylvania Western Universities
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
FALL 2023 Doctor of Nursing Practice Project NURS 9990-402
December 2023

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Date

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Committee Chair

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Date

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Committee Member

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Date

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Committee Member

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Date

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Dean of the College of Health and Human Services
Pennsylvania Western University

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MENTAL HEALTH DISPARITIES IN VULNERABLE COMMUNITIES:
IMPLEMENTATION OF AN EVIDENCE BASED PRACTICE MENTAL HEALTH
DEPRESSION EDUCATION PROGRAM – A PILOT STUDY

Committee Signature Page

Student’s name:

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Dedication
To my family, who endured all the neglectful nights, days, weeks, months, and years it
took for me to get to this point, the light at the end of the tunnel. I appreciate all your support.

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Acknowledgments
I want to thank the nursing faculty at Pennsylvania Western University’s DNP program. I
cannot express enough gratitude and appreciation to my committee chair Dr. Kathleen Morouse,
committee members Dr. Timothy Wilson and Dr. Kenneth Ogali, whose guidance and
encouragement kept me motivated. To Dr. Valera Hascup, thank you for your astute critique
which facilitated in getting this project completed.

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Abstract
The purpose of this evidence-based practice project is to evaluate the effectiveness of a pilot
mental health knowledge questionnaire tool used to assess for change in knowledge. Currently,
there are limited tools being used to assess mental health and depression knowledge in
vulnerable communities. This study’s objective and goal is to improve the current practice for
community mental health education in vulnerable communities with the intent to increase
awareness and dispel cultural misconception of mental health. A self-reported pre-test was
administered to assess baseline knowledge of mental health and depression followed by the
educational program on mental health and depression. The data was analyzed utilizing the
Statistical Package for the Social Sciences (SPSS) 23 for descriptive and inferential statistics.
The scores from a paired t-test were compared to determine the effectiveness of the educational
intervention. This study sought participants aged 18 and older, fluent in speaking, reading, and
understanding English. The findings reflect a positive improvement in knowledge recorded on
the post-test responses. Results also showed an increase in correct responses on the post-test after
the implementation of the mental health depression educational program. Finally, the promotion
of educational programs on mental health and depression in vulnerable communities are
beneficial in bring awareness of mental illness.
Keywords: African Americans, Community-based mental health programs,
discrimination, explicit bias, implicit bias, LGBTQIA+ (lesbian, gay, bisexual, transgender,
queer, intersex, asexual, questioning community), depression, mental health disparity, mental
health education, mental health knowledge awareness, mental health promotion, vulnerable
communities, and vulnerable populations.

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Table of Contents
Dedication ...................................................................................................................................... iii
Acknowledgments.......................................................................................................................... iv
Abstract ........................................................................................................................................... v
Chapter 1: Introduction and Background of the Problem ............................................................... 1
Mental Health and Depression ........................................................................................................ 1
Statement of the Problem ................................................................................................................ 2
Background and Significance of the Problem ................................................................................ 5
Assumptions.................................................................................................................................... 8
Purpose and Objectives ................................................................................................................... 8
PICO Research Question ................................................................................................................ 8
Feasibility Assessment .................................................................................................................. 11
Budget ........................................................................................................................................... 11
Limitations .................................................................................................................................... 11
Chapter 2: Review and Critique of the Literature ......................................................................... 12
Procedures used to Critique the Literature.................................................................................... 12
Conceptual Framework ................................................................................................................. 17
Implication For Practice ................................................................................................................ 18
Summary Of Literature Review .................................................................................................... 19
Chapter 3: Methodology and Implementation .............................................................................. 20
Framework of the Study................................................................................................................ 20
Research Design............................................................................................................................ 21
Setting and Sample ....................................................................................................................... 22
Measurements ............................................................................................................................... 23
Procedure for Data Collection ...................................................................................................... 24
Program Presentation and Time Schedule .................................................................................... 25
Ethical Considerations .................................................................................................................. 25
Chapter 4: Results and Findings ................................................................................................... 27
Analysis of the Results.................................................................................................................. 27
Sample Characteristics .................................................................................................................. 27

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MHKQ Pre/Post-Test Response Results....................................................................................... 29
Chapter 5: Summary of the Findings ............................................................................................ 35
Limitations .................................................................................................................................... 37
Implications for Nursing ............................................................................................................... 38
Recommendation for Future Research.......................................................................................... 39
Conclusion .................................................................................................................................... 39
References ..................................................................................................................................... 42
Appendix A Mental Health Knowledge Questionnaire - Pre/Post-Test ...................................... 52
Appendix B Mental Health Knowledge Questionnaire – Permission to Use ............................... 53
Appendix C John’s Hopkins EBP Model and Tools - Permission to Use ................................... 54
Appendix D Demographic Questionnaire ..................................................................................... 55
Appendix E Letter of Introduction and Statement of Consent ..................................................... 56
Appendix F Institutional Review Board Approval Letter............................................................. 60
Appendix G Facility Agreement ................................................................................................... 62
Appendix H Presentation Flyer .................................................................................................... 63
Appendix I Presentation Educational Handouts A & B................................................................ 64
Appendix J Presentation Resource Brochure ................................................................................ 66

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List of Tables
Table
Page
1. Demographic Questionnaire ……………………………………..……………………29
2. Paired Sample t-test ……………………………………………...…………………………30
3. Mental Health Knowledge Questionnaire – Pre and Post-Test Results…….……………………..32
4. Pre and post-test response graphic representation……………….…………………………33

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List of Figures
Figure

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1. Conceptual Framework of Access to Healthcare………………………………………. 18
2. The Johns Hopkins Evidence Based Practice Model.…………………………….……..22

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Chapter 1: Introduction and Background of the Problem
Current research has identified mental health disparities in vulnerable communities as a
critical problem resulting in negative mental health outcomes. Data from minority communities
report greater disparities in medical and mental health services for vulnerable populations
(Centers for Disease Control [CDC], 2019). The COVID-19 pandemic exacerbated mental health
disorders resulting in alarming incidences of anxiety and depression (CDC, 2019). The purpose
of this evidence-based practice project is to evaluate the effectiveness of a pilot mental health
knowledge questionnaire tool used to assess for change in knowledge.
Mental health disparity is a crisis affecting millions of households across America. These
disparities reflect a long history of systemic and structural inequities rooted in discrimination
(Ndugga & Artiga, 2023). Discrimination is systemically woven in policies that affect vulnerable
individuals. These unjust policies affect racial and ethnic minorities, socio-economically
disadvantaged, the unhoused, disabled, elderly, refugees, lesbian, gay, bisexual, transgender,
queer, intersex, asexual (LGBTQIA+), and the chronically ill (Mezzina et al., 2022).
Mental Health and Depression
Mental health disorders left untreated steadily lead to chronic disabilities and even
suicide (Hsieh & Qin, 2017). Depression significantly affects an individual’s mental health with
feelings of sadness, loss of interest that could even lead to death. Worldwide, an estimated 300
million people have experienced depression affecting their quality of life (Herrman et al., 2018).
Vulnerable populations have adverse mental health outcomes reporting increase depression,
anxiety, post-traumatic stress disorder (PTSD) with limited treatment and access to services
(Diaz et al., 2021).

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Literature on similar topics noted discriminatory policies in healthcare negatively
impacting vulnerable individuals compared to health outcomes of individuals in more affluent
areas (D’Anna et al., 2018). These practices require a change to improve dignity and decency in
the treatment of all human beings. Social factors of inept mental health and structural biases
increase rates of serious mental illness in vulnerable populations created by mistrust, fear, and
cultural differences. (Codjoe et al., 2021). Additional studies are necessary to identify and
dismantle biases in healthcare for meaningful change to occur in practices and policies. Multiple
study outcomes reveal a negative relationship between disparity and the availability of relevant
resources in disadvantaged communities. (Codjoe et al., 2021). This evidence-based practice
(EBP) project contributes to the increased need of mental health education as a practice model
for the promotion of educational awareness in vulnerable communities.
Statement of the Problem
Mental health disparities along with discriminatory practices foster biases that continue to
impact the overall quality of life for vulnerable populations (Commonwealth Care Alliance
[CCA], 2022). These practices lead to inefficient and inequitable assistance affecting mental
health in vulnerable populations (CCA, 2022). Black, Hispanic, and Asian adults were 39% less
likely to receive mental health services than 52% of White adults (Singh, 2023). Research
findings discovered disparities are experienced by minorities, every day of their life, from birth
to death. Minorities experience discrimination economically, environmentally, educationally, and
socially (Williams, 2016). Racial discrimination adversely affects vulnerable populations mental
and physical wellbeing (Berger & Sarnyai, 2015).
Every human being will experience mental health challenges in their lifetime. According
to the Williams (2016), one in five adults in the United States live with mental illness. Mental

