Residential segregation, geographic proximity and type of services used: evidence for racial/ethnic disparities in mental health

The Role of Proximity to Coordinated Specialty Care For Early Psychosis And Program Engagement in Washington State: The Interaction of Travel Time, Race, and Ethnicity

OBJECTIVE

Proximity to mental health services is a predictor of timely access to services. The present study sought to investigate whether travel time was associated with engagement in coordinated specialty care (CSC) for early psychosis, with specific attention to whether the interaction of travel time by race and ethnicity had differential impact.

DATA SOURCE/STUDY SETTING

Data collected between 2019 and 2022 as part of the New Journeys evaluation, the CSC model in Washington State.

STUDY DESIGN

This cross-sectional study included a sample of 225 service users with first episode psychosis (FEP) who had received services from New Journeys.

DATA COLLECTION

Service users' addresses, and the physical location of CSC were geocoded. Spatial proximity was calculated as travel time in minutes. Scheduled appointments, attendance and program status were captured monthly by clinicians as part of the New Journeys measurement battery.

PRINCIPAL FINDINGS

Proximity was significantly associated with the number of appointments scheduled and attended, and program status (graduation/completion and disengagement). Among Hispanic service users with spatial proximity further away from CSC (longer commutes) was associated with a lower likelihood of graduating/completing CSC compared to non-Hispanic service users (p = .04). Non-white services users had a higher risk of disengagement from CSC compared to white service users (p = .03); additionally, the effects of spatial proximity on disengagement were amplified for non-White service users (p = .03).

CONCLUSIONS

Findings suggest that proximity is associated with program engagement and partially explains potential differences in program status among ethnoracial group.

Association of geographical disparities and segregation in regional treatment facilities for Black patients with aneurysmal subarachnoid hemorrhage in the United States

Background and objectives

This study investigates geographic disparities in aneurysmal subarachnoid hemorrhage (aSAH) care for Black patients and aims to explore the association with segregation in treatment facilities. Understanding these dynamics can guide efforts to improve healthcare outcomes for marginalized populations.

Methods

This cohort study evaluated regional differences in segregation for Black patients with aSAH and the association with geographic variations in disparities from 2016 to 2020. The National Inpatient Sample (NIS) database was queried for admission data on aSAH. Black patients were compared to White patients. Segregation in treatment facilities was calculated using the dissimilarity (D) index. Using multivariable logistic regression models, the regional disparities in aSAH treatment, functional outcomes, mortality, and end-of-life care between Black and White patients and the association of geographical segregation in treatment facilities was assessed.

Results

142,285 Black and White patients were diagnosed with aSAH from 2016 to 2020. The Pacific division (D index = 0.55) had the greatest degree of segregation in treatment facilities, while the South Atlantic (D index = 0.39) had the lowest. Compared to lower segregation, regions with higher levels of segregation (global F test p < 0.001) were associated a lower likelihood of mortality (OR 0.91, 95% CI 0.82-1.00, p = 0.044 vs. OR 0.75, 95% CI 0.68-0.83, p < 0. 001) (p = 0.049), greater likelihood of tracheostomy tube placement (OR 1.45, 95% CI 1.22-1.73, p < 0.001 vs. OR 1.87, 95% CI 1.59-2.21, p < 0.001) (p < 0. 001), and lower likelihood of receiving palliative care (OR 0.88, 95% CI 0.76-0.93, p < 0.001 vs. OR 0.67, 95% CI 0.59-0.77, p < 0.001) (p = 0.029).

Conclusion

This study demonstrates regional differences in disparities for Black patients with aSAH, particularly in end-of-life care, with varying levels of segregation in regional treatment facilities playing an associated role. The findings underscore the need for targeted interventions and policy changes to address systemic healthcare inequities, reduce segregation, and ensure equitable access to high-quality care for all patients.

Inequities in Mental Health Services: A 16-Year Longitudinal Study of Youth in the Justice System

OBJECTIVE

To examine: (1) if youth who have mental health disorders receive needed services after they leave detention-and as they age; and (2) inequities in service use, focusing on demographic characteristics and type of disorder.

METHOD

We used data from the Northwestern Juvenile Project, a longitudinal study of 1,829 youth randomly sampled from detention in Chicago, Illinois in 1995. Participants were re-interviewed up to 13 times through 2015. Interviewers assessed disorders using structured diagnostic interviews and assessed service use using the Child and Adolescent Service Assessment and the Services Assessment for Children and Adolescents.

RESULTS

Less than 20% of youth who needed services received them, up to median age 32 years. Female participants with any disorder had nearly twice the odds of receiving services compared with male participants (OR: 1.82; 95% CI: 1.41, 2.35). Compared with Black participants with any disorder, non-Hispanic White and Hispanic participants had 2.14 (95% CI: 1.57, 2.90) and 1.50 (95% CI: 1.04, 2.15) times the odds of receiving services. People with a disorder were more likely to receive services during childhood (< age 18) than during adulthood (OR: 2.29; 95% CI: 1.32, 3.95). Disorder mattered: participants with an internalizing disorder had 2.26 times and 2.43 times the odds of receiving services compared with those with a substance use disorder (respectively, 95% CI: 1.26, 4.04; 95% CI: 1.49, 3.97).

CONCLUSION

Few youth who need services receive them as they age; inequities persist over time. We must implement evidence-based strategies to reduce barriers to services.

Racial and ethnic trends in mental health service utilisation and perceived unmet need in the USA

BACKGROUND

Two decades ago, the Surgeon General issued a report highlighting concerning disparities in mental healthcare among racial and ethnic minority populations. The present study characterised national trends in mental health treatment utilisation by race and ethnicity across a 13-year period.

METHODS

Nationally representative data were drawn from the National Survey on Drug Use and Health from 2008 through 2020 (unweighted n=4 41 993). Trends in mental health treatment utilisation and perceived unmet treatment need among individuals with and without psychiatric illness were stratified by race and ethnicity.

RESULTS

Logistic regression analyses revealed most racial/ethnic minority groups were less likely to receive treatment than white individuals, regardless of mental health status. Treatment utilisation increased among those with (annual per cent change (APC)=0.83, 95% CI=0.41 to 1.26) and without psychiatric illness (APC=1.39, 95% CI=0.53 to 2.26). Among individuals with psychiatric illness, treatment use increased among white (APC=0.88, 95% CI=0.51 to 1.24), Hispanic (APC=2.12, 95% CI=0.70 to 3.57) and black adults (APC=1.07, 95% CI=0.11 to 2.04). White (APC=1.88, 95% CI=0.86 to 2.91) and Hispanic (APC=2.45, 95% CI=0.02 to 4.93) individuals without psychiatric illness also saw increased treatment use. Although increases in perceived unmet treatment need were observed for all racial and ethnic groups except blacks and Native Americans with psychiatric illness, rates remained low across all groups.

CONCLUSIONS

Although national rates of mental health treatment utilisation have risen, this was almost entirely observed among white and Hispanic individuals with and without psychiatric illness, highlighting the limited progress made towards eliminating disparities in care.

