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.

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.

The long-term effects of childhood maltreatment experiences on subsequent illicit drug use and drug-related problems in young adulthood.

OBJECTIVES: The objective of this study was to examine the associations between (a) childhood maltreatment (i.e., physical abuse, sexual abuse, and neglect) and subsequent illicit drug use and (b) childhood maltreatment and drug-related problems in young adulthood. METHODS: Wave 1 and Wave 3 public-use data from the National Longitudinal Study of Adolescent Health were used. Logistic regressions, controlling for adolescent drug use and other important family and peer contextual processes, were estimated to determine the associations between (a) childhood maltreatment experiences and subsequent illicit drug use and (b) childhood maltreatment and drug-related problems in young adulthood. RESULTS: Among the participants, 31.9% reported some form of childhood maltreatment. Childhood physical abuse was associated with a 37% (OR=1.37; 95% CI=1.04, 1.80) increase in illicit drug use during the 30 days prior to the Wave 3 survey, a 48% (OR=1.48; 95% CI=1.16, 1.89) increase in illicit drug use during the year prior to the Wave 3 survey, and a 96% (OR=1.96; 95% CI=1.40, 2.76) increase in drug-related problems in young adulthood. The latter two associations persisted even after controlling for illicit drug use in adolescence. Neglect among females was associated with a higher likelihood of past year illicit drug use in young adulthood (OR=1.31; 95% CI=1.002, 1.71). However, this association was not significant once the effect of illicit drug use in adolescence was statistically controlled for. CONCLUSIONS: The present findings suggest that childhood maltreatment is related to subsequent illicit drug use and drug-related problems in young adulthood and that some of these associations differ by gender. Implications for preventive intervention are discussed.

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.

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.

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.

The relationship between nutritional and sociodemographic factors and the likelihood of children in the Dominican Republic having a BCG scar.

OBJECTIVES: To critically assess the prevalence among schoolchildren 6 to 9 years of age throughout the Dominican Republic of a bacille Calmette-Guérin (BCG) vaccination scar, and to examine the relationship between nutritional and sociodemographic factors and the likelihood of having a BCG scar. METHODS: This correlational study used the database of the Second National Census on Height and Weight of Elementary School First Grade Students, which was conducted in the Dominican Republic August 2001-May 2002, to provide a critical assessment of BCG coverage nationwide. The Census information for the children included the presence of BCG scar, their nutritional status, and basic demographic data. We developed a new sociodemographic indicator, the "Rosa Index," to examine the potential influence of poverty and other environmental characteristics on scar presence. We used logistic regression models to predict the presence of a BCG scar. RESULTS: An overall BCG scar prevalence of 55.3% (85,644/154,887) was found. Malnourished children were less likely to have a BCG scar than were children with adequate nutritional status (odds ratio = 0.91; 95% confidence interval: 0.87, 0.95, P < 0.05). Children who were 7-9 years old were less likely to have a BCG scar than were children 6 years old. Children in the areas of the country more than two hours' driving distance from the capital city of Santo Domingo more often exhibited lower BCG scar prevalence levels than did children in Santo Domingo. A higher Rosa Index (better level of socioeconomic characteristics) was correlated with higher BCG scar prevalence values (r = 0.54, P < 0.05). CONCLUSIONS: Our study findings indicate that BCG coverage appears to be inadequate for schoolchildren in the Dominican Republic. Nevertheless, the presence of a scar in a higher proportion of younger children suggests that coverage has improved in recent years. More programmatic and economic emphasis needs to be placed on extending early BCG vaccination coverage to the areas of the country where vaccination coverage is lower, and on examining the potential role that poverty may have on vaccination effectiveness.

The relationship between nutritional and sociodemographic factors and the likelihood of children in the Dominican Republic having a BCG scar

OBJECTIVES: To critically assess the prevalence among schoolchildren 6 to 9 years of age throughout the Dominican Republic of a bacille Calmette-Guérin (BCG) vaccination scar, and to examine the relationship between nutritional and sociodemographic factors and the likelihood of having a BCG scar. METHODS: This correlational study used the database of the Second National Census on Height and Weight of Elementary School First Grade Students, which was conducted in the Dominican Republic August 2001-May 2002, to provide a critical assessment of BCG coverage nationwide. The Census information for the children included the presence of BCG scar, their nutritional status, and basic demographic data. We developed a new sociodemographic indicator, the "Rosa Index," to examine the potential influence of poverty and other environmental characteristics on scar presence. We used logistic regression models to predict the presence of a BCG scar. RESULTS: An overall BCG scar prevalence of 55.3 percent (85 644/154 887) was found. Malnourished children were less likely to have a BCG scar than were children with adequate nutritional status (odds ratio = 0.91; 95 percent confidence interval: 0.87, 0.95, P < 0.05). Children who were 7-9 years old were less likely to have a BCG scar than were children 6 years old. Children in the areas of the country more than two hours' driving distance from the capital city of Santo Domingo more often exhibited lower BCG scar prevalence levels than did children in Santo Domingo. A higher Rosa Index (better level of socioeconomic characteristics) was correlated with higher BCG scar prevalence values (r = 0.54, P < 0.05). CONCLUSIONS: Our study findings indicate that BCG coverage appears to be inadequate for schoolchildren in the Dominican Republic. Nevertheless, the presence of a scar in a higher proportion of younger children suggests that coverage has improved in recent years. More programmatic and economic emphasis needs...