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health is an individual’s ability to manage daily stressors, remain functional and engage
positively with his family and the community (WHO, 2023). Experiencing positive mental health
is important at every stage of life, from childhood to adulthood (CDC, 2019).
Mental health challenges are amplified by biases which create stress, deteriorate health,
and produce psychological distress. These stresses manifest as mental health disorders, substance
abuse and suicide (Lei et al., 2021) identified significant evidence suggesting reduced
accessibility of daily necessities were contributing factors that deprivation can exacerbate mental
health inequities. Limited availability of affordable housing, employment and health coverage
increases the stress of life, compound that with scare resources deepens mental health distress.
Racism, discrimination, and biases are harmful in healthcare and the population (Hui et
al., 2020). These inequities delay the establishment of adequate, available, culturally affirming
resources and providers. Research results report marginalized patients have a difficult time
locating services (Hui et al., 2020). Mental health inequities result in significant financial costs in
the US health system. The total cost of racial/ethnic disparities in 2009 was $82 billion — $60
billion in excess health care costs and $22 billion in lost productivity (Gaskin, Dinwiddie et al.,
2012). The lack of resources impedes services needed for preventive and chronic care treatment
to maintain a healthy way of life.
Vulnerable populations are disproportionally impacted by the inequities in healthcare.
This population represented individuals that include indigenous groups, gender, race, sexual
orientation, class structure, ethnicity, religion, low-waged, uninsured, elderly, homeless,
pregnant women, disability, human immunodeficiency virus infection and acquired
immunodeficiency syndrome (HIV/AIDS), severe mental illness, displaced individuals, and rural
residents (Tangcharoensathien et al., 2018). The U.S. Census Bureau statistics identified in 2005

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that African Americans were 7.3 times more likely to live in low socioeconomic communities
with limited or no access to mental or behavioral health services (Denton & Anderson, 2005).
After the adaptation of the Affordable Care Act (ACA), African Americans continue to
remain uninsured due to unemployment, expensive insurance premium, extensive program
requirements, shortage of culturally diverse healthcare providers and limited healthcare facilities
within their communities (Gaskin et al., 2012). Multiple psychological research have shown a
disproportionate amount of African Americans continue to be over-diagnosed with
schizophrenia, bipolar disorder and post-traumatic stress disorder. These studies continue to
report consistent findings, revealing African Americans are 78% more likely to be diagnosed
with a psychotic disorder than Euro-Americans (Schwartz & Blankenship, 2014).
LGBTQIA+ population encounter social disadvantages and mental health disparities
exacerbated by social isolation during the COVID-19 global pandemic (Salerno et al., 2020).
Social disparities compound the individual’s mental health thrusting them into a downward spiral
of depression and mental illness. Mental health burden in the LGBTQIA+ individual is made
worse by social inequities (Galea et al., 2020).
It is estimated that about one-sixth of LGBTQIA+ patients experience discrimination in
healthcare and avoid care due to this fear (Powell, 2018). Discrimination does affect an
individual’s mental and physical health. Fear of seeking care leads to declined physical health.
LGBTQIA+ person of color is at a greater risk for mental health disparities. They experience
mounting mental health challenges created by PTSD, anxiety, depression, and suicidality
stemming from ongoing systemic racial discrimination (Galea et al., 2020).
Healthcare inequities are supported by facility operations with policies, regulations and
discriminatory biases manifested in omission of care, inadequate treatment, along with disregard

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of cultural awareness (Baumann & Cabassa, 2020). These inequities are rooted in historical
political injustices present in all areas of care throughout the world largely based on race and
socioeconomic status (Baumann & Cabassa, 2020).
Background and Significance of the Problem
The ethical implications and medical ramifications of implicit and explicit bias in
healthcare to underserved and underrepresented vulnerable populations are concerning as
reflected in the current mental health crisis reported by the WHO (2022). There is a need to
identify and address implicit and explicit racist behaviors in healthcare which is directly related
to the health and wellness of the population. FitzGerald and Hurst (2017), identified in their
study that healthcare professionals display similar levels of implicit bias as the rest of the public.
Healthcare professionals are entrusted to care for individuals, they took an oath to DO
NO HARM. To care for the sick and vulnerable. Implicit associations about a group, be it
prejudice or stereotype, influence the behavior of healthcare providers resulting in negative
evaluations clouded in bias (Holroyd et al., 2016). Whether it is conscious, negligence,
intentional, premeditated, bias in healthcare is a willful attempt to allow harm to befall a
vulnerable human being. The data proves that African Americans, LGBTQIA+, pregnant
women, refugees and other vulnerable populations are in danger in the healthcare system. We are
all now implicit in allowing this practice to continue and do nothing except read it on paper.
Evidence remains consistent in studies showing bias between patient-provider interactions are
linked to discriminatory care (Cooper et al., 2012).
Mental health disparity hinders awareness, knowledge, and the ability to live a healthy
quality of life. This EBP project’s intent is to implement a mental health depression education
program in a vulnerable community to increase awareness, dispel cultural stigmas and normalize

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mental health care. The disparity of financial and transportation burden is eliminated from this
project by conducting this project in the community, making it accessible for the residents to
attend.
The student’s interest was in mental health disparity in vulnerable communities and
identifying the critical need for culturally sensitive resources. As a result, the student investigator
conducted a pilot study to evaluate the effectiveness of a mental health knowledge questionnaire
to assess for change in knowledge to develop and promote mental health and depression
education in a selected vulnerable population in central New Jersey. This interest became the
impetus for this doctoral project. Researchers use the population, intervention, comparison, and
outcome (PICO) framework to conduct a focused literature review on the topic (Eldawlatly et al.,
2018)
The critical need for medical and mental health services in underserved minority
communities is unsettling. These limitations hinder optimal health and mental wellness for the
population, contributing to disparities. The profession of nursing can contribute programs to
decrease disparities in mental health in underserved communities and promote access and
engagement to these services. Advance practice nurses would allow for detection of community
specific needs, steering nursing research to discover and implement culturally relevant
interventions to improve outcomes and quality of life for the community (Grando, 2005;
O’Connor, 2015).
This doctor of nursing practice EBP project will contribute to the gap in programs needed
to reduce mental health disparities in underserved, under-represented groups and other
individuals that have been historically linked to discrimination and exclusion. This program
promotes normalizing mental health care by providing information to allow the individual to

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adapt new self-care habits and understanding (Hartweg & Metcalfe, 2021). The WHO (2022)
recommends the promotion of mental health programs by health providers and collaborators to
contribute to the reduction of disparity to enable a transformation towards better mental health
for all.
Impact of Innovation Technology on Vulnerable Populations
With the progressive innovation of technology, vulnerable individuals’ lives are still
facing alarming risks. There is evidence demonstrating digital divides with the introduction of
health information technology in healthcare with patterns differing by race, ethnicity, and other
socioeconomic characteristics (Saeed & Masters, 2021). Healthcare systems are progressing
forward and relying significantly more on technology. Vulnerable populations will be negatively
impacted by this, as current broadband, artificial intelligence, technologies and bio-metric
devices have limited input for cultural recognition. Inadequate and limited internet access
hinders quality video conferencing required for diagnostic evaluation (Bakhtiar et al., 2020).
The beneficial outcome from eliminating mental health disparity is healthier individuals,
decrease healthcare cost and improved quality of life. Collectively, every citizen will benefit
from the elimination of mental health disparities. The cost of prolonged treatment results in
higher taxes and insurance premiums for everyone. Increasing health access, services, and
resources to eliminate mental health disparities has a potential of saving over $1billion US
dollars (Cook et al., 2015).
Community-based programs are needed to serve as assessment centers, resources, and
preventive facilities in empowering individuals to embrace self-care (Hartweg & Metcalfe,
2021). Collaboration between health professionals and community stakeholders can develop a
shared goal to implement policies to recognize mental health needs among individuals who