The Impact of Neighborhood-Level Factors on Perceived Quality of Hospice Service Satisfaction: A Geographic Information System Study

Racial/ethnic minorities are underrepresented in hospice care in the United States, despite this being the standard of care for terminally ill individuals. Research indicates that location of services (e.g., rural vs. urban) plays a role in the differences in quality and quantity of services observed. However, the influences of neighborhood structural characteristics on quality of hospice services have not been explored. The purpose of this study was to explore the relationship between hospice neighborhood characteristics and caregiver-rated satisfaction with services in Florida. Data were derived from the Consumer Assessment of Healthcare Providers and Systems Hospice Survey and American Community Survey; ArcGIS was used to generate heat maps to provide visual representations. Findings showed that higher neighborhood immigrant density predicted lower family satisfaction with timely care, communication, spiritual support, and likelihood to recommend the agency services. The U.S. population is projected to continue to grow in its diversity, and thus understanding neighborhood characteristics associated with racial/ethnic minorities' perception of care quality are important for shaping care improvements.

The development of the Broaching Assessment Scale: A client-rated measure of therapists' broaching behaviour in clinical counselling

Objective: Addressing ethnic-cultural topics during the process of psychotherapy, i.e. broaching, is considered highly important for ethnic minority clients who consult mental health care services. Surprisingly little is known, however, about clients' perception of a therapist's broaching qualities, and how clients' mental construction of broaching translates into behavioural broaching acts a therapist may display.

Method: Based on previous work and nine in-depth interviews with ethnic minority clients, a client-rated measure of therapists' broaching behaviour was developed and psychometrically evaluated in two samples. Sample 1 (N = 252 UK ethnic minority clients) was used to empirically delineate the factor structure of an initial item set. Participants were then resolicited to complete a revised item pool.

Results: The empirical structure resulted in a final 25-item broaching instrument with five subscales probing into therapists' broaching behaviour. This Broaching Assessment Scale (BrAS) was validated in Sample 2 (N = 239 US ethnic minority clients). Strict measurement invariance of the factor structure was observed across the two samples and distinctive correlational patterns with therapeutic process measures were found.

Conclusion: The BrAS provides new insights on how sensitivity to ethnic-cultural topics can be targeted along its concrete features, and is a promising tool for conceptualizing culturally sensitive mental healthcare assessment.

Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19

Importance

Primary care (PC) receipt is associated with better health outcomes. How telehealth expansion and internet speed are associated with PC use is unclear.

Objective

To examine the association of telehealth and internet speed with PC use across sociodemographic determinants of health.

Design, Setting, and Participants

This cohort study performed difference-in-differences regression of the change in in-person and telehealth PC visits between pre-COVID-19 public health emergency (PHE) (June 1, 2019, to February 29, 2020) and an initial (March 1, 2020, to May 31, 2020) and prolonged (March 1, 2020, to December 31, 2021) PHE period among continuously enrolled nonpregnant, nondisabled Wisconsin Medicaid beneficiaries aged 18 to 64 years. Data were analyzed from March 2022 to March 2023.

Exposure

PHE-induced telehealth expansion.

Main Outcomes and Measures

Change in PC telehealth (using Current Procedural Terminology codes) visits: (1) count; (2) visit share completed by telehealth; (3) percentage of PHE-induced visit decline offset by telehealth. High-speed internet (HSI) defined as living in a census block group with a median block maximum download speed of 940 megabits per second or greater (June 2020 Federal Communications Commission broadband data); other census block groups classified as low-speed internet (LSI).

Results

In the total cohort of 172 387 participants, 102 989 (59.7%) were female, 103 848 (60.2%) were non-Hispanic White, 34 258 (19.9%) were non-Hispanic Black, 15 020 (8.7%) were Hispanic, 104 239 (60.5%) were aged 26 to 45 years, and 112 355 (66.0%) lived in urban counties. A total of 142 433 (82.6%) had access to HSI; 72 524 (42.1%) had a chronic condition. There was a mean (SD) of 0.138 (0.261) pre-PHE PC visits per month. In the pre-PHE period, visit rates were significantly higher for female than male participants, non-Hispanic White than non-Hispanic Black individuals, urban than rural residents, those with HSI than LSI, and patients with chronic disease than patients without. In the initial PHE period, female participants had a greater increase in telehealth visits than male participants (43.1%; 95% CI, 37.02%-49.18%; P < .001), share (2.20 percentage point difference [PPD]; 95% CI, 1.06-3.33 PPD; P < .001) and offset (6.81 PPD; 95% CI, 3.74-9.87 PPD; P < .001). Non-Hispanic Black participants had a greater increase in share than non-Hispanic White participants (5.44 PPD; 95% CI, 4.07-6.81 PPD; P < .001) and offset (15.22 PPD; 95% CI, 10.69-19.75 PPD; P < .001). Hispanic participants had a greater increase in telehealth visits than Non-Hispanic White participants (35.60%; 95% CI, 25.55%-45.64%; P < .001), share (8.50 PPD; 95% CI, 6.75-10.26 PPD; P < .001) and offset (12.93 PPD; 95% CI, 6.25-19.60 PPD; P < .001). Urban participants had a greater increase in telehealth visits than rural participants (63.87%; 95% CI, 52.62%-75.11%; P < .001), share (9.13 PPD; 95% CI, 7.84-10.42 PPD; P < .001), and offset (13.31 PPD; 95% CI; 9.62-16.99 PPD; P < .001). Participants with HSI had a greater increase in telehealth visits than those with LSI (55.23%; 95% CI, 42.26%-68.20%; P < .001), share (6.61 PPD; 95% CI, 5.00-8.23 PPD; P < .001), and offset (6.82 PPD; 95% CI, 2.15-11.49 PPD; P = .004). Participants with chronic disease had a greater increase in telehealth visits than those with none (188.07%; 95% CI, 175.27%-200.86%; P < .001), share (4.50 PPD; 95% CI, 3.58-5.42 PPD; P < .001), and offset (9.03 PPD; 95% CI, 6.01-12.04 PPD; P < .001). Prolonged PHE differences were similar. Differences persisted among those with HSI.

Conclusions and Relevance

In this cohort study of Wisconsin Medicaid beneficiaries, greater telehealth uptake occurred in groups with higher pre-PHE utilization, except for high uptake among Hispanic and non-Hispanic Black individuals despite low pre-PHE utilization. HSI did not moderate disparities. These findings suggest telehealth and HSI may boost PC receipt, but will generally not close utilization gaps.

Social Drivers of Mental Health: A U.S. Study Using Machine Learning

INTRODUCTION

Social drivers of mental health can be compared on an aggregated level. This study employed a machine learning approach to identify and rank social drivers of mental health across census tracts in the U.S.

METHODS

Data for 38,379 census tracts in the U.S. were collected from multiple sources in 2021. Two measures of mental health problems-self-reported depression and self-assessed poor mental health-among adults and three domains of social drivers (behavioral, environmental, and social) were analyzed on the basis of the unit of census tracts using the Extreme Gradient Boosting machine learning approach in 2022. The leading social drivers were found in each domain in the main sample and in the subsamples divided on the basis of poverty and racial segregation.

RESULTS

The three domains combined explained more than 90% of the variance of both mental illness indicators. Self-reported depression and self-assessed poor mental health differed in major social drivers. The two outcome indicators had one overlapping correlate from the behavioral domain: smoking. Other than smoking, climate zone and racial composition were the leading correlates from the environmental and social domains, respectively. Census tract characteristics moderated the impacts of social drivers on mental health problems; the major social drivers differed by census tract poverty and racial segregation.

