Week7 - Lecture'7 Dispari.es Defini.on'of'Dispari.es...

Info icon This preview shows page 1. Sign up to view the full content.

View Full Document Right Arrow Icon
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: Lecture'7' Dispari.es' ' Defini.on'of'Dispari.es' •  "A'popula.on'is'a'health'disparity'popula.on' if'there'is'a'significant'disparity'in'the'overall' rate'of'disease'incidence,'prevalence,' morbidity,'mortality'or'survival'rates'in'the' popula.on'as'compared'to'the'health'status' of'the'general'popula.on.”'' –  Na.onal'Center'for'Minority'Health'and'Health' Dispari.es' ' CDC'defini.on'' •  The'CDC'defini.on'describes'mental'health'dispari.es'as' oEen'falling'into'one'of'these'three'categories:' •  '(1)'dispari.es'between'the'aKen.on'given'mental'health' and'that'given'other'public'health'issues'of'comparable' magnitude,'' •  (2)'dispari.es'between'the'health'of'persons'with'mental' illness'as'compared'with'that'of'those'without,'or' •  '(3)'dispari.es'between'popula.ons'with'respect'to'mental' health'and'the'quality,'accessibility,'and'outcomes'of' mental'health'care.'' –  social'determinants,'such'as'employment,'income,'housing,'and' so'on,'which'can'influence'mental'health'and'access'to'care.' Cultural'advances:'NLAAS' •  Na.onal'es.mates'of'prevalence'rates'rather'than'loca.on'specific'rates' •  NLAAS'was'conducted'in'2002'and'2003'in'English,'Spanish,'Chinese,' Tagalog'and'Vietnamese,'based'on'the'respondents’'language'preference' •  Major'La.no'subgroups'were'sampled'N'='2,554,'868'Mexican,'495'Puerto' Ricans,'577'Cubans,'and'614'Others'(response'rate'of'75.5%)'(PI:' Margarita'Alegria)' •  Asian'sample'was'comprised'of'2,095'individuals:'Chinese'(n'='600),' Filipino'(n'='508),'Vietnamese'(n'='520),'and'“other”'Asian'(n'='467)'(PI:' David'Takeuchi)'' •  Similar'measures'as'NCSeR,'NSAL,'and'NLAAS' NLAAS:'Social'and'environmental' determinants' •  Individual'immigra.on'factors' –  Parental'na.vity'and'age'of'arrival' •  Language'use,'language'spoken'as'a'child,' language'spoken'with'friends,'language'spoken' with'family,'and'language'of'thought' •  Ethnic'iden.ty' •  Accultura.ve'Distress' •  Family'support'scale,'Family'burden,'family' cultural'conflict'scale,'family'cohesion' language use Na.onal'Survey'of'American'Life' (NSAL)' •  N'='3570'African'American,'N'='1623'Afroe Caribbean,'N'='1005'Whites' •  PI:'James'Jackson' •  Na.onal'sample'from'all'regions,'high,'low' density'areas,'urban,'rural'and'suburban' •  Mul.ple'measures'of'social'disadvantage' •  Methods'to'account'for'missing'household' members'' •  70e77%'response'rates' high, low ethnic density addressed the point of going to jails to survey individuals from there to have a fully representative sample for the study, specifically with African Americans Few'Dispari.es'in'Mental'Health' Disorders' generally, ethnic minorities have lower rates of mental health issues than Whites •  Ethnic'minori.es'usually'have'equal'or'fewer' mental'health'disorders'than'Whites/ European'Americans'except'for:' –  Depression'among'Hispanics,'par.cularly'Puerto' Ricans' –  PTSD'and'alcohol'use'in'American'Indians' –  Schizophrenia'in'African'Americans' compared to the general population, ethnic minorities have greater physical, health issues than Whites •  This'is'different'than'health'care'outcomes' which'are'typically'worse'in'ethnic'minori.es' Symptom'level'differences' Ethnic minorities present or report higher symptoms on certain measures, but not necessarily more disorders. This shows that they may be overlooked or cannot be exactly classified into a specific disorder because their diagnosis is difficult to execute, higher threshold for distress, expectations are different for minorities than the general population. Increased'dispari.es'in'service'use'for' ethnic'minori.es' •  African'Americans/Black' –  28e31%'with'need''received'services'(Alegria'et'al.,' 2006;'Neighbors'et'al.,'2007)' •  Caribbean'Blacks'least'likely'to'use'mental'health'services'compared'to' African'Americans'and'Non'Hispanic'Whites(NHW)'(Levine'et'al.,'2013)' •  Asian'Americans'–'22%'with'need'received'services' •  Significant'underu.liza.on'especially'among'immigrants' (LeMeyer'et'al.,'2009)' •  