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utilize their services (Brown et al., 2019). Culturally relevant information is important to address
stigma, misinformation, and cultural indifference in vulnerable populations (Cook et al., 2015).
Assumptions
Implementing an evidence-based mental health depression education program will
improve understanding and awareness of mental illness, normalize care, clarifying cultural
stigmas and increase utilization of services (WHO, 2021). Clarity of cultural misconception and
stigmas. Promoting a self-help mental health model encourages individuals to use tools to
decrease mental distress (Vaughn & Jacquez, 2020). Providers that are culturally representative
of the community will increase resident engagement and trust. Representation is important as it
builds therapeutic trust and relationships.
Purpose and Objectives
The purpose of this evidence-based practice (EBP) change educational project was to
evaluate the effectiveness of a mental health knowledge questionnaire to assess mental health
and depression before and after a mental health and depression educational program. The study
aimed to implement a pre and post-test questionnaire to identify changes in awareness of mental
health and depression symptoms. Currently, there are limited tools being used to assess
awareness of mental health and depressive symptoms in vulnerable communities. The goal was
to improve current practice of increasing mental health and depression awareness in vulnerable
communities to promote and normalize the use of mental health resources.
PICO Research Question
The starting point for evidence-based practice was to develop that crucial clinical
question to facilitate the search for evidence (Polit & Beck, 2022) using a PICO format. The
acronyms represent:

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Population – Vulnerable community (African Americans, Hispanics, LGBTQIA, religious)
Intervention – Depression education program
Comparison – Community awareness with no education on mental health and depression
Outcome – Improved knowledge about mental health, depression, available resources and how
to access them
The PICO Question - Does implementing a mental health depression education program in a
vulnerable community (African Americans, Hispanics and LGBTQIA+), improve knowledge,
and attitude towards mental health care services as compared to the current community level of
awareness with no depression education?
Definitions
The following key terms are defined to help the reader understand the context of each
term in this study. These key terms are:
Depression is an extended period of sadness and despair lasting several days. It interferes with
how you think, feel and care for our daily activities. This results in pain, change in sleeping
pattern, lack of energy and recurrent thoughts of not wanting to be alive (American Psychology
Association, 2017).
Health inequity denotes differences in health outcomes that are systematic, avoidable, and
unjust (He, 2022).
Implicit bias involves unconscious intent or reaction that leads to a negative influence in the
evaluation of a person based on unknown situational cues or characteristics such as race or
gender (FitzGerald & Hurst, 2017).
Explicit bias implies conscious awareness and express negative preferences, beliefs and attitudes
in the evaluation of a person that are endorsed, identified and communicated (Vela et al., 2022).

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Mental health, according to the WHO (2022) mental health is a state of well-being where an
individual realizes their own potential, able to cope with normal stresses of life, able to work
effectively and successfully, and contributes to their community.
Mental health disparity refers to gaps in health, health outcomes, quality of care, and access to
programs towards various populations (He, 2022).
Mental health prevention is intervening to minimize determinants of mental health before they
become problems (WHO, 2010).
Mental health promotion is any attempt to encourage behaviors that can help prevent and
reduce factors that can lead to mental disorders (WHO, 2010).
Social exclusion, also referred to as social isolation, is used to identify the marginalized
participation or exclusion of certain people from economic, social, cultural, and political
involvement according to the United Nations Commission for Europe Task Force on the
Measurement of Social Exclusion (2022).
Vulnerable community: According to the American Hospital Association (2016), vulnerable
communities include groups that may encounter limited access to health services; scant
economical resources; inadequate insurance coverage; cultural challenges; health illiteracy; and
unsafe environmental surroundings.
Vulnerable populations: The National Collaborating Center for Determinants of Health (2022)
define vulnerable populations as group and communities subjected to higher risk for poor health
outcomes related to barriers and exclusions to social, economic, political, and environmental
resources.

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Feasibility Assessment
This study was conducted in a hotel banquet hall in an urban community in New Jersey.
There were no barriers to implementing this study. The study did not require external assistance
or deployment of sophisticated technology or resources to affect it. The study is also justifiable
on medical grounds and the results of this study may influence future decision making for mental
health education in the community to decrease disparities by improving community awareness
and mental health outcomes.
Budget
For this EBP, a hotel banquet hall was used to support the presentation, the cost for this
location was $175 dollars. The cost for paper was $120 dollars, which was covered by Therapy
Confidential & Consulting, LLC, a private mental health practice. The total project cost was
rounded to $450 dollars. The student project investigator paid all other additional costs for this
study. The mental health knowledge questionnaire is a reliable tool to screen for change in
knowledge. This tool is intended to be used, distributed, and reproduced in any medium,
provided the original work is properly cited (Yu, et al., (2015).
Limitations
A possible limitation when using any self-reported questionnaire could be related to the
participant’s unwillingness to report truthfully their psychological experience or distress, thus
affecting the result of the project. Time may play a factor in providing a comprehensive program
that is not overwhelming but easily understood and memorable. This will be limited to one
community, no random sampling, and therefore findings may not be representative or
generalizable to other larger similar communities.

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Chapter 2: Review and Critique of the Literature
A comprehensive search of the literature on the phenomena of interest was conducted
using databases that included EBSCO, the Cumulative Index of Nursing and Allied Health
Literature (CINAHL), Elsevier, World Health Organization (WHO), APA PsycNet, The Centers
for Disease Control and Prevention (CDC), Google Scholar, PubMed, Wiley.
The keywords discussed in this project are, African Americans, Community-based mental
health programs, discrimination, explicit bias, implicit bias, LGBTQIA+ (lesbian, gay, bisexual,
transgender, queer, intersex, asexual, questioning community), depression, mental health
disparity, mental health education, mental health knowledge awareness, mental health
promotion, vulnerable communities, and vulnerable populations. The articles and studies focused
on the relationship between mental health disparities and mental health awareness, depression
and utilization of resources and the impact on vulnerable communities. This information was
relevant in establishing the realities of mental health disparities in vulnerable communities.
Procedures Used to Critique the Literature
The articles were evaluated to determine the hierarchy of the evidence as established by
(Polit & Beck, 2022). Approximately eighteen articles were selected and evaluated for this
literature review. Research reveals, poor utilization of services and policies limiting resources,
access to mental health services and lack of professional trained providers in mental health
remains contributing factors for inequitable mental health services and care in vulnerable
communities (Kaur et al., 2023). Structural racism and discrimination continue to support
inequitable distribution of resources in disadvantaged areas (Egede & Walker, 2020).
An analysis of vulnerable community conducted by the New Jersey Policy Perspective,
found that mental health staff for white and Asian students increased over the decade, while

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mental health staffing in predominantly Black and minority districts drastically decline over the
same period (Weber, 2022). Programs are needed to directly address social and cultural
intervention to increase sustainability to decrease behavioral decline in vulnerable populations
(Egede & Walker, 2020).
While conducting the search for mental health resources in local vulnerable communities
in central New Jersey, it was revealed the number of facilities needed to meet the need of the
total population living in those neighborhoods was inadequate. The lack of resources is a
microcosm of a substantial problem affecting the entire country patterned in disparity (Burns,
2022). Contributing to increasing resources, knowledge and education is the main reasons for
conducting this doctoral nursing project. The goal is to promote mental health and depression
education improving quality of life at home and the community. Public health messaging with
social intervention is an effective technique for the promotion of positive mental health
awareness for vulnerable population (Latha et al., 2020).
Reducing health disparities improves health outcome, structural living conditions are
critical determinants of health disparities in minority populations faced with multiple structural
disadvantages (Brown et al, 2019). Mental health disparities in minority communities have been
identified by the WHO (2022), as a human rights violation against individuals with mental health
illness. This behavior is widespread across systems everywhere. Suicide is still criminalized in
several countries and the most disadvantaged remain the poorest, most at risk and least likely to
receive adequate care (WHO, 2022).
Scientific literature appears to focus on mental health of Blacks, however, Asians,
Hispanics, LGBTQIA+, and other vulnerable minority groups have also been significantly
impacted by declining mental health as evident by the rise in anxiety, depression, PTSD, and