CONCLUSIONS

Population mental health is highly contextualized. Better interventions can be developed on the basis of census tract-level analyses of social drivers that characterize the upstream causes of mental health problems.

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such as clinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

Sociodemographic Correlates of Affordable Community Behavioral Health Treatment Facility Availability in Florida: A Cross-Sectional Study

Behavioral health disorders such as mental disorders (MD) and substance use disorders (SUD) are epidemics in the US; however, the availability of treatment and prevention services remains low. This study assessed neighborhood-level sociodemographic attributes to characterize the availability of behavioral health treatment facilities in Florida. The American Community Survey and SAMHSA's Behavioral Health Treatment Locator were used to identify behavioral health treatment facilities in Florida and calculate their density by census tract. Spatial lag regression models were used to assess census tract-level correlates of facility density for 390 MD treatment facilities, 518 SUD facilities, and subsets of affordable MD and SUD facilities. Behavioral health treatment facility density was negatively associated with rurality and positively associated with the proportion of non-Latino Black, Latino, insured, and college-educated populations. Stark rural-urban disparities in behavioral health treatment availability present opportunities to prioritize telehealth and mobile interventions and improve treatment utilization.

Ethnic enclaves, social capital, and psychological well-being of immigrants: the case of Chinese older immigrants in Chicago

Objectives: Using a large sample of Chinese older immigrants in Chicago, this study asked two questions: (1) Is living in Chinatown associated with better psychological well-being? (2) What is the role of social capital in such an association?Methods: Data were derived from the Population Study of Chinese Elderly in Chicago (N = 3,105). Depression and quality of life (QoL) were compared between those who lived in Chinatown and those who didn't. Negative binomial regressions (for depression) and logistic regressions (for QoL) were performed to examine the associations between Chinatown residence, social capital, and the two outcomes.Results: Net of social capital and the control variables, living in Chinatown was marginally associated with fewer depressive symptoms (β= -.137, p = .057), but a significantly lower likelihood of reporting good QoL (OR = .797, CI: .661-.962). Although various forms of social capital were projective of positive psychological well-being, given the overall low social capital of the Chinatown residents, they heightened the mental health risks of this population.Conclusion: The neighborhood context may function to reproduce social disadvantage among aging immigrant populations. The findings point to the importance of intervention at the mezzo level to improve the psychological wellbeing of this population.

Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care

BACKGROUND

Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation.

METHODS

Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings.

RESULTS

Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources).

CONCLUSIONS

Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.

The more you need, the less you get: Intersectionality and the inverse care law in the Brazilian depression care cascade

Substantial research has shown that the population distribution of major depressive disorder (MDD) is strongly influenced by race, gender, and socioeconomic position. However, a deeper understanding of inequities in access to care for MDD according to these social markers is yet to be reached. We use data from the 2019 Brazilian National Health Survey, which includes 87,187 respondents aged 18 years and over, to test two hypotheses derived from the inverse care law: women, Black, and low-education respondents have higher frequencies of MDD, but lower access to each step of the depression care cascade, including diagnosis by a health professional, regular healthcare visits, and access to specialised treatment (H1); low-education Black women show the highest MDD frequency and the lowest access to care across the entire cascade (H2). Partially supporting H1 and H2, our results reveal a bottleneck in the first step of the depression care cascade. While no racial inequities were observed in the MDD prevalence, Black individuals were less likely than whites to be diagnosed by a health professional (OR 0.74). Women (OR 2.64) and low-education (OR 1.18) were more likely to have probable MDD in relation to men and high-education respondents, respectively, but only women (OR 1.58) were more likely to be diagnosed. Low-education Black women were equally more likely to have probable MDD (OR 3.11) than high-education white men. Conversely, high-education white women emerged as the most likely to be diagnosed with MDD (OR 1.63). Our findings suggest the inverse care law applies to the depression care cascade in Brazil through indication that its healthcare system perpetuates a multilayered system of oppression that overlooks multiply marginalised individuals. We also show that adequate screening by health care professionals should mitigate the complex patterns of inequity revealed by our study.

Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation

PURPOSE

Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question.

METHODS

A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years.

RESULTS

Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races.

CONCLUSIONS

The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.

Social Vulnerabilities and Spatial Access to Primary Healthcare through Car and Public Transportation System in the Albuquerque, NM, Metropolitan Area: Assessing Disparities through GIS and Multilevel Modeling

Primary healthcare (PHC) is a keystone component of population health. However, inequities in public transportation access hinder equitable usage of PHC services by minoritized populations. Using the multimodal enhanced 2-step floating catchment area method and data in 2018 and 2019 for spatial access to PHC providers (n = 1166) and social vulnerability markers through census block (n = 543) and tract data (n = 226), a generalized linear mixed-effect model (GLMEM) was constructed to test the effects of sociodemographic and community area correlates on both car and bus transit spatial access to PHC in the Albuquerque, New Mexico (NM) metropolitan area. Results for bus spatial access to PHC showed lower access for Hispanics (B =  - 0.097 ± 0.029 [- 0.154, - 0.040]) and non-Hispanic Whites (B =  - 0.106 ± 0.032 [- 0.169, - 0.043]) and a positive association between single-family households and bus spatial access (B = 1.573 ± 0.349 [0.866, 2.261]). Greater disability vulnerability (B =  - 0.569 ± 0.173 [- 0.919, - 0.259]) and language vulnerability (B =  - 0.569 ± 0.173 [- 0.919, - 0.259]) were associated with decreased bus spatial access. For car spatial access to PHC, greater SES vulnerability (B =  - 0.338 ± 0.021 [- 1.568, -0.143]), disability (B =  - 0.721 ± .092 [- 0.862, - 0.50 9]), and language vulnerability (B =  - 0.686 ± 0.172 [- 1.044, - 0.362]) were associated with less car spatial access. Results indicate a disproportionate burden of low PHC access among disadvantaged population groups who rely heavily on public transportation. These results necessitate targeted interventions to reduce these disparities in access to PHC.

Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States

OBJECTIVE

The authors aimed to compare national rates and patterns of use of outpatient mental health care among Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

METHODS

Data from the 2018-2019 Medical Expenditure Panel Survey, a nationally representative survey of U.S. households, were analyzed, focusing on use of any outpatient mental health care service by non-Hispanic White (N=29,126), non-Hispanic Black (N=7,965), and Hispanic (N=12,640) individuals ages ≥4 years (N=49,731). Among individuals using any mental health care, analyses focused on those using psychotropic medications, psychotherapy, or both and on receipt of minimally adequate mental health care.

RESULTS

The annual rate per 100 persons of any outpatient mental health service use was more than twice as high for White (25.3) individuals as for Black (12.2) or Hispanic (11.4) individuals. Among those receiving outpatient mental health care, Black (69.9%) and Hispanic (68.4%) patients were significantly less likely than White (83.4%) patients to receive psychotropic medications, but Black (47.7%) and Hispanic (42.6%) patients were significantly more likely than White (33.3%) patients to receive psychotherapy. Among those treated for depression, anxiety, attention-deficit hyperactivity disorder, or disruptive behavior disorders, no significant differences were found in the proportions of White, Black, or Hispanic patients who received minimally adequate treatment.

CONCLUSIONS

Large racial-ethnic gaps in any mental health service use and smaller differences in patterns of treatment suggest that achieving racial-ethnic equity in outpatient mental health care delivery will require dedicated efforts to promote greater mental health service access for Black and Hispanic persons in need.

