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Policy PointsIn low‐income communities in the South Bronx and Puerto Rico, Puerto Rican youth are exposed to many of the same risk and protective factors for developing depression, anxiety, or psychological distress; yet it is unclear how the ethnic minority context of the South Bronx and ethnic majority context of Puerto Rico influence risk.Results from our quasi‐experimental, longitudinal study demonstrate the importance of addressing social factors (parent‐child relationships, youth peer relationships) for youth living in the majority context, and neighborhood and cultural factors (residential mobility, perceived discrimination, perceived social position in the neighborhood) for youth living in the minority context.Our findings support the need for tailoring programs specific to the needs of youth who reside in an ethnic majority or a minority context, since some of the risk factors might operate differently depending on context.Housing and neighborhood environment policies that address discrimination and eliminate structural inequities for ethnic minority groups may protect against the harm of minoritization on young people's mental health. Context: Puerto Rican youth growing up in low‐income communities in the South Bronx and Puerto Rico are exposed to many of the same risk factors for major depressive disorder, generalized anxiety disorder, and psychological distress. One potentially powerful factor differs: Puerto Ricans have been socially marginalized as an ethnic minority group in the South Bronx, but are the ethnic majority of the population in Puerto Rico. A growing body of literature demonstrates the influence of neighborhood, cultural, and social factors and parental psychopathology in the development of mental health problems. An important unanswered question is whether these risk and protective factors have the same impact for youth raised as members of an ethnic majority versus minority group. Methods: Using a population‐based cohort study, with four waves of assessment from early childhood into young adulthood, we investigated whether ethnic minority context alters risk and protective factors for depression, anxiety, and psychological distress. Our longitudinal data set includes 2,491 young children at baseline (82.8% retained at wave 4). Using a quasi‐experimental design, we examine how ethnic minority context can alter the development of mental health disorders as Latinx children transition to late adolescence and young adulthood. Findings: Some risk and protective factors operated differently across minority and majority contexts. Higher discrimination and social position were more powerful risk and protective factors, respectively, in the minority context, whereas positive peer relationships mattered more in the majority context. Children of mothers with depression were significantly more likely to develop anxiety in late adolescence and young adulthood in the majority context (60.0%) compared to the minority context (4.5%). Conclusions: Preventing depression and anxiety disorders in Latinx young adults may require targeting different childhood factors depending on whether they reside within the ethnic majority or minority context. People in the ethnic minority context may benefit more from policies aimed at reducing discrimination and improving economic opportunity, while people in the majority context may benefit more from opportunities for strengthening family and peer relationships. [ABSTRACT FROM AUTHOR]

In an Editorial, Guest Editors Alexander Tsai, Margarita Alegria and Steffanie Strathdee discuss the accompanying Special Issue on Substance Use, Misuse and Dependence. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown positive effects of patient activation on healthcare outcomes, but there is practically no information on the generalization of these findings for Latino patients. Little data are available on whether patient activation is associated with healthcare outcomes for Latino patients and whether activation varies by language proficiency and nativity status.Objective: We examined the levels of activation by characteristics of Latino patients (e.g. nativity, language, health status). We investigated whether patient activation relates to the quality of care received and enhanced doctor-patient communication for Latino patients.Design: We conducted analyses of 1,067 US born and foreign born Latinos who participated in the second wave of the PEW/RWJF Hispanic Healthcare Survey during 2008.Participants: Participants were self-identified Latinos (18+) with a doctor visit, living in the contiguous United States who could be contacted by telephone.Results: US born Latinos had significantly (P < 0.001) greater patient activation scores than foreign born Latinos (75 versus 70). Latinos classified as bilingual and those reporting excellent health evidenced higher mean activation scores as compared to Spanish-speaking Latinos and those reporting fair or poor health. After adjusting for demographics, health status, other language and service use factors, patient activation was strongly associated with self-reported quality of care and better doctor-patient communication among both US and foreign born Latino respondents.Conclusions: Interventions that augment patient activation could increase quality of care and improved patient-provider communication, potentially reducing health care disparities for Latinos. [ABSTRACT FROM AUTHOR]