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suicides (Lee & Waters, 2020). LGBTQIA+ patients continue to report negative mental health
outcomes compounded with discrimination and lack of understanding of their specific concerns
(Liu et al., 2022).
The researcher reviewed multiple peer reviewed articles highlighting and identifying
disparities affecting vulnerable minorities, deprivation of resources, and clinically trained mental
health providers are in demand to address these crisis (Townsend et al., 2023). One researcher
reported that mental health inequities and lack of access is a public health concern festered by
socioeconomic struggles, discrimination, and cultural stigmas, destroying lives, families and
those living within the community (Coombs et al., 2021). Studies on cognitive behavioral skills
development in vulnerable community settings are scarce. Increased evidence-based practice
community programs are needed in mental health services that incorporate cultural relevant
interventions and recommendations to foster an upstream approach to breakdown disparities
(McMorrow et al., 2021).
Culturally competent relevant mental wellness resources and programs specific to
African Americans are minimal, this is an example of inequities pertaining to the overall
available of services within the identified community (McMorrow et al., 2021). To counter this
current system the role of cultural competence is imperative in combating discriminatory
practices. Community integration, cultural awareness of the local community, available
infrastructure and direct service support are characteristics that are supportive of an inclusive
mental health program (Chu et al., 2022).
Addressing vulnerable populations will require cultural awareness and sensitivity.
Cultural competence is the standard of value in the profession of psychology outline in practice
guidelines set forth by the American Psychological Association (APA, 2017). The APA

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developed a framework guiding the practice of administering multiculturally competent service.
This guideline outlines 10 strengths-based approaches when engaging with disadvantaged
vulnerable communities (Clauss-Ehlers et al., 2019).
The evidence in the literature suggests public education on mental health reduces
psychiatric morbidity when focused on the individual, and their environment (Sakiz, 2021). The
introduction of an effective protocol to assist with the treatment of depression, one of the most
common mental health illnesses affecting minority communities, may demonstrate efficiency in
mental wellness (Vargas et al., 2019). This critique will attempt to determine if implementing a
culturally competent mental health promotion program to increase depression awareness
contribute to the reduction in mental health disparities in African American and minority
communities.
Several studies utilized different methodologies for data collection. A cross-sectional
design study with data collected from the National Health Interview Survey between 2017 and
2018 (Coombs et al., 2021). A mixed method process containing the development of a pre and
post-test assessment tools along with the development of a semi-constructed interview as part of
the process evaluation approved by an institutional review board from one of the author’s
institutions (McMorrow et al., 2021).
Vargas (2019) conducted a randomized comparative effectiveness study design
approached with the use of the resilience against depression disparities (RADD) study design to
assess interventions and engagements of the participants with depressive symptoms for LGBTQ
participants (Vargas, 2019). Descriptive statistics were used to explore the relationship between
mental health challenges and the usual source of care (Coombs et al., 2021). Qualitative data

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were reviewed for themes and triangulated to heighten validity of results (McMorrow et al.,
2021).
One result revealed that mental health challenges alone were not drastically affected in
multivariable education programs, but a statistically significant change was detected when two or
more barriers to care were present. Results verified resources in rural areas facing environmental
burden due to large acreage of land in which to provide service coverage (Coombs et al., 2021).
Results indicated improvement in depressive symptoms and overall mental wellness in
participants enrolled in evidenced-based treatment, such as cognitive behavioral therapy as
indicated in score changes on the participants pre and post assessments conducted (Vargas et al.,
2019).
Within the discussion section, the authors focused on variables of mental health
promotion, education, and cultural inclusion in African American, minority and LGBTQ
communities where mental health facilities promote services (McMorrow et al., 2021). It was
also discussed that additional information is needed when addressing depression as this was
identified as a significant scientific gap in promoting depression outcome in racial, ethnic, and
gender conscious minorities (Vargas et al., 2019).
Reviewing the limitations expressed in the study, the researchers were faced with
multiple challenges to overcome. Homogeneity, low completion, rate, and lack of a comparison
group affected the statistical power of the data collected limiting the valuation of the findings
impeding the overall generalization of the population (McMorrow et al., 2021). The anticipation
when conducting research and the need to rely on randomly chosen subjects, is their willingness
to be forthright and honest when providing self-reported measures or subjective data. In this

17

case, access and utilization of mental health services has demonstrated validity in self-reported
use of health services (Vargas et al., 2019).
Conceptual Framework
The Levesque’s Framework for Access to Health will provide the philosophical
foundation for this study and the conceptual framework guiding this evidence-based practice
project (Levesque et al., 2013). This framework suggests healthcare access should be
approachable, acceptable, accommodating, affordable, and relevant (Cu et al., 2021). Levesque’s
framework identifies obstacles in the individual’s ability to recognize, seek, reach, pay or engage
in treatment and as well as the failures of the health system (Cu et al., 2021).
Levesque’s framework is unique in its consideration of both the provider and the
patient’s view of their role, request, and ability in meeting those expectations during the
interaction. The framework has proven successful in measuring access to healthcare from local to
international settings allowing for a comprehensive review of the healthcare process (Corscadden
et al., 2018). Levesque’s Conceptual Framework of Access to Healthcare (figure 1) allows for a
complete review of complicated processes in health facilities and the population (Levesque et al.,
2013).
Figure 1
Conceptual Framework of Access to Healthcare

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From: Patient-centred access to health care: conceptualising access at the interface of
health systems and populations
Implication for Practice
The implication for nursing practice was the identification of a significant need for the
promotion of culturally relevant mental health services to decrease disparities in the African
American and minority communities and the role of the doctor prepared nurse leaders in
addressing these issues (Vargas et al., 2019). Recommendation for continued qualitative or
mixed research to acquire supplementary comprehensive initiatives to address mental health
challenges and the barriers in accessing healthcare services is needed to understand the burdens
on vulnerable populations to the reduction of inequities (Coombs et al., 2021).

19

Summary of Literature Review
In conclusion, cost remains one of the most significant barriers to access to mental health
services along with the lack of health insurance, lack of culturally appropriate health education,
lack of knowledge, availability of resources to vulnerable communities, lack of health facilities
proximity and lack of representation (Coombs et al., 2021). These articles relate to topic of
interest by emphasizing the need for an approach in addressing real-life social issues such as
racial injustice of African Americans and minorities in the United States. Inequities in healthcare
are manifested as implicit and explicit biases in interactions in how we treat the communities we
serve. These issues must be rectified to eradicate disparities, inequalities, and inequities to
mobilize the integration of equality distributed mental health service in all vulnerable
communities including the LGBTQ communities (McMorrow et al., 2021).

20

Chapter 3: Methodology and Implementation
The purpose of this chapter was to introduce the methodology for this evidence-based
practice (EBP) project regarding methods to decrease mental health disparities in vulnerable
communities. The purpose of this evidence-based practice project is to evaluate the effectiveness
of a pilot mental health knowledge questionnaire tool used to assess for change in knowledge.
The aim was to decrease mental health stigma, misinformation, increase awareness and
encourage the practice of mental health care. The intent was to utilize a revised version of the
Mental Health Knowledge Questionnaire (MHKQ; Appendix A) to assess the participant’s
awareness of mental health and depression. This data was used for comparison of the mean test
scores of the pre-test and post-test questionnaire to determine the effectiveness of the educational
intervention on participants’ knowledge of mental health, depression, and resources available to
them. The questionnaire was free to share and adapt providing full credit, link, and any
indication of changes (Appendix B). A PowerPoint covering information on mental health and
depression to assess for change in knowledge was presented to the attendees.
Framework of the Study
The Johns Hopkins Nursing Evidence-Based Practice Model (Figure 2) was the EBP
framework utilized for this project. Permission to use this model has been obtained (Appendix
C). This model utilizes a problem-solving strategy to clinical decision making developed by the
Johns Hopkins Hospital. The model has user-friendly tools to guide the user (Dang et al., 2022).
This model was designed for practicing nurses with a three-step guide called PET: practice
question, evidence, and translation. This ensures for a study to practice patient care without
implementation delay.
Figure 2

21

The Johns Hopkins Evidence Based Practice Model

(Dang et al., 2022)
Research Design
This EBP project study design was a quasi-experimental pre-test-post-test cross-sectional
design utilizing the MHKQ. In addition, participants were asked to complete a demographic
questionnaire (Appendix D) for gender, age, working years, education, marital status, family
status and residence. A letter of introduction explaining the study and the notice of implied
consent (Appendix E) was given to all participants by the investigator. Implementing this project
in a vulnerable community served as an intervention promoting educating the community about
mental health, depression, and available resources to enhance the advancement of mental health
and decrease mental health disparity. This project attempted to foster a safe space to allow for
authentic self-reporting response from the participants (Gershon et al., 2020).