Housing Status as a Predictor for Outpatient Care Following an Emergency or Urgent Care Encounter with a Behavioral Health Diagnosis: A Multivariable Analysis

Individuals without stable housing experience high rates of mental illness and seek behavioral health care in emergency care settings. Little is known about the effect of homelessness on outpatient follow-up after utilizing emergency or urgent care for behavioral health care. Patient encounters with behavioral health diagnoses among 7 emergency department (ED) or urgent care (UC) locations over 4 years were used to determine the correlation between housing status and outpatient follow-up within 90 days. Of 1,160,386 visits by 269,615 unique patients, 55,738 (23%) encounters included a behavioral health diagnosis. Patients with stable housing were twice as likely to follow up with a primary care provider (PCP) and with an outpatient behavioral health provider than patients without housing (aOR 2.60; aOR 2.00, p < 0.0001). Homelessness is associated with difficulty in accessing follow-up behavioral health care. UCs and EDs may use specific interventions to improve outpatient follow-up.

Racial-Ethnic Residential Clustering and Early COVID-19 Vaccine Allocations in Five Urban Texas Counties

Previous research has indicated that racial-ethnic minority communities lack a wide variety of health-related organizations. We examine how this relates to the early COVID-19 vaccine rollout. In a series of spatial error and linear growth models, we analyze how racial-ethnic residential segregation is associated with the distribution of vaccine sites and vaccine doses across ZIP codes in the five largest urban counties in Texas. We find that Black and Latino clustered ZIP codes are less likely to have vaccine distribution sites and that this disparity is partially explained by the lack of hospitals and physicians' offices in these areas. Moreover, Black clustering is also negatively related to the number of allocated vaccine doses, and again, this is largely explained by the unequal distribution of health care resources. These results suggest that extant disparities in service provision are key to understanding racial-ethnic inequality in an acute crisis like the COVID-19 pandemic.

Leveraging multistakeholder engagement to develop an implementation blueprint for a brief trauma-focused cognitive behavioral therapy in primary care

Objective: The implementation of evidence-based treatments (EBTs) to address posttraumatic stress disorder (PTSD) is a public health priority. Successful EBT implementation requires effective collaboration between multiple stakeholder groups, including hospital leaders, providers, and patients, to build buy-in for this effort. Method: We describe our implementation science approach to meaningful stakeholder engagement, as part of a hybrid type I effectiveness-implementation trial of Skills Training in Affective and Interpersonal Regulation for PTSD treatment in primary care (STAIR-PC) at a large safety net hospital. We used primary care and patient community advisory boards (CABs) to interpret key informant interviews and identify strategies to adapt the intervention to ensure fit with the primary care setting. We documented our stakeholder engagement methodology through comprehensive field notes and minutes from CAB meetings, detailing the focus of meetings, suggestions for intervention and delivery adaptations, decision-making processes, and how disagreements about adaptations between stakeholders were resolved. To support replicability, we specify and operationalize implementation strategies to be used across each implementation phase of the trial. Results: Key strategies involved a) ensuring that research questions are relevant to both patients and clinical providers; b) tailoring interventions that are flexible and adaptable to the needs of the local setting; c) continuous engagement of patients and providers throughout the implementation process; and d) building mutual respect, trust, and credibility between the research team, various provider groups, and patients. Conclusions: Our approach to engaging stakeholders informed an implementation blueprint to guide implementation of EBTs for PTSD in safety net hospital primary care clinics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association Between Residence in Historically Redlined Districts Indicative of Structural Racism and Racial and Ethnic Disparities in Breast Cancer Outcomes

Importance

Historical structural racism may be associated with racial, ethnic, and geographic disparities in breast cancer outcomes, but few studies have investigated these potential relationships.

Objective

To test associations among historical mortgage lending discrimination (using 1930s Home Owners' Loan Corporation [HOLC] redlining data), race and ethnicity, tumor clinicopathologic features, and survival among women recently diagnosed with breast cancer.

Design, Setting, and Participants

This cohort study used a population-based, state cancer registry to analyze breast tumor clinicopathology and breast cancer-specific death among women diagnosed from 2008 to 2017 and followed up through 2019. Participants included all primary, histologically confirmed, invasive breast cancer cases diagnosed among women aged at least 20 years and who resided in a HOLC-graded area of New Jersey. Those missing race and ethnicity data (n = 61) were excluded. Data were analyzed between June and December 2021.

Exposures

HOLC risk grades of A ("best"), B ("still desirable"), C ("definitely declining"), and D ("hazardous" [ie, redlined area]).

Main Outcomes and Measures

Late stage at diagnosis, high tumor grade, triple-negative subtype (lacking estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 expression), breast cancer-specific death.

Results

Among a total of 14 964 women with breast cancer, 2689 were Latina, 3506 were non-Latina Black, 7686 were non-Latina White, and 1083 were other races and ethnicities (non-Latina Asian/Pacific Islander/Native American/Alaska Native/Hawaiian or not otherwise specified); there were 1755 breast cancer-specific deaths. Median follow-up time was 5.3 years (95% CI, 5.2-5.3 years) and estimated 5-year breast cancer-specific survival was 88.0% (95% CI, 87.4%-88.6%). Estimated associations between HOLC grade and each breast cancer outcome varied by race and ethnicity; compared with residence in HOLC redlined areas, residence in HOLC areas graded "best" was associated with lower odds of late-stage diagnosis (odds ratio [OR], 0.34 [95% CI, 0.22-0.53]), lower odds of high tumor grade (OR, 0.72 [95% CI, 0.57-0.91]), lower odds of triple-negative subtype (OR, 0.67 [95% CI, 0.47-0.95]), and lower hazard of breast cancer-specific death (hazard ratio, 0.48 [95% CI, 0.35-0.65]), but only among non-Latina White women. There was no evidence supporting associations among non-Latina Black or Latina women.

Conclusions and Relevance

Compared with redlined areas, current residence in non-redlined areas was associated with more favorable breast cancer outcomes, but only among non-Latina White women. Future studies should examine additional factors to inform how historical structural racism could be associated with beneficial cancer outcomes among privileged racial and ethnic groups.

Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees

Importance

Administrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated.

Objectives

To examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid.

Design Setting and Participants

This cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021.

Exposures

Self-reported race.

Main Outcomes and Measures

Rates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures).

Results

Of 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings.

Conclusions and Relevance

In this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority.

Depression among Underserved Rural and Urban Caregivers of Latinas with Breast Cancer

Among Latino/as, informal caregiving duties are often deemed a family responsibility. Understanding psychological outcomes tied to caregivers of Latina breast cancer survivors is important to identify the impacts of cancer. Secondary analysis of baseline data collected in a randomized clinical trial (RCT) from 230 Latina breast cancer survivor-caregiver dyads. Characteristics of caregivers residing in rural/underserved and urban areas were compared using t- or chi-square tests. General linear models were used to analyze depressive symptoms in relation to residence, survivor-caregiver relationship, acculturation, obligation, reciprocity, and comorbidities. Urban residence was significantly associated with higher levels of depression controlling for survivor-caregiver relationship acculturation, obligation, reciprocity, and comorbidities. Mother caregivers had significantly higher levels of depression than other caregivers. Depression among Latino/a caregiver's providing care to an adult child is an important consideration as Latino/as are less likely to seek out/have access to mental health services than other groups.

