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This study examined U.S. Cambodian refugees' utilization of mental health services across provider types, levels of minimally adequate care, and mode of communication with providers.Face-to-face household interviews about mental health service use in the past 12 months were conducted as part of a study of a probability sample of Cambodian refugees. The analytic sample was restricted to the 227 respondents who met past 12-month criteria for posttraumatic stress disorder (PTSD) or major depressive disorder or both. Analyses were weighted to account for complex sampling design effects and for attrition.Fifty-two percent of Cambodian refugees who met diagnostic criteria obtained mental health services in the past 12 months. Of those who obtained care, 75% visited a psychiatrist and 56% a general medical provider. Only 7% had obtained care from other mental health specialty providers. Virtually all respondents who had seen a psychiatrist (100%) or a general medical doctor (97%) had been prescribed a psychotropic medication. Forty-five percent had received minimally adequate care. Most relied on interpreters to communicate with providers.Cambodian refugees' rates of mental health service utilization and minimally adequate care were comparable to those of individuals in the general U.S.Cambodian refugees obtained care almost entirely from psychiatrists and general medical doctors, and nearly all were receiving pharmacotherapy; these findings differ from rates seen in a nationally representative sample. Given this pattern of utilization, and the persistently high levels of PTSD and depression found among Cambodian refugees, treatment improvements may require identification of creative approaches to delivering more evidence-based psychotherapy.

To better document the health status of Cambodian refugees, the physical health functioning, disability, and general health status of Cambodian refugees was compared to that of non-refugee Asian immigrants with similar demographic characteristics. Data were collected between October 2003 and February 2005, from 490 face-to-face interviews conducted with a stratified probability sample of households from the Cambodian community in Long Beach, California. Data on the health status of the general adult population (n = 56,270) was taken from the California Health Interview Survey, a telephone interview of a representative sample California residents. Cambodian refugees reported exceedingly poor health when compared to both the general population to the Asian participants. This disparity was only slightly reduced when Cambodian refugees were compared to the subsample of Asian immigrants who were matched on gender, age, income, and urbanicity. Although Cambodians refugees are older and poorer than the general population, their poor health cannot be fully attributed to these risk factors. Research is needed to guide health policy and practices aimed at eliminating this health disparity.

Each year approximately 1.5 million individuals in the US experience a physical injury serious enough to require hospitalization.1 Survivors of traumatic physical injuries are at increased risk for a variety of mental health problems including posttraumatic stress disorder (PTSD), major depression, and substance abuse problems.2–7 The mental health consequences of traumatic physical injuries can be burdensome and costly. PTSD, depression, and substance abuse have been associated with significant impairments in quality of life, functioning, and physical health.8–16 Despite the availability of effective treatments for the posttraumatic stress reactions that can follow injury,17,18 several studies suggest that the majority of those who could benefit from treatment fail to use mental health services.5,19 In a longitudinal study of trauma injury survivors, over a third perceived a need for treatment but did not seek help.19 In another longitudinal study with men who had been injured through community violence, only 23% of those who had met criteria for possible PTSD had obtained mental health care in the year after the injury.5 Similarly, cross-sectional studies conducted with nationally representative US samples demonstrate that a substantial proportion of individuals with PTSD do not obtain mental health services.20,21 Attempts to understand the factors that facilitate mental health service use have met with limited success.22 Some have posited that this may be partly due to the substantial emphasis placed on patient-related factors.22,23 Most studies on mental health service utilization have focused on patient factors that can be classified within the behavioral model of health service use.22,23 The behavioral model includes individual need, predisposing characteristics, and enabling resources that have been posited as important influences on treatment seeking.24 Need factors include objective (eg, symptoms of PTSD) and subjective (eg, distress) indicators of need. Predisposing characteristics consist of stable factors existing before the illness (eg, age, gender). Enabling resources involve factors that may facilitate or hinder service utilization (eg, health insurance coverage). Studies on mental health service use among trauma survivors have placed a similar, almost exclusive, focus on patient factors as determinants of treatment utilization (for recent reviews see25,26). However, mental health service utilization may be influenced by other factors, above and beyond those of patient characteristics, such as the behavior and actions of providers. In fact, collaborative care perspectives of health care underscore the influential role of providers, in particular physicians, in facilitating access to mental health services.22,27,28 In the President’s New Freedom Commission report,28 physician mental health screening and referral were identified as key components to a transformed mental health system. Physicians can provide an important entryway into the mental health system given that they are often the first point of contact for people with mental health problems.29–33 Yet, limited studies have examined provider influences, such as physician referral, on mental health service use. Moreover, no study has investigated the relative contribution of provider versus patient factors on mental health treatment utilization. Understanding the differential influences of provider and patient factors on mental health service use seems vital to guiding policy and programming. Using longitudinal data on a representative sample of Los Angeles County (LAC) trauma center patients, the purposes of the present study were: (1) to assess rates of mental health service utilization for emotional problems after traumatic injury; and (2) to investigate the relative influence of physician referral and patient-related (ie, need, predisposing, and enabling) factors on mental health service utilization.