22

Setting and Sample
The participants for this project were recruited via a convenience sampling from the
current residents of the community. Flyers were hand delivered to the businesses and residential
buildings within the surrounding area of the project site two weeks prior. The program was
conducted in an urban community in New Jersey with a large population of vulnerable groups,
which includes African Americans, Hispanics, Native Americans, racial/ethnic minorities,
lesbian and gay communities, religious groups, the unhoused, the uninsured, and refugees.
Institutional Review Board (IRB; Appendix F) approval from Pennsylvania Western University
was obtained prior to the start of the program.
A written agreement with the management company where the project was conducted
was obtained (Appendix G). The facility manager’s main role was coordinating and supervising
the operations of the hotel as well as resolving any issues that may arise. The hotel manager is
aware of all hotel guests but is not responsible for their activities or whereabouts. The hotel
offers laundry service, vending machines, and hall rental as additional in-house services
available for guests and patrons. The hotel is in a vulnerable community, providing short and
extended stays for regular guests and for individuals in the process of being unhoused. Governor
Phil Murphy, of New Jersey in 2020, extended the Lockout Protections To People Living in
Hotels, this program attempted to resolve the housing shortage and protect families in New
Jersey from homelessness (Yi, 2020).
Participants were screened prior to the beginning of the educational presentation to check
for inclusion criteria. Participants included in this project were limited to 18 years of age and
older, have the language proficiency to speak, read and understand English, be a member of a
vulnerable population/group or live in a vulnerable community. Individuals who did not meet

23

these inclusion criteria were excluded from the study. After consenting to participate in the study
and meeting the inclusion criteria’s, participants were instructed to complete the demographic
and pre-posttest questionnaire. The forms consisted of the demographic sheet, and the mental
health knowledge pre and post-test questionnaire. The data collection forms were numbered, no
names were used, and were randomly given to attendants, no identifying information was
collected that could link data to any one individual participant. A program flyer (Appendix H)
was placed at the entrance of the hotel and on all seven floors of the hotel to advertise the
project. The participants were provided with a depression education handout A and B (Appendix
I) and a local resource brochure (Appendix J).
Measurements
This project consisted of two questionnaires, a socio-economic demographic
questionnaire and the researcher revised MHKQ questionnaire. The socio-economic
demographic questionnaire collected participants’ age, ethnicity, marital status, employment,
income, and level of education. The MHKQ is a standardized multifaceted 20-item self-reported
questionnaire that was revised by the student investigator for the purpose of assessing mental
health depression knowledge and awareness of the participants in a vulnerable community. This
questionnaire consisted of a twenty-item questionnaire which has been revised to assess mental
health literacy. The first 16 questions are statements referencing mental health prompting the
participants to choose either “true” or “false” as their response. The accurate responses for this
tool are coded as “true” for the following questions 1, 3, 5, 7, 8, 12, 15, and16. The incorrect
responses are coded as “false” for the following questions 2, 4, 6, 9, 10, 11, 13, and 14. Each
correct response gets a score of 1 and incorrect responses are given a score of 0. Questions 17 to
20 inquired about the participants awareness of four promotional mental health days celebrated

24

in the United States. The answers for these four additional questions were given a 1 for “yes” and
a 0 for “no” responses. The original questionnaire scale reported an internal consistency of
Cronbach’s α coefficient of 0.61 (Yu et al., 2015). A Cronbach’s alpha was conducted on the
revised form to obtain the reliability analysis of 0.56. The MHKQ assesses three areas of the
populations understanding of mental health that include knowledge of mental health disorders
(items 1, 2, 3, 5, 7, 8, 11, 15, & 16), causes of mental disorder (items 4, 6, 9, 10, 13, & 14) and
an inquiry of the participants awareness of mental health promotional activities (items 17 to 20).
Procedure for Data Collection
A convenient sample of approximately 15 – 20 participants were sought for this study.
No power analysis is needed with a convenience sample. The participants who attended this
doctoral nursing evidence-based practice educational program received a letter of introduction,
statement of consent, a demographic form, the pre and post-test mental health knowledge
questionnaire, a brochure of resources and educational handouts relating to mental health and
depression.
The project’s presentation was free of cost to all participants. The student investigator
verbally described the study purpose to the participants and provided a letter of introduction that
described the purpose of the doctoral nursing EBP project. Attendees were notified, the
completion of the forms is their implied consent to participate in the project. The participants
were asked to complete the demographic, and the MHKQ before the presentation and instructed
to complete the post-mental health knowledge education questionnaire after the presentation. To
capture all attendants as they entered the hall, the student investigator handed each person a
packet containing the following documents, the introduction letter, consent statement,
demographic questionnaire, pre-questionnaire, post-questionnaire, two educational handouts, and

25

a resource brochure. The participants were asked to place their completed forms back into the
envelope they were provided. The data collection forms were gathered from each participant
before they exited the hall at the end of the program.
Program Presentation and Time Schedule
The program was scheduled and presented on August 11, 2023. The program was
scheduled at 1 PM at the Ramada Hotel banquet hall located in a vulnerable community in New
Jersey. The presentation lasted for sixty minutes with additional time provided at the end of the
program for questions. The program concluded after the ending of the educational presentation
and the collection of all demographic forms and questionnaires.
No participants chose to disclose their mental health status or verbalize self-harm
intentions, in the event someone presented with symptoms, they would have been provided with
a consent and the Patient Health Questionnaire-9 (PHQ-9) assessment tool. The PHQ-9 is a nineitem questionnaire used to assess depression-related symptoms. This is a quick and efficient tool
used by providers to diagnose and monitor patients (Pfizer, 2021).
Ethical Considerations
Approval was obtained from the Institutional Review Board (IRB) from Pennsylvania
Western University and the community center director manager to conduct the program.
Participation was voluntary and participants were able to withdraw at any time without penalty.
Each participant received information regarding the EBP project with an implied consent before
inclusion in the program. To provide confidentiality of the participant, no names were used, and
a number was randomly assigned to each participant. All the program findings are reported in
aggregate, and no individual participant can be identified or connected to the findings. No one
will have access to the data except the student. All written data will be kept in a locked file

26

cabinet accessed only by the student. Any computer data is maintained on a password protected
computer accessed only by the student. Data will be maintained for the required number of three
years per the IRB protocol.

27

Chapter 4: Results and Findings
The intervention implemented for this doctoral nursing evidence-based practice project
was a mental health depression education program, utilizing a modified mental health knowledge
questionnaire with a pre-test post-test design. This design allows for the evaluation of the
effectiveness of the program’s information provided to the participants by assessing their
response before and immediately after the educational program is presented.
Analysis of the Results
The data was analyzed using Dell SPSS Statistics software V.29.0. Sociodemographic
characteristics of the sample were examined using descriptive statistics to compare the mental
health knowledge (MHK) score of respondents. Age, gender, ethnicity, marriage, education,
sexuality, employment, religion, and income were characteristics of the respondents assessed for
the level of current mental health knowledge. The MHKQ characteristics of the participants
responses to the educational program were examined using descriptive statistics, to compare the
mental health knowledge questionnaire pre and post-test results, to assess for measurable level of
change in knowledge before and after the mental health depression education program was
presented.
Sample Characteristics
A total of 16 participants attended the mental health depression educational program. 13
participants completed the questionnaires with a response rate of 81.3%. The median age of the
participants was 39 years with an age range of 18-60+. The majority of the participants were
aged 40-60+. There were more female participants at 61.5% than male at 38.5%. The majority of
the participants were single at 46.2%, with 23.1% being married, 15.4% divorced and widowed
respectively. Most of the participants identified as heterosexual at 84.6%, one person identified

28

as bisexual at 7.7% and another identified as being gay at 7.7%. The majority of the attendants
were African American at 84.6%, while 7.7% represented one Mixed race and one Caucasian
individual. These participants acknowledged having a religion as Christian (84.6%), Islam
(7.7%) and one other person stated they had no religion (7.7%).
The educational background of the participants was almost evenly divided except for one
individual who had some college credits 7.7%. 46.2% of the participants were high school
graduates or had taken a General Educational Development test, and 46.2% were college
graduates. 53.9% of the attendants were employed full-time, 23.1% were retired, and 7.7% were
students, unemployed or preferred not to say. Their income level fell in all ranges assessed. Onehalf of the participants, 46.2% made more than forty-five thousand dollars or more; one-third
made between $20,000 to $30,000 and the others, 7.7%, either made less than $5,000 or
preferred not to say. A more detailed description of the participants is displayed in Table 1.
Table 1
Demographic Questionnaire
Description of the participant (n=13)
Characteristic
Age:
25-39
40-59
60+

n
3
5
5

%
23.1
38.5
38.5

Gender:

Male
Female

5
8

38.5
61.5

Ethnicity:

Black/African American
Mixed race
White/Caucasian

11
1
1

84.6
7.7
7.7

Marital status: Single
Married
Divorced
Widowed

6
3
2
2

46.2
23.1
15.4
15.4

Education:

