Principal Investigator/Program Director (Last, first, middle): Shellman, Juliette
1. The Candidate
1. A. Introduction
I am applying for the Mentored Research Scientist Development Award (K01) to promote my growth as an independent scientist in patient-oriented research. My goal for this five year career development award is to obtain the advanced training I need to develop a culturallyappropriate peer-to-peer reminiscenceintervention and test its effects on decreasing depressive symptoms in older African-Americans in a pilot study.This career development proposal builds on my two years of post-doctoral work as a John A HartfordFoundation Scholar as I tested the effects of reminiscence on depressive symptoms in older African-Americans. Conducting this pilot study enabled me to gain entry into African-American church communities. Preliminary results indicate that integrative reminiscence has a positive effect on reducing depressive symptoms in community-dwelling older African-Americans. However, this experience of working with church communities highlighted my need for further training in community-based participatory research to develop community approaches that will result in a sustainable reminiscence program for older African-Americans. This K01 award will not only provide opportunities for in-depth training to effectively partner with African-American communities, but will also build upon my current research skills to analyzethe functions of reminiscence in older African-Americans andcollect preliminary data in a pilot test for feasibility and directional effectiveness of the peer-to-peer reminiscence intervention on depressive symptomsin a pilot study.
Late-life depression is a public health problem in the U.S. with significanteconomic and health consequences. According to the National Institute of Mental Health (2003), an estimated two million of the 35 million American older adults have a depressive illness andanother five million have subsyndromal or minor depression. The economic cost of depression in older adults has been estimated to cost $43 billion dollars annually in the United States (American Association of Geriatric Psychiatry, 2001). There is little published research on the use of therapeutic interventions to decrease depressive symptoms in older adults and even less regarding depression inolder African-Americans.With the expected increase in the older African-American population there is a critical need for the development and testing of innovative and cost-effective interventionssuch as peer to peer reminiscence programs.Reminiscence programs have been shown to decrease depression (Haight & Webster; 1995; 2002). This reminiscence intervention is innovative because it utilizes a peer-to-peerapproach that can assist in overcoming barriers to African-American older adults’ participation in mental health researchand decrease depressive symptoms. Effectively managing minor depressive symptoms in older African Americans has major implications for their quality of life.
In response to the health disparities among older African-Americans,Haug and Wykle (1999) called forthe following: 1) improved education and increased trust-building efforts to educate older African-Americans about the value their contributions can make to science, 2) increased funds to attract minorities and those interested in studying older African-Americans, and 3) improved health care policies affecting minority elders through cost analyses and studies of different health care delivery models utilized byminority groups. Despite this call to action, mental health disparities and low research participation rates among older African-Americans still exist (Rooks & Whitfield, 2004). My K01career development award directly responds to these needs. By completing the proposed training and research plan, I will gain expertise in a community-based participatory researchapproach with older African-Americans to increase their trust and participation in research,mentor young African-American researchers, and develop a sustainable peer to peer reminiscence intervention program based on the strength of African-American oral traditions. The training and research plans described in this proposal will position me to carry out independent investigations designed to translate an empirical understanding of the functions of reminiscence in older African-Americans into an innovative and cost-effective peer to peer approach to decrease depressive symptoms in this population.
Specifically, the K01 Career Development Award will provide meadditional skills, training and mentoring in: 1) community-based participatory research that includes the use of ethnographic research method, development and management of effective interdisciplinary teams, and formation of partnerships with keystakeholders, 2) the functions of integrative reminiscence in older African-American adults,3) development of a culturally appropriate peer to peer reminiscence training manual in partnership with African-American communities,4) research methods and statistical techniques appropriate to design and implement randomized clinical trialsfor psychosocial interventions.5) the responsible and ethical conduct of psychosocial intervention research, and 6)gaining expertise in grantsmanship through mentored development of an R-series grant application to conduct a clinical trial testing the peer to peer reminiscence intervention in lowering depressive symptoms in older African-Americans. The research aims listed below compliment the training goals for this career development award.The research aims for this project are:1) to explore the meaning and perceived benefits of integrative reminiscence incommunity-dwelling older African-Americans, 2) to test the cultural relevance, acceptability, and psychometric properties of the ReminiscenceFunctionScale with older African-Americans, 3) to describe the functions of reminiscence in community-dwelling older African-Americans, 4) to develop and pilot test the peer reminiscence training manual for its appropriateness, feasibility and acceptability in an older African-American community, and 5) To pilot test the peer-to-peer reminiscence intervention for feasibility and directional effectiveness on depressive symptoms and reminiscence functions in older community-dwelling older African-Americans (N=24).
