Stigma in Mental Health at the Macro and Micro Levels: Implications for Mental Health Consumers and Professionals.

Despite increasing mental health promotion and advocacy, stigma persists and poses a significant threat to the healthy functioning at the macro and micro-sociological levels. Stigma is gradually evolving with the incorporation of broader social contexts at the micro and macro levels in which individuals, institutions and larger cultural constructs shape and influence the perception of what is different and therefore stigmatized. This theoretical paper based on literature underscores how mental health stigma discourages individuals from getting proper mental health treatment. The interface of mental illness, stigma, and mental health treatment has ethical and potentially moral implications.

Influence of critical illness on physicians' prognoses for underlying disease: a randomized study using simulated cases.

OBJECTIVE: During critical illness, physicians often provide estimates of the severity of underlying disease to aid patients and families when formulating care directives. We sought to determine whether factors such as the superimposed acute illness, the prognoses of other patients cared for by the same physician, or the phrasing of inquiry influence these assessments of underlying disease. DESIGN, SETTING, AND SUBJECTS: Internal medicine attending and resident physicians participated in a computerized, Web-available survey that described two case vignettes, one with cardiomyopathy and the other with lung cancer as underlying diseases. Using random assignment, each respondent was presented one case as having septic shock, and the other as an uneventful clinic visit. Respondents were explicitly asked to ignore the context and to assess the severity of the underlying disease alone to predict survival time and quality of life. The order in which subjects encountered the cases and phrasing of the survival question also were varied through randomization. MEASUREMENTS AND MAIN RESULTS: Mortality predictions for the cardiomyopathy case at 5 yrs were sensitive to both context (predicted survival, 39% +/- 23% when presented as septic vs. 52% +/- 24% when presented as a clinic patient; p < .001) and to whether a lung cancer case was presented before it (39% +/- 23% when presented after lung cancer vs. 52% +/- 24% when presented before; p < .001). These effects were independent and led to mean predicted 5-yr survival probabilities ranging from 31% to 59%. Predicted 1-yr survival from lung cancer was sensitive to phrasing (p < .05) but not to context. Quality of life predictions were also sensitive to context and case order. CONCLUSIONS: Physician appraisal of underlying disease severity is potentially vulnerable to a number of biases that may be relevant in the critical care setting. These biases appear to vary with the nature of the underlying disease.

Does Awareness of the Affordable Care Act Reduce Adverse Selection? A Study of the Long-term Uninsured in South Carolina.

Adverse selection predicts that individuals with lower health status would be more likely to sign up for health insurance. This hypothesis was tested among the long-term uninsured population in South Carolina (SC). This study used data from an in-person survey conducted from May 2014 to January 2015. Interviews were held with the long-term uninsured individuals at multiple sites throughout the state, using a multistage sampling method. SC residents aged 18 to 64 years who had had no health insurance for at least 24 consecutive months were eligible for the survey. The dependent variable is the participants' attempt to obtain insurance coverage. Key independent variables are self-reported health status, hospitalization in the past year, use of emergency department in the past year, and presence of serious long-standing health problems. The analysis is stratified by the awareness of the Affordable Care Act (ACA)'s individual mandate while controlling for age, gender, race/ethnicity, and household income. Participants' self-reported health status was not significantly associated with the attempt to sign up for health insurance in both groups (those aware and those unaware of the individual mandate). Being hospitalized in the previous year was significantly associated with their attempt to sign up for insurance in both groups. Participants with serious long-term health problems were more likely to have attempted to sign up for insurance among those who were not aware of the ACA. However, this association was statistically insignificant among those who had heard of ACA. Sicker people were more likely to attempt to sign up for insurance. However, being aware of the ACA's individual mandate seemed to play a role in reducing adverse selection.

Sources and barriers to health care coverage for Haitian immigrants in Miami-Dade county, Florida.

Haitian immigrants represent one of the largest foreign-born groups in Florida. Limited information is available on the health care issues that they face. This study's objective was to identify and evaluate the sources of and barriers to health care coverage for the Haitian immigrant community of Miami-Dade County, Florida. Information was collected on demographic characteristic and health needs and access from a probability sample of county residents of Haitian origin. Chi-square and logistic regression methods were used for data analysis. Only half of the participants had any type of health coverage, including 28% with private insurance and 15% with publicly financed coverage. Education, family income, U.S. citizenship status, length of U.S. residence, and English proficiency were associated with health coverage in bivariate analysis. Gender, citizenship, family income, and length of residence were also associated with coverage in adjusted analysis. These findings suggest that this community confronts serious access challenges that may negatively affect the health outcomes of Haitians in the U.S.

Chronic drug use and reproductive health care among low-income women in Miami, Florida: a comparative study of access, need, and utilization.