High school graduate/GED
Some college
College graduate

6
1
6

46.2
7.7
46.2

Sexuality:

Heterosexual
Bisexual
Gay

11
1
1

84.6
7.7
7.7

29

Employment: Full-time
Retired
Student
Unemployed
Prefer not to say

7
3
1
1
1

53.9
23.1
7.7
7.7
7.7

Religion:

Christianity
Islam
No religion

11
1
1

84.6
7.7
7.7

Income:

Less than $5,000
$5,000-$10,000
$10,000-$20,000
$20,000-$30,000
$45,000+
Prefer not to say

1
1
1
3
6
1

7.7
7.7
7.7
23.1
46.2
7.7

MHKQ Pre/Post-Test Response Results
The computed paired sample statistics performed for the pre-test questionnaire had a
mean score of 8.6, with a standard deviation of 2.39. The results for the post-test had a mean
score of 11.6 with a standard deviation of 1.85. The paired difference before and after the
educational program had a mean score of -2.85, with a standard deviation of 2.33 and a
significance of 0.001. The findings represent an improvement in knowledge after the
presentation evident by the 55 points difference between the pre and post-test results, a change of
21.1% increase in the results. The results show a statistically significant difference between the
pre and post-test knowledge validating the statement that promoting mental health depression
education in a vulnerable community does increase knowledge and awareness of mental health
and depression. Details of these results can be found in Table 2.
Table 2
Paired Sample t-Test
Mean

n

SD

Range

Variance

Pre-test

8.9

20

2.4

9

5.7

Post-Test

11.6

20

1.8

7

3.4

30

Pre - Post

2.85

2.33

Significance
P≤0.001

The four promotional mental health days awareness ranged from 38.5% to 69.2%, with
the Suicide and Crisis Lifeline being the most widely recognized mental health promotional day
69.2% followed by the International Suicide Prevention Day as the second most recognized day
61.5%. Half of the respondents had heard about World Mental Health Day 53.85% and less than
one-third of the respondents had any prior awareness of the International Day of Happiness
38.5%. Every participant had changes in their responses to almost every question on the
questionnaire except for two questions.
The participant’s response for Question # 1 and 10 remained the same on the pre-test as
on the post-test, making them the only two questions that did not have a change in response after
the program, all other questions showed changes in responses from all the participants. Both
questions had an accuracy of 100% on the pre-test and the post-test. Question #1 states: “Mental
health is a part of your health,” the answer was true. Question # 10 states: “Even for severe
mental disorders (such as, schizophrenia), medications should be taken for a short time only;
there is no need to take them for a long time,” the answer for this question was false. It is
important to note that treatment and medication compliance is a precursor to positive health
outcomes resulting in improved health and decreased healthcare cost (Aremu et al., 2022). The
participants awareness of the importance of taking medication for an extended period is
affirming that promotion is effective in getting information to the public increasing their
knowledge and awareness of the subject being promoted.

31

The pre-test and post-test response rate for each question is displayed in table 3.
Table 3
MHKQ Pre/Post Questionnaire Response
T/F

Pre/Post

1.

Mental health is a part of health.

T

13/13

2.

Mental disorders are caused by negative thinking.

F

10/11

3.

Many people have mental problems but do not realize it.

T

11/13

4.

All mental disorders are caused by external stressors.

F

8/11

5.

Elements of mental health include normal intelligence, stable mood, a
positive attitude, quality social relationship and adaptability.

T

11/12

6.

Most mental disorders cannot be cured.

F

8/6

7.

Mental health problems are common health problems.

T

8/12

8.

Psychological problems can occur at any age.

T

11/13

9.

Mental disorders and psychological problems cannot be prevented.

F

7/11

10.

Even for severe mental disorders (e.g., schizophrenia), medications should
be taken for a given time only; there is no need to take them for a long
time.

F

11/11

11.

People with mental illness are more violent than the general population.

F

4/9

12.

Individuals with a family history of mental disorders are at a higher risk
for psychological problems and metal disorders.

T

10/12

13.

Psychological problems in adolescents do not influence academic grades.

F

11/13

14.

Middle-aged or elderly individuals are unlikely to develop psychological
problems and mental disorders.

F

10/13

15.

Individuals with a bad temperament are more likely to have mental
problems.

T

5/9

16.

Mental problems or disorders may occur when an individual is under
psychological stress facing major life events (e.g., death of family
members).

T

10/11

Y/N
17.

Have you heard about World Mental Health Day?

October 10th

Y

7/13

18.

Have you heard about the Suicide and Crisis Lifeline?

9-8-8

Y

9/13

19.

Have you heard about the International Suicide Prevention Day? Sept 10th

Y

8/13

20.

Have you heard about International Day of Happiness?

Y

5/13

March 20th

32

The pre and post-test graphic representation of the changes in response are displayed in
table 4.
Table 4
Pre and Post-Test Response Graphic Representation
Mental Health Knowledge Questionnaire
14
12
10
8
6
4
2

0
1

2

3

4

5

6

7

8

9

10

Pre-Test

11

12

13

14

15

16

17

18

19

20

Post-Test

The first 16 questions referenced knowledge of mental health and depression. Question
#11, “People with mental illness are more violent than the general population,” had a five-point
increase in responses, the most significant change for all the questions. An inference can be made
that the population perceive people with mental illness to be more violent than the general
population. Four participants answered the question correctly on the pre-test and nine
participants responded with the correct answer on the post-test. The responses in the post-test
represented a 38% increase in accuracy.
Questions # 7, 9 and 15 followed next with a four-point increase in positive responses.
Question # 7, “Mental health problems are common health problems,” had eight correct
responses on the pre-test compared to 12 correct responses on the post-test, the second most

33

improved response with a 31% change in response. Question # 9, “Mental disorders and
psychological problems cannot be prevented,” seven responded correctly on the pre-test which
increased to 11 correct on the post-test, a 30.97% increase. Question # 15, “Individuals with a
bad temperament are more likely to have mental problems.” The pre-test had five responses
while the post-test had nine responses representing a 37.8% increase in accuracy.
Question # 4 and 14 had a 3-point increase in their accuracy response, a 23.1% positive
change for both questions, respectively. Question # 4, “All mental disorders are caused by
outside stressors,” eight responded correctly on the pre-test and this number increased to 11 on
the post-test. Question # 14, “Middle-aged or elderly individuals are unlikely to develop
psychological problems and mental disorders,” there were 10 correct responses on the pre-test,
this number was increased to 13 correct responses.
Questions #2, 5 and 16 had the least change with only a one-point change in difference
for accuracy with a change of 7.7% change in accuracy for each question. It can be inferred that
the participants were confident and accurate in their knowledge of the questions posed. Question
# 2 states, “Mental disorders are caused by negative thinking.” Question # 5 states, “Parts of
mental health include normal intelligence, stable mood, a positive attitude, quality social
relationship and adaptability.” Question # 16, “Mental problems or disorders may occur when an
individual is under psychological stress facing major life events (such as a death).”
There were one other significant change resulting in a decline in responses from the
questionnaire, question # 11, “People with mental illness are more violent than the normal
population.” This question had a two-point decline in response from the pre and post-test. Eight
participants initially responded correctly to this question, after the educational program the
responses went down to six correct responses, a 15.4% decline in accuracy. This question will

34

require further investigation to understand the negative outcome of this result. We can infer from
the results that the participants may have been influenced by the education provided which
caused the participants to change their response.