The relationship between access to mental health resources and use of preferred effective mental health treatment

OBJECTIVE

This study examined whether variables related to unequal access to mental health resources (including Black and Latinx racial-ethnic group membership, lower education level, and lower number of community-level treatment providers, and facilities) were associated with current mental health treatment use; and, whether these variables moderated the likelihood that individuals would receive their preferred effective treatment.

METHODS

In a preregistered (osf.io/z28wr) study, 5626 individuals completed a mental health history form and measures of implicit and explicit beliefs about the effectiveness of therapy versus medication.

RESULTS

Individuals with more (vs. less) education were more likely to report current treatment use. Individuals who were Black/Latinx (vs. non-Latinx White) or who lived in a community with fewer (vs. more) providers sometimes had a lower probability of accessing preferred effective treatment, though results varied across implicit and explicit measures.

CONCLUSIONS

Findings highlight the need to increase access to mental health resources among marginalized groups.

Impact of geographic access to primary care providers on pediatric behavioral health screening

Behavioral Health (BH) screening is critical for early diagnosis and treatment of pediatric mental disorders. The objective of this study was to assess the impact of geographic access to primary care providers (PCP) on pediatric BH screening in children with different race/ethnicity. A retrospective cohort study was conducted using the 2013-2016 administrative claims data from a large pediatric Medicaid Managed Care Plan that have been linked to 2010 US Census data and the 2017 National Provider Identifier (NPI) Registry. Geographic access was defined as the actual travel distance to nearest PCP and the PCP density within 10-mile travel radius from each individual's residence. Stratified multivariate logistic regression was conducted to examine the association between the geographic access to PCP and the likelihood of receiving screening for behavioral disorders within each racial/ethnic group. BH screening rate was 12.6% among 402,655 children and adolescents who met the inclusion criteria. Multivariable analysis stratified by individual race/ethnicity revealed that Hispanic and Black children were more vulnerable to the geographic access barriers than their non-Hispanic White counterparts. The increase in travel distance to the nearest PCP was negatively associated with screening uptake only among Hispanics (10-20 miles vs. 0-10 miles: OR = 0.78, 95% CI [0.71-0.86]; 20-30 miles vs. 0-10 miles: OR = 0.35, 95% CI [0.23-0.54]). In a subgroup that had access to at least one PCP within 10 miles of travel distance, the variation in PCP density had a greater impact on the screening uptake among Hispanics and Blacks than that in non-Hispanic Whites.

Understanding The Health Landscapes Where Latinx Immigrants Establish Residence In The US

The diversity of health contexts in which members of the US Latinx population establish residence may provide insights into the variety of health challenges they face. We investigated differences in health professional shortages, general health services, health care safety-net supply, health access, and population health rankings across 3,113 US counties classified as established, new, or other Latinx population destinations. Compared with new destinations, established destinations had more health professional shortages, as well as higher rates of child and adult health uninsurance. New destinations had fewer health care safety-net services per 100,000 county residents than established destinations. Health contexts thus differ in significant ways across new and established Latinx destinations, and these differences have key implications for Latinx immigrant health.

Using artificial intelligence and longitudinal location data to differentiate persons who develop posttraumatic stress disorder following childhood trauma

Post-traumatic stress disorder (PTSD) is characterized by complex, heterogeneous symptomology, thus detection outside traditional clinical contexts is difficult. Fortunately, advances in mobile technology, passive sensing, and analytics offer promising avenues for research and development. The present study examined the ability to utilize Global Positioning System (GPS) data, derived passively from a smartphone across seven days, to detect PTSD diagnostic status among a cohort (N = 185) of high-risk, previously traumatized women. Using daily time spent away and maximum distance traveled from home as a basis for model feature engineering, the results suggested that diagnostic group status can be predicted out-of-fold with high performance (AUC = 0.816, balanced sensitivity = 0.743, balanced specificity = 0.8, balanced accuracy = 0.771). Results further implicate the potential utility of GPS information as a digital biomarker of the PTSD behavioral repertoire. Future PTSD research will benefit from application of GPS data within larger, more diverse populations.

Geographic Disparities in Access to Specialty Care Programs for Early Psychosis in Washington State

Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural-Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods.

Geolocation of Maryland Medical Marijuana Dispensaries by Community Income and Racial Characteristics: An Ecological Design

Background: Prior investigations have documented disparities in the supply side of Maryland's Medical Marijuana program. Initially a disproportionate share of licenses to cultivate and distribute medical marijuana were awarded to Non-Hispanic White owned businesses. The state has implemented measures to ameliorate the inequity by prioritizing license awards to qualified minority owned businesses. Objectives: The objective of this study is to examine the racial and income characteristics of communities where licensed dispensaries are located. We quantify the racial and income characteristics of communities where Maryland medical cannabis dispensaries are located and explore whether Maryland medical marijuana dispensaries disproportionately locate in high-income, majority-White zip codes. Method: Using data from the Maryland Medical Cannabis Commission and the American Communities Survey, we create geocodes for each of the operating dispensaries as of December 2019. We examine the distribution of medical cannabis dispensaries by zip code level household income and zip code level racial distribution. The data set encompasses 85 operating cannabis dispensaries in Maryland and 6.1 million Marylanders distributed across 468 zip codes in 2018-2019. Results: The analysis indicates that dispensaries are concentrated in zip codes whose residents are racially diverse, and with higher concentrations of retail establishments. Conclusion: Community level racial or income disparities in access to medical cannabis were not observed in Maryland. Access to medical cannabis, based on ability to pay out of pocket for the product, may be uneven.

Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study

OBJECTIVE

Posttraumatic stress disorder (PTSD) treatment delivery by peer specialist providers could increase access to and engagement with PTSD treatment in low resource settings. The current pilot study tested the feasibility, acceptability, and initial effectiveness of a peer-delivered, brief cognitive-behavioral therapy for PTSD.

METHOD

Four certified peer specialists delivered the intervention to 18 participants with probable PTSD. We assessed PTSD symptoms weekly and administered surveys and interviews at baseline and posttreatment.

RESULTS

Our mixed-methods approach suggests that the intervention was feasible and acceptable, demonstrating high client satisfaction. We also found significant improvements in PTSD, depressive, anxiety, and general stress symptoms.

CONCLUSIONS

Peer-delivered interventions may be a good fit for addressing posttraumatic stress symptoms for people accessing care in low resource settings. Future research should evaluate peer-delivered PTSD treatment as a strategy for both reducing symptoms and improving access and engagement in professional care.

Effectiveness of a Modular Cognitive-Behavioral Skills Curriculum in High-Risk Justice-Involved Youth

The aim of this study was to evaluate the effectiveness of a flexible modular cognitive-behavioral theory (CBT) skills curriculum delivered by paraprofessionals in a community organization targeting high-risk justice-involved youth. Programmatic data were collected from 980 high-risk young men (Mage, 21.12; SD, 2.30), and Cox proportional hazards regression was used. The results showed that compared with young men with no CBT encounters, those with one or more CBT encounters had a 66% (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.28-0.42; p < 0.001) lower risk of unenrolling from programming, 65% (HR, 1.65; 95% CI, 1.29-2.12; p < 0.001) higher risk of obtaining a job, and no difference in risk of engaging in new criminal activity while enrolled in programming (HR, 0.99; 95% CI, 0.78-1.25; p = 0.918), despite higher risk factors. Training paraprofessionals to deliver CBT skills to high-risk populations is effective and has scalability potential.