The misuse of alcohol and illicit drugs is implicated with injury and repeat injury. Admission to a trauma center provides an opportunity to identify patients with substance use problems and initiate intervention and prevention strategies. To facilitate the identification of trauma patients with substance use problems, we studied alcohol abuse and illegal substance use patterns in a large cohort of urban trauma patients, identified correlates of alcohol abuse, and assessed the utility of a single item binge-drinking screener for identifying patients with past 12-month substance use problems.Between February 2004 and August 2006, 677 patients from four large trauma centers in Los Angeles County were interviewed. The sample was broadly representative of the entire Los Angeles County trauma center patient population.Twenty-four percent of patients met criteria for alcohol abuse and 15% reported using an illegal drug other than marijuana in the past 12 months. Male gender, assaultive injury, peritrauma substance use, and history of binge drinking were prominent risk factors. A single item binge drinking screen correctly identified alcohol abuse status in 76% of all patients; the screen also performed moderately well in discriminating between those who had or had not used illegal drugs in the past 12 months, with sensitivity estimates reaching 0.79 and specificity estimates reaching 0.74.A large proportion of urban trauma patients abuse alcohol and use illegal drugs. Distinct sociodemographic and substance use history may indicate underlying risky behaviors. Interventions and injury prevention programs need to address these causal behaviors to reduce injury morbidity and recidivism. In the busy trauma care setting, a one-item screener could be helpful in identifying patients who would benefit from more thorough assessment and possible brief intervention.

We consider situations in which externally observable characteristics allow experts to quickly categorize individual households as likely or unlikely to contain a member of a rare target population. This classification can form the basis of disproportionate stratified sampling such that households classified as "unlikely" are sampled at a lower rate than those classified as "likely," thereby reducing screening costs. Design weights account for this approach and allow unbiased estimates for the target population. We demonstrate that with sensitivity and specificity of expert classification at least 70 percent, and ideally at least 80 percent, our approach can economically increase effective sample size for a rare population. We develop heuristics for implementing this approach and demonstrate that sensitivity drives design effects and screening costs whereas specificity only drives the latter. We demonstrate that the potential gains from this approach increase as the target population becomes rarer. We further show that for most applications, unlikely strata should be sampled at 1/6 to 1/2 the rate of likely strata. This approach was applied to a survey of Cambodian immigrants in which the 82 percent of households rated "unlikely" were sampled at 1/4 the rate as "likely" households, reducing screening from 9.4 to 4.0 approaches per complete. Sensitivity and specificity were 86 percent and 91 percent, respectively. Weighted estimation had a design effect of 1.26, so screening costs per effective sample size were reduced by 47 percent. We also note that in this instance, expert classification appeared to be uncorrelated with survey outcomes of interest among eligibles.