35

Chapter 5: Summary of the Findings
The purpose of this evidence-based practice (EBP)project was to evaluate the
effectiveness of a mental health depression educational program, utilizing a revised
questionnaire, in a vulnerable community to promote mental health awareness to reduce mental
health disparities in vulnerable populations. This chapter includes a discussion of major findings
from the project and related literature on mental health disparities in vulnerable communities.
The programs and projects for the elimination of mental health disparities are not popular topics
available for review, more research is needed to effectively increase the number of programs for
minority health. Promotional projects were identified to be effective vulnerable communities
(Brown et al., 2019).
The effectiveness of this EBP mental health depression education program was observed
within the quantitative findings as noted in the difference in responses between the pre-test
questionnaire and the post-test questionnaire data. The results of the findings represent an
increase in accurate responses for almost every question except for two which were unchanged
by the presentation. From the findings we can deduce that knowledge was increased for all
participants involved in the program as evident by the positive results. The need for mental
health promotional educational intervention is essential in vulnerable communities to enhance
mental health awareness (Zingg et al., 2016).
This EBP project focused on mental health disparities in vulnerable communities and the
application of an educational program to improve mental health outcomes in the community. The
outcome from this project supports the hypothesis that implementing a mental health depression
education program in vulnerable communities, improve knowledge, and attitude towards mental
health care services as compared to the current community level of awareness with no depression

36

education. A common theme and statement from the participants were, not knowing about the
two weeks’ time period needed for continuation of symptoms prior seeking mental health
assistance from a provider.
Mental health symptoms exhibited nearly every day during a two-week period meet
criteria to make the determination of a mental health disorder (Uher et al., 2014).
Compared to the 69.2% awareness rate of the Suicide and Crisis Lifeline, the awareness
rates of the World Mental Health Day, International Suicide Prevention Day and International
Day of Happiness were much lower. The reasoning may be due to the emphasis placed on
suicide prevention resulting from a significant increase in suicide rates of 37%, over the past
twenty years (Saunders & Panchal, 2023). The other three days also require The program defined
disparities, mental health and depression, the participants were provided information on how to
identifying mental illness the symptoms, treatments, and the impact mental health disorder have
on the community. Majority of the participants verbalized learning something new from the
information provided during the presentation. A review of the post results showed a significant
increase in correct responses in most areas on the post-test questionnaire compared to their
original responses on the pre-test questionnaire. Comparable promotion to foster public health
awareness to decrease suicidal rate is also needed.
Mental health disparities in vulnerable communities are significant problems resulting in
negative financial and overall health outcomes. The reports all indicate widespread disparities in
medical and mental health resources for vulnerable populations exacerbating incidences of
mental illness such as anxiety and depression (Center for Disease Control, 2022). This project
was specifically targeted towards vulnerable populations that have endured systemic

37

discrimination culminating in the inequitable distribution of resources from policies enforcing
biases in practice.
Organization discriminatory practices influence health outcomes and the ability to
participate in preventive, supportive treatment services to prioritize and enhance quality of care
for vulnerable communities (Brown et al., 2019). Minority communities have fewer social and
financial opportunities exposing them to severe negative risks impacting food, housing, safety,
and transportation. The data also support establishing collaboration in the community to increase
buy-in, motivation and commitment to the initiatives, to increase sustainability and create
trusting relationships between minority population and mental health providers (Egede &
Walker, 2020).
Limitations
The mental health knowledge questionnaire (MHKQ) utilized for this evidence-based
practice project was modified adjusting questions to the population being presented from the
original used in China. The original questionnaire had an internal consistency and Cronbach α
coefficient of 0.61. The MHKQ Cronbach scale is used to evaluate the reliability of the tool
being used to capture data. The original scale of 0.61 indicates an acceptable but low internal
consistency with a weak reliability relating to possible question correlation and uniformity (Yu et
al., 2015). The intent of this project was not to validate the properties of the mental health
knowledge questionnaire, but to assess the level of change in knowledge before and after an
evidence-based practice educational programs in a vulnerable community. The scale of the
psychometric properties for the mental health knowledge questionnaire is comparable in
different studies and was not made a leading focus in this project (Yu et al., 2015).

38

The lack of comparison between the MHKQ and other tools used to measure mental
health knowledge is another limitation of this project. The original version of the MHKQ was
conducted in Chinese, the translated English version has been proven effective but not in
comparison to other tools to evaluate interventional outcome. Additional studies may benefit
from implementing both the English version of the MHKQ and another scale to analyze its
feasibility and psychometric properties in comparison to other tools (Yu et al., 2015).
A notable limitation of this study was the location where the project was presented. This
program was only conducted in one vulnerable community, significantly impacting the
generalization of the findings. The findings, though significantly positive, are absent of
supportive data to generalize the training to other communities. This program will require
replication in additional communities to analyze the findings from those studies. A
recommendation for future studies to improve the mental health awareness to reduce stigma in
vulnerable communities is much needed (Codjoe et al., 2021).
Implications for Nursing
This study emphasizes the need for evidence-based practice mental health promotional
programs to combat disparities and improve awareness of mental health in vulnerable
communities. Mental health disparities in vulnerable communities highlight opportunities for
doctoral prepared nurses to implement evidence-based practice education programs in
partnership with community members towards developing, implementing, and improving
challenges for minority populations (Morales et al., 2020). The World Health Organization
(WHO, 2022) recommends the promotion of mental health programs by health providers and
collaborators to contribute to the reduction of disparity to enable a transformation towards better
mental health for all.

39

The data on successful sustainable and replicable interventions are lacking requiring
additional studies reproducing studies with reportable outcomes. This doctor of nursing practice
EBP project will contribute to the limited programs available to reduce mental health disparities
in underserved, under-represented groups and other marginalized individuals that have been
historically discriminated and excluded. This program promotes the normalization of mental
health care through dissemination of information allowing the individual to adapt new self-care
habits and understanding while incorporating Levesque’s conceptual framework for independent
access to healthcare (Levesque et al., 2013).
Recommendation for Future Research
Future directed programs may be beneficial in educating the public on accurate detection
and causes of mental illness. To extend the impact of these studies, the level of influence must
address structural discriminations, risks and factors that affect vulnerable communities (Morales
et al., 2020). Further, this program emphasizes the importance of integrating effective
community engagement approaches to develop close partnerships with community leaders to
address healthcare inequalities for minority populations (Codjoe et al., 2021). Active
involvement of medical personnels, community leaders, policy makers and media organizations
are needed to eradicate inequities, disparities and stigmas related to mental health and mental
illness (Kaur et al., 2023).
Conclusion
Financial insecurity, systemic discrimination, inadequate access to healthy food, clean
drinking water, safe living environment, deprived educational system, poor employment
prospects, and limited outdoor activity spaces, are some of the numerous factors contributing to

40

disparities in vulnerable communities (Brown, 2019). Influencing change within the community
requires multiple-system interventions to effectively decrease mental health disparities.
Programs such as this may provide a framework on implementing evidence-based
practice mental health depression education by healthcare providers transforming science into
practice (Varges et al., 2019). Teaching and learning have a fundamental part to play in
encouraging the process of promoting mental, emotional, and social health in schools
(Macklem,2014)
Interventions, such as this doctoral nursing evidence-based practice mental health
depression educational program, are needed to decrease mental health disparities and promote
awareness in vulnerable population regarding the correct characteristics of mental disorders. This
project has demonstrated to be an effective tool to positively increase awareness impacting the
outcome of physical, mental, and social health (Yu et al., 2015). This framework provides a
useful structure to guide study designs that can address the complexities of delivering vulnerable
population mental health care and identify mechanism underlying disparity and how best to
remedy them (Morales et al., 2020)
This project adds to the evidence of promotional education supporting sustained
improvements for vulnerable populations mental health and reduce disparities that can help
individuals and their communities gain the highest level of health. Significant contributions of
successful educational programs are critical in dispelling stigmas, improving awareness, gaining
understanding, and normalizing mental health care. (Brown et al., 2019).
The successful development of evidence-based practice projects requires dissemination
and constant engagement to sustain effective practices by community leaders and healthcare
professionals. Community involvement is a significant partnership for integrating science,

41

practice, and policies to counter factors that contribute to mental health disparities in vulnerable
population and communities (Brown et al., 2019). Mental health in vulnerable communities is in
crisis in the United States and the world. The rise in violence and uncertainty will continue to
exacerbate the increase of mental distress. As demonstrated by this pilot study, mental health and
depression promotion educational programs are successful in increasing knowledge in vulnerable
communities. This improved knowledge can be used in nursing practice to improve self-care
practices in patients seeking mental health services.

42

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52

Appendix A
(Participants will get two copies, a pre-test, and a post-test later in the program)
Study ID #: ________
Date: ________
MENTAL HEALTH KNOWLEDGE QUESTIONNAIRE
Pre - Test
STUDY PARTICIPANT, please answer the questions to the best of your ability. Your answers
to the following questions will be used for research purposes only and will be kept strictly
confidential.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

17.
18.
19.
20.