Interviews of low-income women in Miami, FL, addressed reproductive health issues in a stratified, network-referred sample of chronic drug users (CDUs) and socially and ethnically similar women who were not CDUs. Women who were not CDUs were significantly more likely to report a regular source of health care than CDUs. About one third of each group reported experiencing reproductive health problems (other than pregnancy) in the 12 months preceding their interview. Chronic drug users were twice as likely to report that these problems remained untreated. Measures of use of preventive services (physical exam, breast exam, pelvic exam, family planning visit) consistently showed lower use by CDUs. A higher proportion of women who were not CDUs reported pregnancies in the 12 months preceding interview. The 32 pregnant CDUs were much less likely to have received prenatal care than the 42 pregnant women who were not CDUs. For women who reported a pregnancy in the year preceding interview, logistic regression analysis showed a strong and robust negative effect of being a CDU on receiving prenatal care even when the effects of having a usual source of care and having third-party coverage were controlled.

Risk and protective factors for binge drinking among Hispanic subgroups in Florida.

This study examines differences in risk and protective factors for binge drinking among six ethnic/national subgroups of Hispanic adolescents in Florida. We note differences in the frequency of binge drinking by gender and ethnic subgroup as well as differences in the salience of items drawn from the five domains of risk and protective factors among these subgroups. Rather than treating all Hispanics as a unitary culture, tailoring of prevention programs to address risk and protective factors that differentially affect national/ethnic subgroups may be a valuable strategy when adolescents live in communities that are relatively homogenous in terms of nationality/ethnicity.

Psychosocial mediators of the impact of acculturation on adolescent substance abuse.

To identify and evaluate socio-psychological factors that are associated with differences in substance abuse prevalence between non-acculturated and acculturated Florida youth, we employed t-test and logistic regression to analyze self-reported data from 63,000 middle and high school student participants in the 2004 Florida Youth Substance Abuse Survey. Questionnaire items covered socio-demographics, tobacco, alcohol, and illicit substance use; and perceptions and attitudes toward drug use. The outcome variables were past 30 day use of "any illicit drug." The key independent variable was language used at home (English/Another language). The covariates were 32 socio-psychological factors that are considered risk and protective factors for adolescent drug abuse. Findings support the growing body of evidence suggesting that acculturation status is a strong predictor of substance use among adolescents. This effect may be mediated principally through the family and peer/individual psychosocial domains. The findings may have important implications for the design and implementation of drug prevention programs targeting teenagers.

Inhalant use in Florida youth.

PURPOSE: To determine (1) the prevalence of use, (2) risk and protective factors for use of inhalants in Florida youth. METHODS: The Florida Youth Substance Abuse Survey 2004 is a comprehensive assessment of youth substance abuse attitudes and practices obtained by sampling youth from sixty-five counties. RESULTS: The sample consisted of 60,345 students from 6th to 12th grade; ages 10 to 19 + years (mean 14.5 years +/- 4), 53% were female with 59% White, 19% African-American, 16% Hispanic, 5% Native American, 2% Asian and 7% other. Lifetime use was highest among 14 year olds (16.5%), and current use among 13 year olds (16.7%). Females had significantly (p < .000) higher rates than males for lifetime (14.2% vs. 12.7%) and current use (5.1% vs. 4.1%). Native Americans had the highest rates of lifetime use (17%) followed by Whites (15%), mixed/other (15%), Hispanics (14%), Asians (13%), and Blacks (9%). The younger the age of first use of alcohol, cigarettes and marijuana, the higher the lifetime and current prevalence of use of inhalants. Inhalant users were more likely to be depressed, acknowledge deviant behavior and skipping school, have lower grades, have siblings and friends who used illegal substances and parents with a history of antisocial behavior (p < .000). CONCLUSION: Inhalant use may be a marker for adolescents with a high-risk profile for subsequent illegal drug use. Prevention efforts should be directed to these students at an early age.

Utilization of preventive care by Haitian immigrants in Miami, Florida.

In order to evaluate the health needs and consequences of barriers to health care access for the Haitian immigrant community of Miami-Dade County, Florida, we collected in 2001 demographic and health needs and access data from a probability sample of county residents of Haitian origin. We computed frequencies and prevalence ratios, and employed chi-square and logistic regression methods for data analysis. Hypertension and diabetes were among the most prevalent health conditions mentioned. Up to 39% of participants failed to have an annual physical and 10% failed to receive care for their serious health conditions. On bivariate analysis, insurance coverage, a usual place of care, educational attainment, household income, citizenship status, and duration of residency were associated with services utilization. Citizenship status was the strongest independent predictor of services utilization. The findings suggest that this community faces distinct health needs and daunting challenges to meet those needs.

The CDRC principles of international health research.

The Comprehensive Drug Research Center (CDRC) at the University of Miami was established in the early 1970s. Through the decades, investigators from the CDRC have worked with investigators from several countries to establish joint research efforts. Countries often do not have the infrastructure or monetary resources to carry out research on their own. Collaborating with institutions in these countries to build a sustainable capacity for research is a worthwhile and satisfying endeavor, and it presents a method for initiating research and building the necessary research structures. However, working with other countries presents a unique set of challenges and ethical dilemmas. This article presents some of the specific challenges encountered in these research efforts and describes what we have done to resolve the problems and work more effectively and efficiently with foreign investigators.