La.nos'–'30%'with'need'received''services' •  Significant'underu.liza.on'especially'those'with'Limited'English' Proficiency'(Kim'et'al.,'2011)' Consistently, relatively to their needs, ethnic minorities are not receiving the same healthcare services than others. Typically, limited understanding of English tends to demonstrate inadequate distribution of resources. In general, those with mental health problems, regardless of ethnic group, are not getting the resources they need. Mental'Health'Service'Use'Trends' •  Racial'and'ethnic'minori.es'have'less'access'to' mental'health'services'than'whites'have' •  More'likely'to'receive'poor'quality'care' •  More'likely'to'delay'or'not'seek'mental'health' treatment'' •  AEer'entering'treatment,'less'likely'to'receive' evidence'based'treatments'(for'anxiety'and' depression)' •  More'likely'to'terminate'treatment'early' These'paKerns'are'not'improving' not readily available where they live, cannot afford healthcare insurance and if they do, it usually is lower quality care because physicians may be seeing too many patients in the clinics and the best doctors will probably be in higher quality hospitals or areas Dispari.es'among'Youth' –  Ini.al'AKendance' •  Many'noeshows'among'La.no'and'African'American' families'(Mckay'et'al.,'1996;'Harrison'et'al.,'2004;'Kazdin'&'Wassel,' 2000)' Text –  No'show'rate;'approximately'48e62%' –  Ongoing'aKendance' – La.nos'and'Asians'are'more'likely'to'prematurely' drop'out'of'services'(Sue'et'al.,'1991;'Kendall'et'al.,'1997;' Huey,'1998)' »  60e75%'drop'out'aEer'just'one'session' –  Less'likely'to'have'evidence'based'care'(Wang'et'al.,' 2002)' What accounts for disparities? ENVIRONMENT Mental Health Care System External Environment INDIVIDUAL AND PROVIDER CHARACTERISTICS Predisposing, Enabling and Need Factors HEALTH BEHAVIORS HEALTH OUTCOMES -Perceived MH Status Use of Services (uptake & adherence) (e.g. functioning) -Evaluated MH Status (e.g. diagnoses/ symptoms) -Satisfaction Figure 1. A Mental Health Services Use Model (adapted from Andersen, 1995) Barriers to Care ! !  Predisposing factors-demographic characteristics (e.g., age and gender, education, ethnicity, marital status, occupation) including health beliefs. !  Enabling factors-(e.g., insurance, transportation, childcare, language, time). Organizational factors (e.g., type of provider and health services organizations) and social support systems can also be included here. literacy issues, hard to know what services are available !  Perceptions of need : the way people view their own health (i.e., mental health) and functioning (e.g., severity level, impairment, level of burden) if the burden of the children’s symptoms are not serious enough, parents will not attend to treatment efforts Predisposing: Cultural Beliefs •  Stigma –  Ethnic minorities more likely to anticipate stigma related barriers to treatment (Alvidrez and Azocar, 1999) •  Beliefs about discipline and therapy (McCabe, 2002) –  Latina mothers believe that they should be able to overcome their child s mental health problems on their own and that emotional and behavioral problems should be handled by increasing discipline •  Predicts premature termination •  Less likely to recognize need and minimize impairment (Chavira et al., 2006;Garcia and Lindgren, 2009; Nadeem, Lange & Miranda, 2009; Roberts, Alegria, Roberts and Chen, 2005) •  Explanatory Models may affect helpseeking (Yeh, McCabe, Hough, Lau, Fakhry, and Garland, 2005) –  Among Latino parents, service use associated with beliefs that child s problems have a biological or trauma based etiology What else may contribute to disparities? Barriers Personal/Family – Acceptability – Cultural beliefs – Language/literacy – Attitudes, beliefs – Preferences – Involvement in care – Health behavior – Education/income Structural – Availability – Appointments – How organized – Transportation Financial – Insurance coverage – Reimbursement levels – Public support Use of Services Visits •  Primary care •  Specialty •  Emergency Procedures •  Preventive •  Diagnostic •  Therapeutic Mediators Quality'of'providers' "  Cultural'competence' "  Communica.on'skills' "  Medical'knowledge' "  Technical'skills' "  Bias/stereotyping' "  