Racial/Ethnic Inequities in Access to High-Quality Dialysis Treatment in Chicago: Does Neighborhood Racial/Ethnic Composition Matter?

OBJECTIVES

Blacks and Hispanics face a higher incidence rate of end-stage renal disease (ESRD) and tend to experience poorer access to quality health care compared with Whites. Income, education, and insurance coverage differentials are typically identified as risk factors, but neighborhood-level analyses may provide additional insights. We examine whether neighborhood racial composition contributes to racial/ethnic inequities in access to high-quality dialysis care in Chicago.

METHODS

Data are drawn from the United States Renal Data System merged to the ESRD Quality Incentive Program file and the American Community Survey (2005-2009) for facility and neighborhood characteristics (N = 2797). Outcomes included (1) spatial access (travel time to dialysis facilities) and (2) realized access (actual use of quality care). Neighborhood racial/ethnic composition was categorized into four types: predominantly White, Black, and Hispanic neighborhoods, and racially integrated neighborhoods.

RESULTS

Blacks lived closer to a dialysis facility but traveled the same distance to their own dialysis compared with Whites. Hispanics had longer travel time to any dialysis than Whites, and the difference between Hispanics and Whites became no longer significant after adjusting for neighborhood racial/ethnic composition. Blacks and Hispanics had better access to a high-quality facility if they lived in integrated neighborhoods (OR = 1.85 and 3.77, respectively, p < 0.01) or in neighborhoods with higher concentrations of their own race/ethnicity (OR = 1.68 for Blacks in Black neighborhoods and 1.92 for Hispanics in Hispanic neighborhoods, p < 0.05) compared with Whites in predominantly White neighborhoods.

CONCLUSION

Expanding opportunities for Blacks and Hispanics to gain access to racially integrated and minority neighborhoods may help alleviate racial/ethnic inequities in access to quality care among kidney disease patients.

Independent and joint contributions of economic, social and physical environmental characteristics to mortality in the Detroit Metropolitan Area: A study of cumulative effects and pathways

OBJECTIVE

Previous studies have demonstrated associations between race-based residential segregation, neighborhood socioeconomic and physical environmental characteristics, and mortality. Relatively few studies have examined independent and joint effects of these multiple neighborhood characteristics and mortality, including potential mediating pathways. In this study we examine the extent to which associations between race-based residential segregation and all-cause mortality may be explained by multiple socioeconomic indicators and exposure to air pollutants.

METHODS

Drawing on data from multiple sources, we assessed bivariate associations between race-based residential segregation (operationalized as percent non-Hispanic Black), education (percent with graduate equivalency degree), poverty (percent below poverty), income inequality (GINI coefficient) and air pollution (ambient PM2.5) and age adjusted all-cause, all race mortality (henceforth all cause mortality) at the census tract level in the Detroit Metropolitan Area. We used inequality curves to assess the (in)equitable distribution of economic and environmental characteristics by census tract racial composition. Finally, we used generalized estimating equations (GEE) to examine independent and joint associations among percent NHB, education, income inequality, and air pollution to all-cause mortality, and test for mediating effects.

RESULTS

Bivariate associations between racial composition, education, poverty, income inequality, PM2.5 and all-cause mortality were statistically significant. Census tracts with higher concentrations of NHB residents had significantly lower educational attainment, higher poverty, and greater exposure to PM2.5. In multivariate models, education, income inequality and PM2.5 fully attenuated associations between racial composition and all-cause mortality.

CONCLUSIONS

Results are consistent with the hypothesis that race-based residential segregation is associated with heightened all-cause mortality, and that those effects are mediated by education, income inequality, and exposure to air pollution at the census tract level. Public health and cross-sector interventions to eliminate race-based residential segregation or to eliminate the maldistribution of educational and economic resources, and environmental exposures, across census tracts could substantially reduce regional inequities in all-cause mortality.

The Role of County Characteristics in Mental Health Service Use by Older African Americans

OBJECTIVE

Older African Americans may underutilize mental health services, although they experience mental health problems at rates comparable with those of whites. Untreated mental disorders contribute to increased risk of morbidity and mortality and decreased quality of life, and therefore, understanding the factors that influence racial disparities in service use is critical. This study examined whether county characteristics were associated with mental health service use by older African Americans after the analyses adjusted for individual characteristics.

METHODS

This study combined individual-level data from the 2008-2012 Medical Expenditure Panel Survey with county-level data for 2008-2012 from the 2013-2014 Area Health Resources Files and county-level data from the 2008-2012 Chronic Conditions Report of the Chronic Conditions Data Warehouse for 1,567 community-dwelling African Americans ages 60 and older. Multilevel logistic regressions were used to examine the role of county characteristics on mental health services use with adjustment for individual-level risk factors.

RESULTS

At the county level, individuals living in a county with a higher proportion of African Americans were less likely to use mental health services. At the individual level, higher income and mental health status were associated with mental health service utilization.

CONCLUSIONS

Among older African Americans, the racial composition of one's county of residence played a role in mental health service use, indicating the need for future research focusing on the relationship between an area's racial composition and mental health service use. Programs may be able to ameliorate racial disparities in mental health care by targeting areas with a higher percentage of African Americans.

Community-Based Implementation of a Paraprofessional-Delivered Cognitive Behavioral Therapy Program for Youth Involved with the Criminal Justice System

Psychosocial interventions for common emotional and behavioral difficulties have been developed for use in correctional facilities, yet these programs are largely unavailable upon community re-entry due to a shortage of trained mental health specialists. In this study, we developed and piloted a youth worker-delivered cognitive behavioral therapy (CBT) program for young men at high risk for incarceration receiving services at a youth development organization. We formed a community-academic partnership to support the conduct of research across all phases of this project (2014-2016). We analyzed data gathered through focus groups and individual interviews with program staff, administrators, and young men. This study reports on implementation process and outcomes across phases. Main findings indicate the preliminary feasibility and acceptability of the youth worker-delivered CBT curriculum. We discuss strengths and limitations of our approach and provide suggestions for future studies that aim to implement paraprofessional-delivered CBT programs within community-based organizations.

Diversity and Inclusion in Psychiatry: The Pursuit of Health Equity

The increasing diversity of America requires a workforce that is able to serve the mental health needs of individuals from multiple backgrounds, with a culturally proficient, inclusive, and affirming approach. To accomplish this, clinicians must be mindful of the multiple challenges presented by social determinants of mental health and access to care; the role of culture in wellness protection, mental illness expression, symptom attribution, and help seeking; the impact of provider factors, such as availability and cultural and linguistic congruence and proficiency; and the interaction of clinician and patient, who are with increasing frequency members of differing identity groups. The authors highlight the central role of clinical providers, academic institutions, and service organizations to advance health equity through training and commitment to increase high-quality services that are available, accessible, affordable, and acceptable, improving the care of all individuals.