Objectives. We examined potential pathways by which time in the United States may relate to differences in the predicted probability of past-year psychiatric disorder among Latino immigrants as compared with US-born Latinos. Methods. We estimated predicted probabilities of psychiatric disorder for US-born and immigrant groups with varying time in the United States, adjusting for different combinations of covariates. We examined 6 pathways by which time in the United States could be associated with psychiatric disorders. Results. Increased time in the United States is associated with higher risk of psychiatric disorders among Latino immigrants. After adjustment for covariates, differences in psychiatric disorder rates between US-born and immigrant Latinos disappear. Discrimination and family cultural conflict appear to play a significant role in the association between time in the United States and the likelihood of developing psychiatric disorders. Conclusions. Increased perceived discrimination and family cultural conflict are pathways by which acculturation might relate to deterioration of mental health for immigrants. Future studies assessing how these implicit pathways evolve as contact with US culture increases may help to identify strategies for ensuring maintenance of mental health for Latino immigrants. [ABSTRACT FROM AUTHOR]

My experiences as a mentor of young investigators, along with conversations with a diverse pool of mentees, led me to question the ability of conventional research methods, problem formulation, and instruments to address the unique challenges of studying racial and ethnic minorities. Training of new investigators should prepare them to explore alternative research paradigms and atypical research strategies, such as community-based participatory research and Photovoice technique. Unconventional approaches to research may challenge common explanations for unmet needs, noncompliance with treatments, and poor service outcomes. Mentors may need to develop broader theoretical insights that will facilitate unconventional problem formulation. The teaching of scientific research and mentoring of young investigators who study minority populations should evolve along with the changing research environment. (Am J Public Health. 2009;99:S26-S30. [ABSTRACT FROM AUTHOR]

Objectives. We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States. Methods. We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos. Results. Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non-Puerto Ricans and foreign-born Latinos. Conclusions. Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria. [ABSTRACT FROM AUTHOR]

Objectives. We examined the prevalence of depressive, anxiety, and substance use disorders among Latinos residing in the United States. Methods. We used data from the National Latino and Asian American Study, which included a nationally representative sample of Latinos. We calculated weighted prevalence rates of lifetime and past-year psychiatric disorders across different sociodemographic, ethnic, and immigration groups. Results. Lifetime psychiatric disorder prevalence estimates were 28.1% for men and 30.2% for women. Puerto Ricans had the highest overall prevalence rate among the Latino ethnic groups assessed. Increased rates of psychiatric disorders were observed among US-born, English-language-proficient, and third-generation Latinos. Conclusions. Our results provide important information about potential correlates of psychiatric problems among Latinos that can inform clinical practice and guide program development. Stressors associated with cultural transmutation may exert particular pressure on Latino men. Continued attention to environmental influences, especially among third-generation Latinos, is an important area for substance abuse program development. [ABSTRACT FROM AUTHOR]

Research on disparities in health and services should include a critical examination of how social cultural and contextual factors affect the connection between symptoms and psychiatric disorders. Systematic differences in this connection by these factors will mean that clinicians using a universalist approach to disorders may make more diagnostic errors for certain patients (e.g., ethnic minorities, the poor). Based on the literature on normative clinical decision-making, this study tests for whether the effect of specific psychiatric disorders on key symptoms is the same for certain groups of the population. The data come from the National Comorbidity Survey. Conditional probabilities of disorders and symptoms, the elements feeding into clinical decision-making, are calculated and tested for equivalence across various racial/ethnic, educational income, and gender groups. We find some significant differences in the relation of key symptoms to disorders across groups. These findings should encourage testing relativistic frameworks in diagnostic nosology as a step to improve clinical decision-making and reduce diagnostic and treatment disparities in mental health services. [ABSTRACT FROM AUTHOR]

Conclusions. Reallocation of mental health services may be a result of expanding Medicaid eligibility. (Am J Public Health. 2001;91:1431-1434) [ABSTRACT FROM AUTHOR]

Background: This paper describes utilization of mental health services by poor Puerto Ricans living on the island. It examines the utilization rates, within health sectors, and settings for the provision of mental health services. Methods. Data are based on an islandwide probability sample of 18- to 64-year old respondents living in low socioeconomic areas. We assessed need with the Psychiatric Symptom and Dysfunction Scales. Results: Approximately one-third of our study population (31.5%) met criteria for need. Of these, only 32% had received any mental health care in the past year. Need was significantly associated with use of physical or mental health services for mental health problems. We found those who needed services to be five times more likely than those who did not need services to have used one or both sectors of care at least once in the past year. Among the first group 21.8% used the physical health sector to deal with mental health problems in contrast with 17.9% who sought care in the mental health sector. In the physical health sector, subjects used the public and private settings equally. In the mental health sector, 70% of subjects used the public setting. Conclusions: This suggests the nonpsychiatric physician as a main provider for mental health treatment. [ABSTRACT FROM AUTHOR]