Appropriateness'of'care' "  Efficacy'of'treatment' "  Pa.ent'adherence' Outcomes Health'Status' "  Mortality' "  Morbidity' "  Wellebeing' "  Func.oning' ' Equity'of'Services' Pa.ent'Views'of'Care' "  Experiences' "  Sa.sfac.on' "  Effec.ve'partnership' cultural compentency Sta.s.cal'discrimina.on;'“percep.on'that' ethnic'minority'pa.ent'is'less'likely'to'be'ill”'in' comparison'to'white'pa.ent'because'of'“facts”' Modified from Institute of Medicine. Access to Health Care in America: A Model for Monitoring Access. Washington, DC: National Academy Press; 1993. Cooper LA, Hill MN, Powe NR. J Gen Internal Med. 2002;477-486. Policy'recommenda.ons'to'reduce' dispari.es' •  health'care'systems'take'steps'to'improve'access'to'care' •  provide'interpreter'services' •  Incen.vize'providers'for'improving'pa.ent'provider' communica.on' •  Implement'appropriate'screening'and'evidence'based'care' for'all' •  Greater'diversity'in'the'mental'health'workforce'(African' Americans'and'La.nos'are'3e5%'of'psychiatrist'and' psychologists)' •  Culturally'appropriate'educa.on'for'providerseeduca.ng' providers'about'issues'in'minority'communi.es'' What'can'be'done'in'clinical'prac.ce' (skills'and'interven.ons)?' •  Try'to'address'service'use'barriers'as'early' as'possible'and'throughout'treatment' •  Engagement'interven.ons'are'a'part'of' culturally'competent'clinical'prac.ce' Engagement' Engagement'Interven.ons:' Review'(Munson'and'McKay,'2012)' !  13'RCTs'of'engagement'interven.ons' #  Pre'and'early'treatment'strategies' 1.  Appointment'reminders' 2.  Brief'interven.ons'to'address'interpersonal'and'prac.cal' barriers*' 3.  Family'engagement'approaches*' #  Con.nuous'strategies' 1.  Monetary'incen.ves'per'session' 2.  Structural'adapta.ons'and'addi.ons'(use'of'family'groups'and' paraprofessionals)' 3.  Adjunc.ve'family'support/case'management*' 4.  Mo.va.onal'interviewing*' * Favorable empirical support Engagement'for'inner'city'families' (McKay'et'al.,'1996;'1998;'2002)' •  Goals' 1.  Clarify'need'for'mental'health'care'and' what'is'mental'health'care' •  (perceived'need,'demys.fy'process=alliance)' 2.  Increase'caregiver'investment'and'efficacy' •  (reduce'selfeblame'and'unrealis.c'paren.ng' expecta.ons)' 3.  Iden.fy'awtudes'about'previous' experiences'with'mental'health'care'and' ins.tu.ons' •  (s.gma,'nega.ve'outcome'expectancies)' 4.  Problem'solve'around'concrete'obstacles' •  (transporta.on,'childcare,'.me,'compe.ng' priori.es'etc.')' Ac.ve'Problem'Solving' •  What'do'you'think'about'coming?' •  What'could'stand'in'the'way'of'gewng'here?*' •  How'are'you'going'to'get'here?' •  Who'are'you'going'to'bring?' •  How'will'people'feel'about'coming?*' •  What'.me'is'best'for'you?' •  Will'this'interfere'with'anything'else?*' •  How'comfortable'do'you'feel'talking'about'your'child s'needs?' •  How'hopeful'do'you'feel'that'this'will'help?* Telephone'Engagement'Design' •  Sewng:'Outpa.ent'child'mental' health'clinic'in'inner'city,'NYC' •  Par.cipants:'108'La.na'and'African' American'Mothers'' •  Design:'Random'assignment'' –  Telephone'engagement'interven.on' –  Business'as'usual =no'planned' engagement' •  Outcome' –  #'families'that'came'to'an'ini.al' appointment' Telephone'Engagement'Results' 100' 80' 72.7' 45.3' 60' 40' 20' 0' Engagement' Business'as'usual' Results 100' 90' 100' 100' 88' Attendance 80' 85' 76' 70' 64' 60' 52' 50' 40' 40' 30' 20' 10' 0' Accepted' 1st'appt' 2nd'appt' 3rd'appt' Engagement' Business'as' usual' Engagement for EBP-Parent Management Training !  RCT'of'a'brief'interven.on'for' increasing'par.cipa.on'in'Parent' Management'Training'(Nock'and' Kazdin,'2005)' !  N'='76'families' !  Mo.va.onal'interviewing'strategies' !  Reasons'for'change' !  Barriers'to'change' !  Expecta.ons'of'treatment' Conclusions' •  We'need'to'work'harder'to'engage'ethnic'minority' families'in'services' •  Poor'engagement'is'not'necessarily'a'reflec.on'of'a' client s' unwillingness'to'change ' •  Understand'barriers'are'unique'to'the'individual' –  Barriers'may'include'cultural'issues' •  Try'to'address'barriers'as'early'as'possible'' •  THIS!IS!A!FORM!OF!CULTURALLY!COMPETENT!CARE! ...
View Full Document

{[ snackBarMessage ]}

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern