Differential Engagement by Race/Ethnicity in Experimental Trials of Mental Health Treatment Interventions: A Systematic Review.

Objective: Research on mental health interventions, largely from observational studies, suggests that individuals who are Black, Indigenous, and People of Color (BIPOC) have lower treatment engagement than non-Latino Whites. This systematic review focuses on prospective, experimental treatment trials, which reduce variability in patient and intervention characteristics and some access barriers (eg, cost), to examine the association of race/ethnicity and engagement.Data Sources: A systematic search of PubMed and PsycINFO through May 2020 using terms covering mental health treatment, engagement, and race/ethnicity.Study Selection: US-based, English-language, prospective experimental (including quasi-experimental) trials of adults treated for DSM-defined mental disorders were included. Studies had to compare engagement (treatment initiation and retention, medication adherence) across 2 or more ethnoracial groups. Fifty-five of 2,520 articles met inclusion criteria.Data Extraction: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Collaboration bias-risk assessment tool were used to report study findings.Results: Twenty-nine articles (53%) reported significant ethnoracial engagement differences, of which 93% found lower engagement among BIPOC groups compared largely to non-Latino Whites. The proportion of significant findings was consistent across quality of studies, covariate adjustments, ethnoracial groups, disorders, treatments, and 4 engagement definitions. Reporting limitations were found in covariate analyses and disaggregation of results across specific ethnoracial groups.Conclusions: Prospective experimental treatment trials reveal consistently lower BIPOC engagement, suggesting persisting disparities despite standardized study designs. Future research should improve inclusion of understudied groups, examine covariates systematically, and follow uniform reporting and analytic practices to elucidate reasons for these disparities.

Racial/Ethnic Disparities in Substance Use Treatment in Medicaid Managed Care in New York City: The Role of Plan and Geography.

OBJECTIVE: The aim was to assess the magnitude of health care disparities in treatment for substance use disorder (SUD) and the role of health plan membership and place of residence in observed disparities in Medicaid Managed Care (MMC) plans in New York City (NYC). DATA SOURCE: Medicaid claims and managed care plan enrollment files for 2015-2017 in NYC. RESEARCH DESIGN: We studied Medicaid enrollees with a SUD diagnosis during their first 6 months of enrollment in a managed care plan in 2015-2017. A series of linear regression models quantified service disparities across race/ethnicity for 5 outcome indicators: treatment engagement, receipt of psychosocial treatment, follow-up after withdrawal, rapid readmission, and treatment continuation. We assessed the degree to which plan membership and place of residence contributed to observed disparities. RESULTS: We found disparities in access to treatment but the magnitude of the disparities in most cases was small. Plan membership and geography of residence explained little of the observed disparities. One exception is geography of residence among Asian Americans, which appears to mediate disparities for 2 of our 5 outcome measures. CONCLUSIONS: Reallocating enrollees among MMC plans in NYC or evolving trends in group place of residence are unlikely to reduce disparities in treatment for SUD. System-wide reforms are needed to mitigate disparities.

Oral Health-Related Quality of Life Among Publicly Insured Mental Health Service Outpatients With Serious Mental Illness.

OBJECTIVE: The study investigated factors associated with unmet need for dental care and oral health-related quality of life (OHQoL) among individuals with serious mental illness receiving outpatient care in a public mental health program serving a largely low-income population, mostly from racial-ethnic minority groups. METHODS: Cross-sectional interview data were collected from a convenience sample (N=150) of outpatients. Adjusted risk ratios (ARRs) and adjusted risk differences (ARDs) were estimated by logistic regression models to examine the independent contribution of sociodemographic and clinical factors to low OHQoL and past-year unmet dental need, defined as inability to obtain all needed dental care. RESULTS: More than half of participants reported low OHQoL (54%) and a past-year dental visit (61%). Over one-third (39%) had past-year unmet dental need. Financial barriers (ARR=3.16) and nonfinancial barriers (ARR=2.18) were associated with greater risk for past-year unmet dental need after control for age, gender, high dental anxiety, and limited English proficiency. ARDs for financial and nonfinancial barriers indicated absolute differences of 40 and 27 percentage points, respectively. Unmet dental need (ARR=1.31), xerostomia severity (ARR=1.20), and a schizophrenia spectrum diagnosis (ARR=1.33) were associated with low OHQoL, after control for age and current smoking, with ARDs ranging from 11 to 15 percentage points. CONCLUSIONS: Improving oral health promotion, oral health service access, and the integration of the mental and oral health systems may help reduce the high prevalence of low OHQoL in this population, given that low OHQoL is partly driven by unmet dental need.

Disparities in perceived unmet need for supportive services among patients with lung cancer in the Cancer Care Outcomes Research and Surveillance Consortium.

BACKGROUND: The authors investigated the prevalence, determinants of, and disparities in any perceived unmet need for 8 supportive services (home nurse, support group, psychological services, social worker, physical/occupational rehabilitation, pain management, spiritual counseling, and smoking cessation) by race/ethnicity and nativity and how it is associated with perceived quality of care among US patients with lung cancer. METHODS: Data from a multiregional, multihealth system representative cohort of 4334 newly diagnosed patients were analyzed. Binomial logistic regression models adjusted for patient clustering. RESULTS: Patients with any perceived unmet need (9% overall) included 7% of white-US-born (USB), 9% of white-foreign-born (FB), 13% of black-USB, 8% of Latino-USB, 24% of Latino-FB, 4% of Asian/Pacific Islander (API)-USB, 14% of API-FB, and 11% of "other" patients (P < .001). Even after controlling for demographic and socioeconomic factors, health system and health care access, and need, black-USB, Latino-FB, and Asian-FB patients were more likely to perceive an unmet need than white-USB patients by 5.1, 10.9, and 5.6 percentage points, respectively (all P < .05). Being younger, female, never married, uninsured, a current smoker, or under surrogate care or having comorbidity, anxiety/depression, or a cost/insurance barrier to getting tests/treatments were associated with any unmet need. Patients with any unmet need were more likely to rate care as less-than-"excellent" by 13 percentage points than patients with no unmet need (P < .001). CONCLUSIONS: Significant disparities in unmet supportive service need by race/ethnicity and nativity highlight immigrants with lung cancer as being particularly underserved. Eliminating disparities in access to needed supportive services is essential for delivering patient-centered, equitable cancer care.

Mental health service use from a religious or spiritual advisor among Asian Americans.

BACKGROUND: Asian Americans experience significant underuse of mental health treatment. Religious clergy and spiritual advisors play a critical role in delivering mental health care in the United States. Limited knowledge exists about their use among Asian Americans. OBJECTIVE: We describe mental health service use from a religious/spiritual advisor among Asian Americans. METHODS: We analyzed data from 2095 respondents in the 2002-2003 National Latino and Asian American Study. RESULTS: Lifetime and 12-month prevalence of mental health service use from a religious/spiritual advisor (5.5% and 1% overall, respectively) was generally higher among U.S.-born Asians and those with a 12-month mental disorder (23.6% and 7.5%, respectively). Religious/spiritual advisors were seen by 35% of treatment-seeking Asian Americans with a lifetime mental disorder. They were seen as commonly as psychiatrists but less commonly than a mental health specialist or general medical provider. Approximately 70% of those seeking treatment had a mental disorder, significant proportions of whom sought treatment in the absence of a psychiatrist, a mental health specialist or even a healthcare provider. A significant majority with 12-month use perceived the care as helpful, felt accepted/understood and satisfied (71-86%). However, only 31% rated the care as excellent, 28% quit completing care, and referral rates for specialty mental health treatment were low, even among those with a mental disorder (9.5%). CONCLUSIONS: Religious/spiritual advisors are a key source of treatment-seeking for Asian Americans with a mental disorder. Quality of care and low referral rates for specialty mental health treatment warrant further attention and need for increased collaboration with the mental health system.

Nativity and occupational class disparities in uninsurance and routine preventive care use among Asian Americans.

Using data from 1,530 Asian respondents of the 2002-2003 National Latino and Asian American Study, we examined how nativity and occupational class are associated with uninsurance, no routine physical check-up in the past year and no dental/eye exam use in the past year using weighted multivariate logistic regression models. Recent immigrants had increased odds of uninsurance and no dental/eye exam use than US-born Asians which became nonsignificant after controlling for occupational class and covariates. Unemployed and service workers had increased odds of uninsurance than white-collar workers even after controlling for income and limited English proficiency (LEP). Approximately 35-40 % of blue-collar and service workers reported neither type of preventive care use. Even after controlling for LEP, income, uninsurance, having a regular doctor or place of care, service workers had significantly increased odds of no physical check-up and no dental/eye exam use and blue-collar workers had marginally significant increased odds of no dental/eye exam use. Significant occupational disparities exist in access and preventive care use with workers in service occupations being particularly underserved.

Does an immigrant health paradox exist among Asian Americans? Associations of nativity and occupational class with self-rated health and mental disorders.

A robust socioeconomic gradient in health is well-documented, with higher socioeconomic status (SES) associated with better health across the SES spectrum. However, recent studies of U.S. racial/ethnic minorities and immigrants show complex SES-health patterns (e.g., flat gradients), with individuals of low SES having similar or better health than their richer, U.S.-born and more acculturated counterparts, a so-called "epidemiological paradox" or "immigrant health paradox". To examine whether this exists among Asian Americans, we investigate how nativity and occupational class (white-collar, blue-collar, service, unemployed) are associated with subjective health (self-rated physical health, self-rated mental health) and 12-month DSM-IV mental disorders (any mental disorder, anxiety, depression). We analyzed data from 1530 Asian respondents to the 2002-2003 National Latino and Asian American Study in the labor force using hierarchical multivariate logistic regression models controlling for confounders, subjective social status (SSS), material and psychosocial factors theorized to explain health inequalities. Compared to U.S.-born Asians, immigrants had worse socioeconomic profiles, and controlling for age and gender, increased odds for reporting fair/poor mental health and decreased odds for any DSM-IV mental disorder and anxiety. No strong occupational class-health gradients were found. The foreign-born health-protective effect persisted after controlling for SSS but became nonsignificant after controlling for material and psychosocial factors. Speaking fair/poor English was strongly associated with all outcomes. Material and psychosocial factors were associated with some outcomes--perceived financial need with subjective health, uninsurance with self-rated mental health and depression, social support, discrimination and acculturative stress with all or most DSM-IV outcomes. Our findings caution against using terms like "immigrant health paradox" which oversimplify complex patterns and mask negative outcomes among underserved sub-groups (e.g., speaking fair/poor English, experiencing acculturative stress). We discuss implications for better measurement of SES and health given the absence of a gradient and seemingly contradictory finding of nativity-related differences in self-rated health and DSM-IV mental disorders.

Research on discrimination and health: an exploratory study of unresolved conceptual and measurement issues.

OBJECTIVES: Our goal in this study was to better understand racial and socioeconomic status (SES) variations in experiences of racial and nonracial discrimination. METHODS: We used 1999 and 2000 data from the YES Health Study, which involved a community sample of 50 Black and 50 White respondents drawn from 4 neighborhoods categorized according to racial group (majority Black or majority White) and SES (≤ 150% or > 250% of the poverty line). Qualitative and quantitative analyses examined experiences of discrimination across these neighborhoods. RESULTS: More than 90% of Blacks and Whites described the meaning of unfair treatment in terms of injustice and felt certain about the attribution of their experiences of discrimination. These experiences triggered similar emotional reactions (most frequently anger and frustration) and levels of stress across groups, and low-SES Blacks and Whites reported higher levels of discrimination than their moderate-SES counterparts. CONCLUSIONS: Experiences of discrimination were commonplace and linked to similar emotional responses and levels of stress among both Blacks and Whites of low and moderate SES. Effects were the same whether experiences were attributed to race or to other reasons.

Using a Spanish surname match to improve identification of Hispanic women in Medicare administrative data.

OBJECTIVE: To assess the effectiveness of a Spanish surname match for improving the identification of Hispanic women in Medicare administrative data in which Hispanics are historically underrepresented. DATA SOURCES: We collected self-identified race/ethnicity data (N=2,997) from a mailed survey sent to elderly Medicare beneficiaries who resided in 11 geographic areas consisting of eight metropolitan counties and three nonmetropolitan areas (171 counties) in the fall of 2004. The 1990 Census Spanish Surname list was used to identify Hispanics in the Medicare data. In addition, we used data published on the U.S. Census Bureau website to obtain estimates of elderly Hispanics. STUDY DESIGN: We used self-identified race/ethnicity as the gold standard to examine the agreement with Medicare race code alone, and with Medicare race code+Spanish surname match. Additionally, we estimated the proportions of Hispanic women and men, in each of the 11 geographic areas in our survey, using the Medicare race code alone and the Medicare race code+Spanish surname match, and compared those estimates with estimates derived from U.S. Census 2000 data. PRINCIPAL FINDINGS: The Spanish surname match dramatically increased the accuracy of the Medicare race code for identifying both Hispanic and white women, producing improvements comparable with those seen for men. CONCLUSIONS: We recommend the addition of a proxy race code in the Medicare data using the Spanish surname match to improve the accuracy of racial/ethnic representation.To assess the effectiveness of a Spanish surname match for improving the identification of Hispanic women in Medicare administrative data in which Hispanics are historically underrepresented. We collected self-identified race/ethnicity data (N=2,997) from a mailed survey sent to elderly Medicare beneficiaries who resided in 11 geographic areas consisting of eight metropolitan counties and three nonmetropolitan areas (171 counties) in the fall of 2004. The 1990 Census Spanish Surname list was used to identify Hispanics in the Medicare data. In addition, we used data published on the U.S. Census Bureau website to obtain estimates of elderly Hispanics. We used self-identified race/ethnicity as the gold standard to examine the agreement with Medicare race code alone, and with Medicare race code+Spanish surname match. Additionally, we estimated the proportions of Hispanic women and men, in each of the 11 geographic areas in our survey, using the Medicare race code alone and the Medicare race code+Spanish surname match, and compared those estimates with estimates derived from U.S. Census 2000 data. The Spanish surname match dramatically increased the accuracy of the Medicare race code for identifying both Hispanic and white women, producing improvements comparable with those seen for men. We recommend the addition of a proxy race code in the Medicare data using the Spanish surname match to improve the accuracy of racial/ethnic representation.

Medicare beneficiary knowledge: measurement implications from a qualitative study.

Medicare beneficiary knowledge about fee-for-service (FFS) Medicare versus managed care alternatives (MCA) has been studied extensively. However, these efforts might be compromised by lack of familiarity with common Medicare terminology. We used qualitative methods to examine beneficiaries' familiarity with Medicare Programs (FFS and MCA) and terminology. Twenty-one indepth, semi-structured beneficiary interview transcripts were analyzed through iterative review. Across sex, race/ethnicity, and benefits programs, participants found interview questions with Medicare terminology difficult to answer, potentially causing missing, incorrect, and inaccurate responses to interview questions. Assessment of beneficiary knowledge may be fundamentally impacted by absence of basic familiarity with Medicare Programs terminology.