By Tariana V. Little
In July 2017, I had the opportunity to present, “Mobile App to Prevent Depression in the Dominican Republic: Sociocultural Adaptations and International Collaborations,” at Sigma Theta Tau International’s 28th International Nursing Research Congress, held in Dublin, Ireland, on findings from a mobile health, “mHealth”, pilot project promoting mental health in the Dominican Republic (DR), based out of Rutgers University School of Nursing in collaboration with the Dominican Ministry of Public Health. The rapid increase of cell phone use in low and middle income countries provides an opportunity to leverage mHealth, or tech-based interventions for public health (World Health Organization; WHO, 2011). Nearly 85% of the DR population has cell phones, thus mHealth could be a feasible alternative to address some limitations of face-to-face mental health service delivery. With my Harvard DrPH Summer 1 coursework behind me, I now look back on the challenges and successes of this research through a different lens, one of increased self-awareness as a scholar and leader.
A major pillar of the Enabling Change curriculum involves learning more about ourselves and our values as the first step to enabling change in the world around us; the Harvard DrPH calls this Personal Mastery. Early on in the Personal Mastery course, we welcomed as guest lecturer Dr. Howard Koh, Harvard Chan professor, former US Assistant Secretary for Health Services under President Obama, and former MA Commissioner of Public Health. Dr. Koh spoke about his career and the role of spirituality in his leadership, prompting us to consider: What brings meaning to your work? Why are you here? For me, the answer is clear: I am in the DrPH program at Harvard Chan to expand my understanding of public health and strengthen my leadership to contribute to social justice. As a first-generation Dominican-German American seeking to promote the health and well-being of a marginalized community that is also of my heritage, this work is personal.
Moreover, Enabling Change emphasizes clear thinking for effective action. For Fundamentals of Public Health, led by Dr. Suerie Moon, we independently identified a location, researched its health profile, and wrote a Thought Paper making a case for certain health needs. This paper was an opportunity to apply my transdisciplinary training to a real world situation. Using WHO data on DR, I argued for chronic conditions such as heart disease and strokes as health needs because they were leading causes of death and disability.
While available epidemiologic data did not portray mental health as a need, my professional and personal judgment was that this was only part of the story. In our qualitative research on unmet mental health service needs in DR, my colleagues and I found structural barriers, including insufficient government funding for mental health services, limited access to care, lack of mental health professionals, and unaffordable treatment (Caplan, Little, Reyna, Sosa Lovera, Garces-King, Queen, & Nahar, 2016) as well as stigma (Caplan, Little, & Garces, 2016). Moreover, the DR allocates less than 0.5% of its national budget to healthcare, the smallest proportion of all countries assessed by the WHO Caribbean region. Given such conditions, how are data on mental health disparities supposed to surface?
This viewpoint was reinforced when, later on in the course, I teamed up with classmates to produce performance scores for a list of countries. When Dr. Moon revealed her own scores based on the exact same data, hers was contradictory to ours. I was fascinated at how we arrived at this: different answers based on different metrics, and no clear-cut “right” or “wrong” answer. In that ambiguity and challenge is where we, as public health practitioners, can be most reflective and open to rethinking approaches and ways to lead.
In this formative research in DR, I am humbled and challenged to consider the complexity of its public health system and financial, social, and political realities that can influence a mHealth project. Our next step is to further contribute to the nascent mHealth field by publishing on the sociocultural adaptation of mental health interventions in low-resource settings, as suggested by prior research (Farrington, Aristidou, & Ruggeri, 2014), particularly focused on Latin America (Janevic et al., 2016). As we say, “¡Pa’lante!”