OBJETIVOS: Evaluar críticamente la prevalencia de cicatrices por la vacunación con el bacilo de Calmette-Guérin (BCG) en niños de 6 a 9 años de la República Dominicana y examinar la relación entre los factores nutricionales y socioeconómicos y la probabilidad de tener cicatriz de BCG. MÉTODOS: Para este estudio correlacional se empleó la base de datos del II Censo Nacional de Talla y Peso en Escolares de Primer Grado de Básica, realizado en la República Dominicana entre agosto de 2001 y mayo de 2002, para evaluar críticamente el nivel de cobertura nacional de la vacunación con BCG. Entre la información censal de los niños estaban si tenían cicatriz de BCG, su estado nutricional y sus datos demográficos básicos. Se desarrolló un nuevo indicador sociodemográfico, el "índice de Rosa", para analizar la posible influencia de la pobreza y de otras características ambientales en la presencia de esa cicatriz. Se emplearon modelos de regresión logística para predecir la presencia de la cicatriz de BCG. RESULTADOS: La prevalencia general de cicatrices de BCG fue de 55,3 por ciento (85 644/ 154 887). Los niños desnutridos presentaron una menor probabilidad de tener cicatriz de BCG que los niños con un adecuado estado nutricional (razón de posibilidades = 0,91; intervalo de confianza de 95 por ciento: 0,87 a 0,95; P < 0,05). Los niños de 7-9 años tuvieron menor probabilidad de tener cicatriz de BCG que los niños de 6 años. Los niños de zonas del país que se encuentran a más de dos horas de viaje de Santo Domingo, la capital, presentaron menor prevalencia de cicatrices de BCG con mayor frecuencia que los niños de Santo Domingo. Se encontró correlación entre tener un mayor índice de Rosa (mejor nivel en las características socioeconómicas) y una mayor prevalencia de cicatrices de BCG (r = 0,54; P < 0,05). CONCLUSIONES: Los resultados del presente estudio indican que la cobertura de vacunación de escolares con la vacuna BCG parece no ser la adecuada...

The relationship between nutritional and sociodemographic factors and the likelihood of children in the Dominican Republic having a BCG scar

OBJECTIVE: To critically assess the prevalence among schoolchildren 6 to 9 years of age throughout the Dominican Republic of a bacille Calmette-Guerin (BCG) vaccination scar, and to examine the relationship between nutritional and sociodemographic factors and the likelihood of having a BCG scar. METHODS: This correlational study used the database of the Second National Census on Height and Weight of Elementary School First Grade Students, which was conducted in the Dominican Republic August 2001-May 2002, to provide a critical assessment of BCG coverage nationwide. The Census information for the children included the presence of BCG scar, their nutritional status, and basic demographic data. We developed a new sociodemographic indicator, the "Rosa Index", to examine the potential influence of poverty and other environmental characteristics on scar presence. We used logistic regression models to predict the presence of a BCG scar. RESULTS: An overall BCG scar prevalence of 55.3 percent (85 644/154 887)was found. Malnourished children were less likely to have a BCG scar than were children with adequate nutritional status (odds ratio = 0.91; 95 percent confidence interval: 0.87, 0.95, P<0.05). Children who were 7-9 years old were less likely to have a BCG scar than were children 6 years old. Children in the areas of the country more than two hours' driving distance from the capital city of Santo Domingo more often exhibited lower BCG scar prevalence levels than did children in Santo Domingo. A higher Rosa Index (better level of socioeconomic characteristics) was correlated with higher BCG scar prevalence values (r=0.54, P<0.05). CONCLUSIONS: Our study findings indicate that BCG coverage appears to be inadequate for schoolchildren in the Dominican Republic. Nevertheless, the presence of a scar in a higher proportion of younger children suggests that coverage has improved in recent years. More programmatic and economic emphasis needs to be placed on extending early BCG vaccination coverage to the areas of the country where vaccination coverage is lower, and on examining the potential role that poverty may have on vaccination effectiveness (AU)

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.

Prenatal care utilization in rural areas and urban areas of Haiti.

OBJECTIVES: This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Haiti. Using the DHS information on women aged 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2) for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. METHODS: The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. RESULTS: Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16%, compared to 85.83% in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 prenatal care visits, compared to 5.06 visits for the women in urban areas. CONCLUSIONS: A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centers in rural areas constituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti.