The authors offer reflections on the Latin American/North American exploratory workshop held in October 2009 which investigated societal determinants of health inequities between and within countries. They express concern with how social injustice harms health and recognize that social inequalities in health have long been documented and debated. The authors offers an appreciation on the importance of theory in shaping analysis of health inequalities which is differences in health outcomes due to injustice.

This paper examines the association of depressive symptoms with human immunodeficiency virus (HIV) infection and risk behaviors among 127 sex workers. Data were obtained by a structured interview and blood specimens tested for HIV. Findings showed a high prevalence rate of depressive symptoms for all sex workers regardless of HIV infection status. Results of a logistic regression analysis indicated that the use of injected drugs and engaging in unprotected intercourse with clients were strongly associated with a high level of depressive symptoms. [ABSTRACT FROM AUTHOR]

Objective: To investigate how the COVID‐19 pandemic impacted low‐income individuals with substance use disorder (SUD) in New York City (NYC) during the beginning of the pandemic, using a structural competency and structural vulnerability theoretical framework and a qualitative research approach. Data Sources: Primary qualitative data were collected from racial/ethnic minority adults enrolled in Medicaid receiving outpatient substance use treatment (e.g., medication, counseling) in NYC. Study Design: Semi‐structured in‐depth qualitative interviews (N = 20) were conducted during "stay‐at‐home" orders in NYC, the first epicenter of the COVID‐19 pandemic in the United States. Interviews were conducted over the phone during the earlier stages of the pandemic, between April 2020 and June 2020. Data Collection/Extraction Methods: Semi‐structured in‐depth interviews were conducted and audio recorded, transcribed, and analyzed using a thematic analysis approach. Principal Findings: Three themes were yielded from our thematic analysis: (1) COVID‐19 heightened food insecurity and housing conditions increased risks of infection; (2) stay‐at‐home orders limited access to resources but had positive impacts in strengthening social relationships and reducing substance use triggers; and (3) although COVID‐19 created challenges for treatment, most described that SUD care improved during the pandemic. Conclusions: While COVID‐19 exacerbated numerous structural vulnerabilities among low‐income individuals with SUD, programmatic adaptations to COVID‐19 SUD care, including telehealth and loosening restrictions around medications for opioid use disorders mitigated past difficulties that patients had faced. Reducing structural vulnerabilities for Medicaid patients will require continuation of telehealth treatment delivery, retaining flexible medication regulations, and mobilizing community resources to mitigate economic disparities. [ABSTRACT FROM AUTHOR]

Objective: To explore how stakeholders responded to research evidence regarding supported employment (e.g., vocational rehabilitation), and ways evidence could be incorporated into policy and action. Data sources: Qualitative data were collected from three stakeholder groups—people with lived experience of mental health challenges, community health advocates, and state health policy makers. Study design: This study consisted of two sequential steps. First, three focus groups were conducted after presenting stakeholder groups (inclusive of 22 participants) with simulation data showing that improvement in employment status had a stronger impact on mental health than improvement in education or income for racially/ethnically diverse groups. Second, with guidance from focus group findings, researchers conducted additional in‐depth interviews (n = 19) to gain a deeper understanding of the opportunities and challenges related to incorporating these findings into policy and practice. Data collection/extraction methods: Focus groups and in‐depth interviews were conducted, audio recorded, transcribed, and analyzed using a thematic analysis approach. Principal findings: People with lived experience described the positive effect of employment in their own life while highlighting the need to increase workplace accommodations and social supports for those with mental health challenges. Across stakeholder groups, participants emphasized the need for linguistic and cultural competence to promote equity in delivery of supported employment programs. Stakeholders also underscored that centralizing existing resources and using evidence‐based approaches are crucial for successful implementation. Conclusion: Implementing effective supported employment programs should focus on meeting the specific needs of target individuals, as many of those needs are not considered in current employment‐related programming. Collecting information from diverse users of research demonstrates what other aspects of supported employment are required for the likelihood of successful uptake. Implementation and dissemination efforts need to fortify collaborations and knowledge transfer between stakeholders to optimize supported employment and mental health resources. [ABSTRACT FROM AUTHOR]

Objectives. In disparities models, researchers adjust for differences in ''clinical need,'' including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities. Data. Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n511,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care. Study Design. First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates. Principal Findings. We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black-white disparities and decreased Latino-white disparities. Conclusions. Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities. [ABSTRACT FROM AUTHOR]

Objectives. We examined patterns of body mass index (BMI) and obesity among a nationally representative sample of first-, second-, and third-generation Latinos and Asian Americans to reveal associations with nativity or country of origin. Methods. We used data from the National Latino and Asian American Survey (2002-2003) to generate nationally representative estimates of mean BMI and obesity prevalence and explored changes in the distribution of BMI by generational status. Analyses tested the association between generational status and BMI and examined whether this association varied by ethnicity, education, or gender. Results. We found substantial heterogeneity in BMI and obesity by country of origin and an increase in BMI in later generations among most subgroups. The data suggest different patterns for Latinos and Asian Americans in the nature and degree of distributional changes in BMI with generational status in the United States. Conclusions. Generational status is associated with increased BMI and obesity among Latinos and Asian Americans. Aggregate estimates not accounting for nativity and country of origin may mask significant heterogeneity in the prevalence of obesity and patterns of distributional change, with implications for prevention strategies. (Am J Public Health. 2007; 97: 70-77. doi: 10. 2105/AJPH. 2006. 102814) [ABSTRACT FROM AUTHOR]

We examined correlates of lifetime parent-to-child aggression in a representative sample of 1,293 Asian American parents. Correlates examined included nativity, indicators of acculturation, socioeconomic status, family climate, and stressors associated with minority status. Results revealed that Asian Americans of Chinese descent and those who immigrated as youth were more likely to report minor parental aggression; ethnicity and nativity were not associated with severe aggression. Indices of acculturation did not predict risk, but minority status stressors (perceived discrimination, low social standing) predicted risk of both minor and severe aggression. Affective climate differed markedly in families with minor versus severe aggression. Parental aggression in Asian American families may not be cultural per se, but stress associated with immigrant family context may heighten vulnerability. [ABSTRACT FROM AUTHOR]

Three-hundred eleven female drug-using sex workers in urban Puerto Rico were asked to describe their last negotiation with a client. They described efforts to protect themselves from many hazards of sex work, including violence, illness, and drug withdrawal. They also described efforts to minimize the stigma and marginalization of sex work by cultivating relationships with clients, distinguishing between types of clients, and prioritizing their role as mothers. Sex workers adopted alternating gender roles to leverage autonomy and respect from clients. Their narratives suggest that sex workers negotiate a world in which HIV is relative to other risks, and in which sexual practices which are incomprehensible from an HIV-prevention perspective are actually rooted in a local cultural logic. Future HIV prevention efforts should frame condom use and other self-protective acts in terms that build upon sex workers' own strategies for understanding their options and modifying their risks. [ABSTRACT FROM AUTHOR]

Background: Results of previous studies attest to the greater illness burden of common mental disorders (anxiety and depression) in older Latinos and the need for developing preventive interventions that are effective, acceptable, and scalable. Happy Older Latinos are Active (HOLA) is a newly developed intervention that uses a community health worker (CHW) to lead a health promotion program in order to prevent common mental disorders among at-risk older Latinos. This pilot study tests the feasibility and acceptability of delivering HOLA to older, at-risk Latinos.Methods/design: HOLA is a multi-component, health promotion intervention funded by the National Institute of Mental Health (NIMH). This prevention approach will be tested against a fotonovela, an enhanced psychoeducation control condition, in a sample of Latino elderly with minor or subthreshold depression or anxiety. A total of 60 older Latinos (aged 60+) will be randomized to receive HOLA or the fotonovela. The primary outcomes of interest are recruitment, adherence, retention, and acceptability. Data will also be collected on: preemption of incident and recurrent major depression, generalized anxiety, and social phobia; reduction in depression and anxiety symptom severity; physical functioning; sedentary behaviors; social engagement; and self-efficacy.Discussion: The results of this study could have implications for other high-risk, highly disadvantaged populations. The development of a health promotion intervention designed to prevent common mental disorders could be a means of addressing multiple disparities (for example, mental health outcomes, mental health service use, stigma) among racial/ethnic minority elderly. CLINICALTRIALS.Gov Identifier: NCT02371954 . Date of registration: 21 January 2015. [ABSTRACT FROM AUTHOR]