True

False

Yes

No

Mental health is a part of your health.
Mental disorders are caused by negative thinking.
Many people have mental health problems but do not realize it.
All mental disorders are caused by outside stressors.
Parts of mental health include normal intelligence, stable mood, a positive attitude, quality social
relationship and adaptability.
Most mental health disorders cannot be cured.
Mental health problems are common health problems.
Mental health problems can occur at any age.
Mental disorders and psychological problems cannot be prevented.
Even for severe mental disorders (such as, Schizophrenia), medications should be taken for a short
time only; there is no need to take them for a long time.
People with mental illness are more violent than the general population.
Individuals with a family history of mental disorders are at a higher risk for psychological problems
and mental disorders.
Psychological problems in adolescents do not influence academic grades.
Middle-aged or elderly individuals are unlikely to develop psychological problems and mental
disorders.
Individuals with a bad temperament are more likely to have mental problems.
Mental problems or disorders may occur when an individual is under psychological stress facing
major life events (such as, death).
Have you heard about World Mental Health Day?
Oct. 10th
Have you heard about the Suicide and Crisis Lifeline?
9-8-8
Have you heard about the International Suicide Prevention Day?
Sept. 10th
Have you heard about International Day of Happiness?
March 20th

53

Appendix B
Mental Health Knowledge Questionnaire – Permission to Use

Yu et al., (2015) with changes. https://creativecommons.org/licenses/by-nc/4.0/
6/7/23, 10:27 PM
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54

Appendix C
JOHNS HOPKINS EBP MODEL AND TOOLS- PERMISSION

setting to focus on your project, collaborate with peers, and get expertise and assistance
from our faculty. COMING in 2024!

55

Appendix D
Study ID: ________
Date: ________
DEMOGRAPHIC QUESTIONNAIRE
Fill in the following information about the PARTICIPANT. Your answers will be used for
education only

Section A: Obtaining Information
Who is completing this form?
 The study participant
 A parent/guardian of study participant
 Spouse of study participant
 Other: _________________________
ANSWER THE FOLLOWING QUESTIONS AS THEY RELATE TO YOU – THE PARTICIPANT
Section B: Participants Information
1. Which is your age?




2. Which gender do you identify with?
 25 to 39
 60 plus
 ______

18 to 24
40 to 59
Prefer not to say

3. Which race/ethnicity do you identify with?





Hispanic/Latino
White/Caucasian
Mixed race
Prefer not to say

 Asian or Pacific Islander
 Black/African American
 Other…

5. What is your level of education?






No schooling
Elementary to 8th grade
High school grad or GED
Technical school
Prefer not to say
Employed – Full time
Employed – Part time
Retired
Prefer not to say




Female
Other…

4. What is your marital status?





Single
Divorced
Separated
Other






Married
Widowed
Never married
Prefer not to say

6. What is your sexual identification?





Some schooling
Some college
College graduate
Other…

7. What is your employment status?





 Male
 Transgender
 Prefer not to say







Heterosexual
Bisexual
Asexual
Gay
Prefer not to say






Homosexual
Pansexual
Lesbian
Other…

8. What is your religion?
 Unemployed
 Student

9. What is your total monthly household income?
 Less than $5,000
 $20,000 to $30,000
 $5,000 to $10,000
 $30,000 to $40,000
 $10,000 to $20,000
 $45,000 +
 Prefer not to say






Christianity
Judaism
Buddhism
Prefer not to say

 Islam
 Hinduism
 No religion

56

Appendix E
LETTER OF INTRODUCTION

University Affiliation:

Pennsylvania Western University of PA Administrative Office
108 Carrier Administration Building
Clarion, PA 16214
814-393-2337

Project Title: MENTAL HEALTH DISPARITIES IN VULNERABLE
COMMUNITIES: IMPLEMENTATION OF AN EVIDENCE-BASED PRACTICE
MENTAL HEALTH DEPRESSION EDUCATION PROGRAM

Principal Investigator:

Claudette L. Blake-Tonge, APRN
s_clblake@pennwest.edu
973-704-3756

You are invited to take part in a DNP program study being conducted through
Pennsylvania Western University. We ask that you read this form and ask any questions you may
have before you decide whether you want to take part in the study. The University requires that
you give your signed agreement if you choose to take part.
Purpose of the Study:
▪

The purpose of this evidence-based practice project is to evaluate the effectiveness of a
pilot mental health knowledge questionnaire tool used to assess for change in knowledge.
Currently, there are limited tools being used to assess mental health and depression
knowledge in vulnerable communities. This study’s objective and goal is to improve the

57

current practice for community mental health education in vulnerable communities with
the intent to increase awareness and dispel cultural misconception of mental health.
Procedures:
Completing the questionnaires is your implied consent to participate in this study. You
will be asked to do the following:
▪ Complete an anonymous demographic information form. (This form will ask for
information such as age, education, race).
▪ If you consent to participate, you will be in an educational program with other
participants. You may know other participants as clients of The New Essecare of NJ or
residents of the community.
▪ Program location:
o Ramada Hotel 120 Evergreen Place, East Orange, NJ 07018, 973-677-3100
▪ The program will be conducted on July 8th, 2023, at 1pm. The program will be
completed in one day lasting sixty minutes.
▪ There is no direct cost associated with participation. Indirect costs include your time.
▪ YOU SHOULD NOT PARTICIPATE IN THIS PROJECT…
If you are UNDER 18 years old.
Risks of Being in the Study:
▪

There are no foreseeable or potential risks associated with taking part in this project.

▪

Claudette L. Blake-Tonge (Investigator) has successfully completed the Collaborative
Institutional Training Initiative (CITI).
o This program focuses on ethical principles, informed consent, privacy,
confidentiality, and Pennsylvania Western University’s standards of research.

▪

This project has been reviewed and approved by the Pennsylvania Western University
Institutional Review Board to ensure the participants have minimal risk.

▪
▪
▪

The Benefits to Participation are…
There is no guarantee that you will get any benefit from taking part in this program.
However, you may gain more understanding of mental health and depression.
Your willingness to take part in this project may help you save someone’s life.

58

Compensation:
▪

There will be no compensation of any kind for taking part in this project.
Confidentiality:

▪
▪
▪
▪
▪

To protect your identity, the data collection forms will not ask for any identifying
information such as your name, address, email, phone number, or social security number.
Please complete all the forms and place them in the unmarked envelope provided. Handdeliver the envelope to the investigator.
The demographic data information will be entered into a password protected spreadsheet.
Your consent and all data collection forms will be kept with the principal investigator in a
secured cabinet for the next three years.
No video recording will be done of this program.
What else do I need to know?

You should know that Therapy Confidential & Consulting, LLC, a privately owned
psychiatric mental health practice, will supply financial and/or material support for this study.
Additionally, The Ramada Hotel is providing support for the project by supplying the facility to
conduct this DNP project.
Right to Refuse or End Participation:
Understand that you may refuse to take part in this study or withdraw at any time.
Understand also, you can be excused from the study at any time by the investigator.

Complaints or Concerns: Please contact the Committee Chair: __Dr. Kathleen
Morouse, DNP at morouse@pennwest.edu_ and/ or The Institutional Review Board at
Pennsylvania Western University of Pennsylvania.
Pennsylvania Western University of PA Administrative Office
108 Carrier Administration Building
Clarion, PA 16214
814-393-2337

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Statement of Consent:
By completing the questionnaires, you are giving your consent to participate in this
project, and you are certifying that you are 18 years of age or older. You acknowledge that
you have read the information described above and have received a copy of this information.
You have asked any questions that you had regarding the project and have received answers to
your satisfaction.

________________________________
Signature of Investigator

IRB Research Approval #: Proposal #PW23-002

Thank you for your participation.

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Appendix F
Institutional Review Board Pennsylvania Western University IRB Approval Letter

Institutional Review Board
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Melissa Sovak, Ph.D.
Dear Claudette Blake,

Please consider this email as official notification that your proposal titled “Mental Health
Disparities in Vulnerable Communities: Implementation of an Evidence-Based Practice Mental
Health Depression Education Program” (Proposal #PW23-002) has been approved by the
Pennsylvania Western University Institutional Review Board as submitted.
The effective date of approval is 07/20/2023 and the expiration date is 07/19/2024. These dates
must appear on the consent form.
Please note that Federal Policy requires that you notify the IRB promptly regarding any of the
following:
(1) Any additions or changes in procedures you might wish for your study (additions or changes
must be approved by the IRB before they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are necessitated by any events
reported in (2).
(4) To continue your research beyond the approval expiration date of 07/19/2024, you must file
additional information to be considered for continuing review. Please contact instreviewboard@calu.edu
Please notify the Board when data collection is complete.

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Regards,
Melissa Sovak, PhD.
Chair, Institutional Review Board

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Appendix G
Facility Agreement

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Appendix H
Presentation Flyer

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Appendix I
Presentation Educational Handout A

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Presentation Educational Handout B

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Appendix J
Presentation Resource Brochure

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