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.

Prenatal care utilization in rural areas and urban areas of Haiti

OBJETIVOS: El presente estudio se basa en la Encuesta de Demografía y Salud del año 2000 en Haití. Los objetivos del estudio, que se basó en información sobre las mujeres de 15 a 49 años de edad que habían dado a luz en los tres años anteriores a la entre-vista, fueron: 1) examinar los factores que determinan la probabilidad de que las mu-jeres acudan a atención prenatal en las zonas rurales y urbanas del país y 2) dentro del grupo de mujeres con una o más consultas prenatales, examinar los factores que determinan el número de dichas consultas en las zonas rurales y urbanas.MÉTODOS: En el análisis multifactorial se emplearon modelos logísticos para deter-minar qué factores explicaban la decisión de acudir a control prenatal, y se usaron modelos binomiales negativos para determinar el número de consultas prenatales dentro del subgrupo de mujeres que consultaron por lo menos una vez.RESULTADOS: La probabilidad esperada de acudir a control prenatal, determinada según el valor medio de las variables de control, fue de 77,16% en las zonas rurales, en comparación con 85,83% en las zonas urbanas de Haití. Dentro del grupo de mu-jeres que acudieron a servicios de control prenatal, las madres en zonas rurales tuvieron un número esperado de consultas prenatales de 3,78, en comparación con 5,06 en las zonas urbanas. CONCLUSIONES: Un buen porcentaje de mujeres embarazadas tiene acceso a servicios de atención prenatal en Haití, pero las madres en zonas rurales que eligieron acudir a dichos servicios tuvieron un poco menos del mínimo de cuatro consultas recomendado por la Organización Mundial de la Salud. El nivel educativo de las madres y de sus parejas es un factor pronóstico muy importante en relación con el uso de servicios de atención prenatal. Las consultas repetidas se vieron obstaculizadas en las zonas rurales por el mayor tiempo de desplazamiento y la mayor distancia hasta el centro de salud. Los formuladores de políticas y los proveedores de atención sanitaria deben tener en cuenta estos resultados a la hora de tomar decisiones sobre la prestación y administración de los servicios de salud en Haití.

Prenatal care utilization in rural areas and urban areas of Haiti

OBJECTIVES: This study is based on the 2000 Demographic and Health Survey (DHS) conducted in Haiti. Using the DHS information on women ages 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2) for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. METHODS: The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did make prenatal care visits. RESULTS: Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16 percent, compared to 85.83 percent in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 percent prenatal care visits, compared to 5.06 visits for the women in urban areas. CONCLUSIONS: A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centers in rural areas consituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti (AU)

Prenatal care utilization in rural areas and urban areas of Haiti

OBJECTIVES: This study is based on the 2000 Demograpic Health Survey (DHS) conducted in Haiti. Using the DHS information on women aged 15 to 49 who had given birth during the three years preceding the survey interview, this study was intended to: (1) examine the determinants of the likelihood of the women using prenatal care in the rural areas and in the urban areas of the country and (2)for the women who made at least one prenatal care visit, examine the determinants of the number of prenatal visits in the rural areas and the urban areas. METHODS: The multivariate analysis used logistic models to identify which factors explained the decision to seek prenatal care, and negative binomial models were used to determine how many prenatal visits were conducted by the subgroup of women who did not make prenatal care visits. RESULTS: Estimated at the mean values of the control variables, the expected probability of using prenatal care services in rural Haiti was 77.16 percent, compared to 85.83 percent in urban Haiti. Among users of prenatal care services, mothers in rural areas made an expected number of 3.78 prenatal care visits, compared to 5.06 visits for the women in urban areas. CONCLUSIONS: A substantial percentage of pregnant women have access to prenatal care services in Haiti, but mothers in rural areas who decided to seek care still fell slightly below the four visits recommended by the World Health Organization. The education levels of both mothers and and their partners is a dominant predictor of prenatal care use. Longer travel times and greater distances to health centres in rural areas constituted barriers to repeated visits. Policymakers and health care providers need to take these findings into consideration as they decide on the delivery and management of health care services in Haiti(AU)

The Florida Clergy End-of-Life Education Enhancement Project: a description and evaluation.

The Florida Clergy End-of-Life Education Enhancement Project was a model program developed to provide an interdenominational and statewide model of clergy education on loss, grief dying, and death. The authors describe the project including materials and curriculum as well as present data from the project's evaluation. Clergy and their partners in ministry responded enthusiastically to the project. As a whole, they reported higher levels of knowledge on end-of-life (EOL) issues at the conclusion of the training. Clergy and their ministerial teams also reported that they were better informed about the technical, procedural, medical, and legal issues that arise at the end of life and expressed the desire for subsequent training. The project indicates that clergy both recognize the need for additional training and are anxious to improve their abilities to minister to the dying and bereaved. The model presented here could easily be applied to local organizations such as hospices or denominational training.

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.