Objective To examine the development, feasibility, and use of a vignette approach as an important tool in health services disparities research. Data Source Interviews with vignette developers and qualitative data from a novel mental health services disparities study that used vignettes in two samples: (1) predominantly low-income parents of children attending mental health specialty care who were Latino or non-Latino White and (2) Latino and non-Latino mental health clinicians who treat children in their practice. Study Design We conduct a content analysis of qualitative data from patients and providers in the Ethnic Differences Study to explore the feasibility of vignette methodology in health services disparities research, and we identify lessons learned that may guide future vignette development. Principal Findings Vignettes provide a valuable approach that is acceptable to participants, elicits important insight on participant experience and services, and sheds light on factors that can help optimize study design for exploring health disparities questions. Conclusions Researchers, clinicians, and others should consider a set of factors that help determine when a vignette approach is warranted in research, training, or for other uses, including how best to address identified weaknesses. [ABSTRACT FROM AUTHOR]

Purpose: Limited research in health valuation analyzes samples with high proportions of racial/ethnic minorities within the United States. The primary objective was to explore patterns of health valuation across race/ethnicity using the Collaborative Psychiatric Epidemiology Surveys. A secondary objective was to analyze whether mental health disorder and immigrant status were associated with these estimates. Methods: Health valuation questions using different metrics (time and money) were analyzed. Ordered logit models stratified across poor and moderate health tested differences by race/ethnicity, with mental health disorder and immigrant status as covariates. Results: Asians in moderate health and Latinos were willing to pay more for health than non-Latino whites. Asians in moderate health were willing to trade more time for health. Latinos in poor health were less willing to trade time and gave disproportionate zero-trade responses. Lifetime history of anxiety disorder was positively associated with both metrics. Immigrant status confounded money valuation for Asians in moderate health, and time valuation for Latinos in poor health. Conclusions: Health valuation estimates vary across race/ethnicity depending upon the metric. Time valuation scenarios appear less feasible for Latinos in poor health. More research is necessary to understand these differences and the role of immigrant status in health valuation. [ABSTRACT FROM AUTHOR]

Objectives. We examined rates of mental health-related service use (i.e., any, general medical, and specialty mental health services) as well as subjective satisfaction with and perceived helpfulness of care in a national sample of Asian Americans, with a particular focus on immigration-related factors. Methods. Data were derived from the National Latino and Asian American Study (2002-2003). Results. About 8.6% of the total sample (n=2095) sought any mental health-related services; 34.1% of individuals who had a probable diagnosis sought any services. Rates of mental health-related service use, subjective satisfaction, and perceived helpfulness varied by birthplace and by generation. US-born Asian Americans demonstrated higher rates of service use than did their immigrant counterparts. Third-generation or later individuals who had a probable diagnosis had high (62.6%) rates of service use in the previous 12 months. Conclusions. Asian Americans demonstrated lower rates of any type of mental health-related service use than did the general population, although there are important exceptions to this pattern according to nativity status and generation status. Our results underscore the importance of immigration-related factors in understanding service use among Asian Americans. [ABSTRACT FROM AUTHOR]

Objectives. We examined lifetime and 12-month rates of any depressive, anxiety, and substance abuse disorders in a national sample of Asian Americans. We focused on factors related to nativity and immigration as possible correlates of mental disorders. Methods. Data were derived from the National Latino and Asian American Study, the first national epidemiological survey of Asian Americans in the United States. Results. The relationships between immigration-related factors and mental disorders were different for men and women. Among women, nativity was strongly associated with lifetime disorders, with immigrant women having lower rates of most disorders compared with US-born women. Conversely, English proficiency was associated with mental disorders for Asian men. Asian men who spoke English proficiently generally had lower rates of lifetime and 12-month disorders compared with nonproficient speakers. Conclusions. For Asian Americans, immigration-related factors were associated with mental disorders, but in different ways for men and women. Future studies will need to examine gender as an important factor in specifying the association between immigration and mental health. [ABSTRACT FROM AUTHOR]