1. B. Career Goals and Objectives: Scientific Biography
My professional career began in education. After earning both a Bachelor of Science and a Master ofScience in Education and teaching for 12 years I entered the field of nursing. Upon graduation from nursing school, I first worked in a long term care facility caring for older adults on a sub-acute unit. This experience enabled me to develop clinical skills in the care of older adults with acute illnesses and management of psychosocial problems such as depression and end-of-life care. It was this experience that led to my interest in caring for older adults and the use of reminiscence as a possible intervention to decrease depression and increase life-satisfaction. During my graduate studies in nursing I was attracted to community health nursing because of its focus on prevention, restorative and maintenance health care for older adults. My community health clinical education included care of older adults in community-based settings as well as in the home. An important aspect of this education was conducting a community needs assessment in a rural area in Connecticut and my subsequent establishment of blood pressure clinics and wellness program for older adults at a senior center in Connecticut. This led to my first publication (Shellman, 2000) and recognition by the University of Connecticut with the Eleanor K. Gill Award for Excellence in Clinical Practice.
Predoctoral Experience
While studying for a master’s degree in community health nursing at the University of Connecticut School of Nursing I formally began my research training under the mentorship of Dr. Patricia Neafsey who is well known for her work on preventing drug interactions in older adults. During this experience I learned recruitmentstrategies, focus groups techniques, and data collection methods. As project director for Dr. Neafsey’s study, Preventing over the Counter Drug and Prescription Medication Interactions in Older Adults, I trained undergraduate research assistants and carried out an interactive computer intervention. This work led to numerous publications as a co-author and multiple local and national presentations. The experience also enabled me to develop an appreciation for the methods and challenges of conducting field research. Simultaneously, I focused my graduate coursework on the use of reminiscence in nursing practice, gaining depth in its theoretical underpinnings and expertise in facilitating reminiscence with older adults in the community. My first study was conducted using reminiscence with Haitian elders as part of an international community health experience. While reminiscing with the older Haitians, it became apparent that reminiscence enabled the Haitian elders to remember the happier times of the past and relieve the pain of their present living conditions. In addition, the findings suggested that reminiscence could be beneficial for health care providers as a tool for learning about elders’ cultural beliefs and practices. These findings significantly informed my reminiscence work and research focus for my doctoral studies.
In 1999, I began pursuing my doctorate at the University of Connecticut under the guidance of Dr. Henrietta Bernal, RN, Ph.D., a nurse anthropologist. Throughout my doctoral experience I sought to gain a better understanding of the uses and benefits of reminiscence, while strengthening my clinical training in the care of older adults in the community. While at the University of Connecticut, I became involved in the development of the award winning CARELINK Model of Care for older adults in the community (Bernal, Shellman & Reid, 2004). In this community-university partnership, nursing students provide services during their community health practicum to older adults no longer eligible for compensated care through the regular visiting nurse services. As part of the CARELINK model of care, I developed a reminiscence education program to teach students how to facilitate reminiscence with older adults. My dissertation work emerged from this experience. First, I modified the Cultural Self-Efficacy Scale developed by Bernal & Froman (1987; 1993) and developed a reliable and valid scale to measure Students’ Eldercare Cultural Self–Efficacy (ECSES) (Shellman, 2006).A principal factor analysis revealed a four factor structure with alpha coefficients ranging from .82-.95. This 28 item scale was found to be reliable and valid measure of eldercare cultural self-efficacy in baccalaureate nursing students. Secondly, I employed an interrupted time series witha nonequivalent no-treatment controlgroup design with the ECSES as the measurement. The Effects of a Reminiscence Education Program on BSN Students’ Cultural Self-Efficacy in Caring for Elders was conducted with senior nursing students. The quantitative findings indicated that nursing students receiving the reminiscence intervention had higher levels confidence in caring for older adults of different ethnic backgrounds than those not receiving the reminiscence intervention (Shellman, 2006). These findings were supported with contextual data gathered during the study that provided insight into the students’ perceptions of the reminiscence education program (Shellman, 2006). My dissertation work resulted in two published manuscripts and numerous presentations at local and regional nursing conferences. Upon graduation I received the Carolyn Ladd Widmer Award given to a doctoral candidate for outstanding dissertation research.
As part of my doctoral work and under the continued guidance of Dr. Bernal, I started the groundwork for patient-oriented research and focused work on the use of reminiscence with African-American elders. In addition to conducting my dissertation research, I was named an American Nurses Association Presidential Scholar and was funded by the American Nurses Foundation to conduct the study “Understanding Life Experiences of African-American Elders”. This phenomenological study revealed key themes as well as the benefits of reminiscence for African-American older adults (Shellman, 2004). This foundational reminiscence study provided important groundwork for the next phases of my reminiscence research program.
Postdoctoral Experience
After my appointment as an Assistant Professor at the University of Connecticut School of Nursing in the fall of 2003, I began to formalize my program of research and continued focusing on patient-oriented reminiscence research. Through clinical work in the CARELINK program, I discovered the importance of the issues of depression and social isolation in community-dwelling minority older adults and the existing disparities in mental health care for this population. These observations in addition to my previous reminiscence work with older African-Americans led me to this research path of the use of reminiscence to decrease depressive symptoms.