A socioecological psychology of racism: making structures and history more visible

Psychology has been accused of 'psychologizing' racism. Here, we summarize the argument that Psychology routinely neglects structural racism and historical legacies of racism. We then discuss two cases-healthcare and police use of force-in which studying individual bias could benefit from incorporating a focus on structures and history. We close by echoing others who have advocated that Psychology move forward with a better integrated view of racism; in particular, we suggest a socioecological view that contextualizes individual bias within the relevant realities of historical and structural racism.

An Overlapping Systems Conceptual Framework to Evaluate Implementation of a Behavioral Health Intervention for Justice-Involved Youth

Background:

Nearly 65% of justice–involved youth have a substance use and/or mental health disorder. Although evidence–based practices have been established for adolescents with co–occurring mental health and substance use disorders, these practices are not widely used in juvenile justice agencies due to environmental and organizational complexities.

Methods:

Our study builds on Juvenile Justice—Translational Research on Interventions for Adolescents in the Legal System (JJ–TRIALS), a multi–site cooperative research initiative of juvenile justice and partnering behavioral health agencies. We also integrate state and county–level data to support broader assessment of key drivers of implementation success.

Results:

We present an economics/systems conceptual model describing how the environmental context, systems organization, and economic costs of implementation can affect implementation outcomes. Comparison of intervention condition (Core vs Enhanced) and pre–implementation costs (High vs Low) found differences in insurance reimbursements and types, as well as agency staffing characteristics.

Discussion:

Implementing new procedures or policies at a systems level must consider implementation outcomes in a broad context. Factors such as population demographics, primary care and behavioral health treatment capacity, unemployment rates, and public funding for treatment and other services are important in determining intervention success and sustainability.

Examining Associations of Racial Residential Segregation With Patient Knowledge of Breast Cancer and Treatment Receipt

BACKGROUND

The effect of racial residential segregation on breast cancer treatment disparities is unclear. We examined whether racial segregation is associated with adjuvant treatment receipt and patient knowledge of disease.

PATIENTS AND METHODS

We surveyed a population-based sample of women in Northern California with stage I to III breast cancer diagnosed in 2010 to 2011 (participation rate = 68.5%, 500 patients). For black, Hispanic, and white women, we measured black and Hispanic segregation using the location quotient (LQ) of racial residential segregation, a proportional measure of the size of a minority group in the census tract compared with the larger metropolitan statistical area. We categorized LQ values for black and Hispanic participants into quartiles, with quartile 1 representing a lower relative level of segregation than quartile 4. We used multivariable logistical regression to assess the odds of receiving guideline-recommended adjuvant therapy and patient knowledge of tumor characteristics according to relative residential segregation.

RESULTS

We observed greater residential segregation for black versus Hispanic patients (P < .05). Overall, there were no treatment differences according to Hispanic or black LQ, except for black LQ quartile 3 (vs. 1) for which we observed higher odds of hormonal therapy. Knowledge of disease did not vary according to black LQ, but patients in the Hispanic LQ quartile 3 (vs. quartile 1) had less tumor knowledge.

CONCLUSION

We did not find clear associations for racial residential segregation and treatment or cancer knowledge in Northern California, an area with low levels of segregation. Additional research should assess the effect of segregation on breast cancer treatment disparities in a variety of geographical locations.

Racial and ethnic differences in mental health service utilization among the Hawaii medicaid population

Background: Racial/ethnic differences have not been adequately addressed in the utilization of mental health services among Medicaid populations. Aim: This study aimed to examine racial/ethnic differences in the utilization of health services for mental disorders in a Medicaid adult population aged between 21 and 64 years. Methods: Racial/ethnic differences in inpatient, outpatient and emergency department services utilization were assessed using 2010 Hawaii Medicaid data. Zero-inflated negative binomial regressions were employed adjusting for age, sex and residential area. Results: Among 73,200 beneficiaries, 29.7% were Whites, 28.5% Asians, 34.7% Native Hawaiians and Pacific Islanders (NHPIs); 60.2% were younger (21-44 years) and 58.6% were females. The patterns of utilization of health services differed across race/ethnicity. Compared to Whites, Asians and NHPIs were less likely to use outpatient services and had lower rates of inpatient visits. NHPIs were also estimated to have lower rates of outpatient and emergency department visits. Conclusion: Variation in the utilization of health services emphasizes the importance of race/ethnicity in mental health management. Various factors, such as language barriers and cultural differences, should be considered in developing clinical interventions or integrative health programs that aim to reduce racial/ethnic disparities among people with mental disorders.

Disparities in the Treatment of Substance Use Disorders: Does Where You Live Matter?

This study focused on (1) whether disparities in timely receipt of substance use services can be explained in part by the characteristics of the community in which the clients reside and (2) whether the effect of community characteristics on timely receipt of services was similar across racial/ethnic groups. The sample was composed of adults receiving publicly funded outpatient treatment in Washington State. Treatment data were linked to data from the US census. The outcome studied was "Initiation and Engagement" in treatment (IET), a measure noting timely receipt of services at the beginning of treatment. Community characteristics studied included community level economic disadvantage and concentration of American Indian, Latino, and Black residents in the community. Black and American Indian clients were less likely to initiate or engage in treatment compared to non-Latino white clients, and American Indian clients living in economically disadvantaged communities were at even greater risk of not initiating treatment. Community economic disadvantage and racial/ethnic makeup of the community were associated with treatment initiation, but not engagement, although they did not entirely explain the disparities found in IET.

Racial/Ethnic Residential Segregation, the Distribution of Physician’s Offices and Access to Health Care: The Case of Houston, Texas

Previous research has demonstrated the impacts of racial/ethnic residential segregation on access to health care, but little work has been conducted to tease out the mechanisms at play. I posit that the distribution of health care facilities may contribute to poor access to health care. In a study of the Houston area, I examine the association between residential segregation, the distribution of physician’s offices, and two health care access outcomes of having a personal physician, as well as the travel time to their office location. Using the 2010 Health of Houston Survey combined with several census products, I test these relationships in a series of spatial and multilevel models. I find that Black segregation is related to a lower density of physician’s offices. However, I find that this distribution is not related to having a personal physician, but is related to travel times, with a greater number of facilities leading to shorter travel times to the doctor. I also find that Black segregation is positively associated with travel times, and that the distribution of physician’s offices partially mediates this relationship. In sum, these findings suggest that a more equitable provision of health care resources across urban neighborhoods would mitigate some of the negative effects of segregation.

Racial, Ethnic, and Nativity Differences in Mental Health Visits to Primary Care and Specialty Mental Health Providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015

Background. Black and Latino minorities have traditionally had poorer access to primary care than non-Latino Whites, but these patterns could change with the Affordable Care Act (ACA). To guide post-ACA efforts to address mental health service disparities, we used a nationally representative sample to characterize baseline race-, ethnicity-, and nativity-associated differences in mental health services in the context of primary care. Methods. Data were obtained from the Medical Expenditures Panel Survey (MEPS), a two-year panel study of healthcare use, satisfaction with care, and costs of services in the United States (US). We pooled data from six waves (14–19) of participants with serious psychological distress to examine racial, ethnic, and nativity disparities in medical and mental health visits to primary care (PC) and specialty mental health (SMH) providers around the time of ACA reforms, 2010–2015. Results. Of the 2747 respondents with serious psychological distress, 1316 were non-Latino White, 632 non-Latino Black, 532 identified as Latino with Mexican, Central American, or South American (MCS) origins, and 267 as Latino with Caribbean island origins; 525 were foreign/island born. All racial/ethnic groups were less likely than non-Latino Whites to have any PC visit. Of those who used PC, non-Latino Blacks were less likely than Whites to have a PC mental health visit, while foreign born MCS Latinos were less likely to visit an SMH provider. Conditional on any mental health visit, Latinos from the Caribbean were more likely than non-Latino Whites to visit SMH providers versus PC providers only, while non-Latino Blacks and US born MCS Latinos received fewer PC mental health visits than non-Latino Whites. Conclusion. Racial-, ethnic-, and nativity-associated disparities persist in PC provided mental health services.

Beck Depression Inventory-II: Factor Analyses with Three Groups of Midlife Women of African Descent in the Midwest, the South, and the U.S. Virgin Islands

This research encompasses a factor analysis of the Beck Depression Inventory-II (BDI-II), which involves three groups of midlife women of African descent who reside in the Midwest, the South, and the U.S. Virgin Islands. The purpose of the study was to determine the factor structure of the BDI-II when administered to a sample of women aged 40-65 of African descent who reside in the three distinct geographical regions of the United States. A correlational, descriptive design was used, and 536 women of African descent were invited to participate in face-to-face interviews that transpired in community settings. Results of the factor analysis revealed a two-factor explanation. Factor one included symptoms such as punishment feelings and pessimism (cognitive), and the second factor included symptoms such as tiredness and loss of energy (somatic-affective). The application of the Beck Depression Inventory-II among the three groups of women generated specific information about each group and common findings across the groups. Knowledge gained from the research could help to guide specific intervention programs for the three groups of women, and explicate the common approaches that could be used for the three groups.

The Role of Social Context in Racial Disparities in Self-Rated Health

Race disparities in self-rated health in the USA are well-documented, such that African Americans rate their health more poorly than whites. However, after adjusting for health status, socioeconomic status (SES), and health behaviors, residual race differences are observed. This suggests the importance of unmeasured variables. Because African Americans and whites tend to live in differing social contexts, it is possible that accounting for social and environmental conditions may reduce racial disparities in self-rated health. Differences in self-rated health among whites and African Americans were assessed in a low-income, urban integrated community (Exploring Health Disparities in Integrated Communities (EHDIC)) and compared with a national sample (National Health Interview Survey (NHIS)). Controlling for demographics, SES, health insurance, status, and behaviors, African Americans in NHIS had higher odds of reporting fair or poor health (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.18-1.66) than whites. In EHDIC, there was no race difference in self-rated health (OR = 0.83, 95% CI = 0.63-1.11). These results demonstrate the importance of social context in understanding race disparities in self-rated health.

Nuclear genes involved in mitochondrial diseases caused by instability of mitochondrial DNA

Mitochondrial diseases are defined by a respiratory chain dysfunction and in most of the cases manifest as multisystem disorders with predominant expression in muscles and nerves and may be caused by mutations in mitochondrial (mtDNA) or nuclear (nDNA) genomes. Most of the proteins involved in respiratory chain function are nuclear encoded, although 13 subunits of respiratory chain complexes (together with 2 rRNAs and 22 tRNAs necessary for their translation) encoded by mtDNA are essential for cell function. nDNA encodes not only respiratory chain subunits but also all the proteins responsible for mtDNA maintenance, especially those involved in replication, as well as other proteins necessary for the transcription and copy number control of this multicopy genome. Mutations in these genes can cause secondary instability of the mitochondrial genome in the form of depletion (decreased number of mtDNA molecules in the cell), vast multiple deletions or accumulation of point mutations which in turn leads to mitochondrial diseases inherited in a Mendelian fashion. The list of genes involved in mitochondrial DNA maintenance is long, and still incomplete.

Reducing Preventable Hospitalization and Disparity: Association With Local Health Department Mental Health Promotion Activities

INTRODUCTION

Serving as the center of community-engaged health programs, local health departments can play a critical role in promoting community mental health. The objectives of this study were to explore the association between local health department activities and (1) preventable hospitalizations for individuals with mental disorders, and (2) associated racial disparities in preventable hospitalizations.

METHOD

Employing the linked data sets of the 2012-2013 Healthcare Cost and Utilization Project state inpatient discharge file of the State of Maryland, the National Association of County and City Health Officials Profiles Survey, the Area Resource File, and U.S. Census data, the authors estimated the association between local health department activities (i.e., provision of mental health preventive care and community mental health promotion) and the reduction of the preventable hospitalizations for ambulatory care-sensitive conditions and coexisting mental disorders. All the data analyses were conducted during September 2016-August 2017.

RESULTS

Multilevel regression showed that local health departments' provision of mental health preventive care (OR=0.76, 95% CI=0.63, 0.92) and mental health promotion activities (OR=0.77, 95% CI=0.62, 0.94) were significantly associated with lower rates of preventable hospitalizations for individuals with ambulatory care-sensitive conditions and coexisting mental disorders. Decomposition results suggested that local health departments' direct provision of mental health preventive care could reduce 9% of the racial disparities.

CONCLUSIONS

Improving care coordination and integration are essential to meeting the growing demands for healthcare access, while controlling costs and improving quality of service delivery. These results suggest that it will be effective to engage local health departments in the integrated behavioral health system.

Influence of social and neighborhood contexts on smoking cessation among urban minorities

A range of individual, social, and neighborhood factors influence the smoking-related health inequities of urban minorities. Yet little is known about how these factors interact to influence smoking behaviors, including cessation. Hierarchical linear modeling was used to estimate the variance in cessation service utilization among a sample of primarily African American adults accounted for by individual, social, and neighborhood factors. Findings showed individual and social factors were important predictors of cessation service utilization. Social contexts have significant effects on smoking cessation service use, and social influences were more significant predictors of cessation service use than neighborhood factors.

Racial/ethnic differences in perception of need for mental health treatment in a US national sample

PURPOSE

To resolve contradictory evidence regarding racial/ethnic differences in perceived need for mental health treatment in the USA using a large and diverse epidemiologic sample.

METHODS

Samples from 6 years of a repeated cross-sectional survey of the US civilian non-institutionalized population were combined (N = 232,723). Perceived need was compared across three non-Hispanic groups (whites, blacks and Asian-Americans) and two Hispanic groups (English interviewees and Spanish interviewees). Logistic regression models were used to test for variation across groups in the relationship between severity of mental illness and perceived need for treatment.

RESULTS

Adjusting statistically for demographic and socioeconomic characteristics and for severity of mental illness, perceived need was less common in all racial/ethnic minority groups compared to whites. The prevalence difference (relative to whites) was smallest among Hispanics interviewed in English, -5.8% (95% CI -6.5, -5.2%), and largest among Hispanics interviewed in Spanish, -11.2% (95% CI -12.4, -10.0%). Perceived need was significantly less common among all minority racial/ethnic groups at each level of severity. In particular, among those with serious mental illness, the largest prevalence differences (relative to whites) were among Asian-Americans, -23.3% (95% CI -34.9, -11.7%) and Hispanics interviewed in Spanish, 32.6% (95% CI -48.0, -17.2%).

CONCLUSIONS

This study resolves the contradiction in empirical evidence regarding the existence of racial/ethnic differences in perception of need for mental health treatment; differences exist across the range of severity of mental illness and among those with no mental illness. These differences should be taken into account in an effort to reduce mental health-care disparities.