In 2004 I submitted and was awarded a Large Faculty Grant from the UCONN Research Foundation to begin pilot work on Effects of a Structured Reminiscence Program on Depression and Life Satisfaction in African-American Elders. At the same time, I began establishing linkages with leaders in gerontological nursing at New YorkUniversity. Subsequently, I was awarded a 2004 John A. Hartford Foundation Post-Doctoral Fellowship. Dr. Elizabeth Capezuti from New YorkUniversity and Dr. Lois Evans from the University of Pennsylvania served as co-mentors. Both of these geriatric experts have been instrumental in my continuing on this path of reminiscence intervention research with older adults. With the support of the Hartford Foundation, I have been able to pursue my interest in reminiscence research and depression in African-American elders while developing important networks with other gerontological nursing leaders.
The pilot study Effects of a Structured Reminiscence Program on Depression and Life Satisfaction in African-American Elders has provided important contextual and quantitative data. One article describing qualitative results from the study “Keeping the Bully Out.” The Meaning of Depression in a Sample of African-American Elders is under review for the Journal of the American Psychiatric Nurses Association. Preliminary findings from this study have been disseminated at the Gerontological Society of America’s 58th Annual Conference and a manuscript is in progress. The experience of conducting this research has provided me with insight into the following challenges of conducting mental health research with minority populations. Specifically, 1) I experienced first-hand the mistrust and hesitancy of gatekeepers to allow me, a white researcher, entry into their communities, 2) recruitment and retention of both African-American research assistants and participants required constant effort, and 3) the sensitivity and stigma surrounding the topic of depression. While conducting this study, Dr. Bernal introduced me to Dr. Jean Schensul, Founder and Director of Research at the Institute for Community Research (ICR) in Hartford, CT. I have attended programs and met with various staff members from ICR including Dr. Schensul over the past two years. It has become evident to me from making these contacts and observing the work conducted at ICRthat the community-based participatory research model practiced by ICR would be most appropriate for conducting my program of research.
During my post-doctoral experience, I was selected to participate in the National Institute of Aging’s Summer Institute on Aging Research Program in July, 2005. Through networking opportunities and individual research consultation provided at the institute, I was encouraged to examine my research career goals and identify the resources and skills I would need to attain these goals. All of these experiences were influential in my decision to pursue this career development award. I subsequently sought a faculty position in a research intensive environment and in the summer of 2006 was appointed as an Assistant Professor at Yale University School of Nursing. All of these experiences have been invaluable, and I am now ready to take the next step toward becoming an independent researcher.
Under the guidance of Drs. Capezuti and Evans, I have developed important research skills and have come to understand the value of networking with experts in the field of mental health aging research. As a result of their guidance, I have met with gerontological leaders such as Dr. Terry Mills from University of Florida and Dr. Peter Lichtenberg from WayneStateUniversity to assist me in developing goals for this career development award. I am seeking additional training to address the mental health and well-being of older African-Americans with an innovative and community-developed reminiscence training manual. Additional mentoring from noted experts in the fields of community-based participatory research, depression, and minority research will enhance my expertise in developing community partnerships, interdisciplinary research teams, and the dissemination of a culturally appropriate and acceptable reminiscence training manual that will result in a sustainable peer to peer reminiscence intervention program for African-American communities.
According to the Surgeon General’s 2001 Mental Health Report: Culture, Race and Ethnicity, the disparities affecting mental health care of minorities are the result of having less access to mental health services, receiving poorer quality of care, and an under-representation of minorities in mental health research. Mistrust of health care providers, research, and researchers have been cited as factors for low minority participation in studies (Curry & Jackson, 2004). Using a participatory approach to research, and recognizing the community’s cultural values and health concerns are paramount in developing community partnerships. Interdisciplinary research partnerships can have immediate and long-term benefits (Schensul, 2006). One of the most significant challenges to conducting community-based participatory research is the significant time and effort required to build relationships among partners (Israel, Lichtenstein, Lantz, McGranagan, Allen, Guzman, Softley, & Maciak, 2001). At this phase in my career, protected time to pursue the proposed research career development plan, and develop relationships and community participatory activities is crucial. I willcommit at least 75% effort to the research and career development activities outlined in this award for a period of five-years to meet the goals described in this plan (see letter of support from Dean Grey in appendix).
1. C. Career Development Activities during Award Period
Long-term Goals
My research experiences, as well as my academic training and clinical work, reflect my strong interest in the use of reminiscence to decrease depressive symptoms in older African-Americans. The major long-term goal of this five year career development award is to establish myself as an independent reminiscence researcher who will, in partnership with communities, develop a peer-to-peer reminiscence intervention that will decreasedepressive symptoms in this population.My three year plan of development is to execute high-quality, original reminiscence research and make significant contributions to the field.The career development activities and research plan proposed in this application will provide me with the needed training and experience, as well as essential reminiscence pilot data to conduct a clinical trial in the future. During Year 3 of this career development award, I will begin to develop an application for an R series grant which will allow me to test this peer-to-peer reminiscence intervention in a larger scale study. My ultimate research goal after this career development award is completed and sufficient pilot data is gathered is to submit an R01 to test the clinical effectiveness of a reminiscence intervention on depressive symptoms and reminiscence functions in older African-Americans.