Surveys of the recipients of health care are increasingly important means of assessing the care provided by health plans, hospitals, physicians, and other entities (Lied et al. 2003; Tai-Seale 2004; Darby, Hays, and Kletke 2005). At the same time, an aging population means that more patients are unable to answer surveys themselves. The use of proxy respondents provides a practical solution to survey nonresponse and missing data attributable to limitations in the ability of patients, beneficiaries, or nursing home residents to respond themselves. By asking representatives to respond on behalf of the patient, survey researchers need not omit the experiences of the least healthy and most vulnerable. For these reasons, most health care surveys allow the use of proxy respondents. Yet, questions inevitably arise about whether proxies give responses comparable to what might have been self-reported. One might ask whether there is systematic bias or substantial decrement in reliability from the use of proxy responses that erodes much of the apparent gains from reducing the selective omission of those needing assistance in responding. Prior research on proxy response has largely focused on differences between self- and proxy responses reporting on the experiences of the same individual. Much of this work has taken place with small convenience samples of patients, often with severe health problems (e.g., end-of-life, schizophrenia, or lung cancer) (Kutner et al. 2006; Hoe et al. 2007; Wennman-Larsen et al. 2007). In such a design, any differences between the self- and proxy responses are because the proxy is reporting on the same experiences in a different way than self-respondents. While typically in poor health, targets in these studies are by definition able and willing to provide self-responses, and thus differ fundamentally from individuals who require proxy assistance. Those who are unable to respond for themselves are not represented in these prior studies and may differ in other important ways. This prior research finds that proxies can both over- and underestimate morbidity and disability (Magaziner et al. 1988; Sneeuw et al. 1997; Shaw, McColl, and Bond 2000; Todorov and Kirchner 2000; Duncan et al. 2002; Tang and McCorkle 2002; Pickard et al. 2004) and other aspects of health-related quality of life (Hays et al. 1995; Andresen, Vahle, and Lollar 2001; Becchi et al. 2004; Higashi et al. 2005; Kutner et al. 2006; Hoe et al. 2007). Proxy reporting differences may be attributable to different cognitive and perceptual strategies to answering questions (Todorov and Kirchner 2000; Stineman et al. 2004; Lynn Snow et al. 2005). Proxy respondents rely on observable factors, such as counts or the presence or absence of a symptom (Lynn Snow et al. 2005), suggesting smaller discrepancies between self- and proxy-reports for objective or observable measures than for subjective measures (Whiteman and Green 1997; Todorov and Kirchner 2000; Sneeuw, Sprangers, and Aaronson 2002; Pickard et al. 2004; Stineman et al. 2004). The relationship of the proxy to the intended respondent may also influence the accuracy of proxy responses. Some research suggests that spouses and proxies who live with the intended respondent provide responses that are closer to those of the intended respondent than do other family members (Shaw et al. 2000; The Medical Research Council Cognitive Function and Ageing Study 2000). This finding may be a function of both the opportunity for direct observation and of a similarity in perspective attributable to similarity in age, education, and other factors (Qian and Preston 1993) that are known to influence evaluations of health care (Elliott et al. 2001; Zaslavsky et al. 2001). In nursing homes and other institutional settings, spouses and family members are often less readily available than nonrelative adults, such as health care workers. Several studies examined the similarity of these proxy responses to those from spouses and other relatives (Rubenstein et al. 1984; Becchi et al. 2004; Kane et al. 2005; Kutner et al. 2006). The answer may depend on the subjectivity of the measure. For example, compared with relatives, nurse proxy reports on number of instrumental activities of daily living are closer to patient self-reports (Rubenstein et al. 1984), but nonrelative and relative proxies reports on nursing home resident quality of life were about equally close to resident self-reports. When beneficiaries are unable to provide responses independently to the CAHPS® Medicare Fee-for-Service (MFFS) and Medicare Managed Care (MMC, now Medicare Advantage or MA) surveys, proxies are permitted to participate in ways that range from assistance (by reading the questions, writing down the answers the beneficiary gives, translating the questions into the beneficiary's language, or helping in some other similar manner) to serving as a proxy respondent (i.e., answering about the beneficiary's experiences in place of the beneficiary). The current practice in the CAHPS MFFS is to use case-mix adjustment (CMA) with “assisted” and “proxy respondent” cases distinguished from “unassisted” cases, controlling for age, self-rated health, and education (Zaslavsky, Zaborski, and Cleary 2000; Elliott et al. 2001; Zaslavsky et al. 2001). This approach has found consistently less positive evaluations when proxy respondents were used (Zaslavsky, Zaborski, and Cleary 2000; Elliott et al. 2001; Zaslavsky et al. 2001), but the reasons for these differences have not been investigated. When subgroups, such as unassisted and proxy respondent cases, are very dissimilar, CMA and other regression methods by themselves may produce biased estimates of the effect of proxy use if the regression model is misspecified. This may occur because proxy status is not typically randomly assigned and standard regression methods give equal weight to all cases, including those cases with almost no chance of membership in the group to which they are being compared. To address this limitation, we employed propensity score weighting (PSW) to focus the comparison on the subgroup of beneficiaries who most resembled the beneficiaries who employed assistance or proxy respondents (Hirano and Imbens 2001). The propensity score is the probability that an individual belongs to a naturally occurring treatment group based on the individual's characteristics (Rosenbaum and Rubin 1983). This approach approximates inference under experimental assignment of treatment group under the assumption that there are no omitted variables in the propensity model relevant to selection into treatment. In practice, the technique may greatly reduce bias due to selection of the less healthy into the proxy treatment group and result in a more accurate measure of the effects of proxy use even when the assumption is not fully met, because it makes the regression model less sensitive to misspecification (Robins, Hernan, and Brumback 2000). Similarly, the use of covariates in regression in combination with PSW increases the robustness to misspecification of the propensity model (Robins et al. 2000). The PSW technique has been demonstrated to substantially reduce unadjusted differences in between self- and proxy reported health among Medicare beneficiaries (Ellis, Bannister, and Cox 2003). We hypothesize that PSW will also reduce the estimated size of proxy effects on evaluation of care received. Our study investigates proxy effects so that we can better measure the care received by vulnerable recipients of health care. We explore the extent to which observed differences in ratings and reports of care are likely to be a result of actual patient experience and unobserved selection. We also assess whether rating differences vary as a function of characteristics of the survey items and by the nature of full proxy respondents. This study extends the existing literature by (1) estimating proxy effects among those who cannot or will not self-respond in dyad studies and (2) examining the extent to which mere assistance may influence survey responses. Additionally, we compare proxy estimates obtained from the standard regression-based approach with estimates obtained using PSW, bringing a new approach to the study of proxy effects on responses.

Purpose: To determine whether early adolescents who are exposed to alcohol marketing are subsequently more likely to drink. Recent studies suggest that exposure to alcohol ads has a limited influence on drinking in mid-adolescence. Early adolescents may be more vulnerable to alcohol advertising effects. Methods: Two in-school surveys of 1786 South Dakota youth measured exposure to television beer advertisements, alcohol ads in magazines, in-store beer displays and beer concessions, radio- listening time, and ownership of beer promotional items during 6th grade, and drinking intentions and behavior at 7th grade. Multivariate regression equations predicted the two drinking outcomes using the advertising exposure variables and controlling for psychosocial factors and prior drinking. Results: After adjusting for covariates, the joint effect of exposure to advertising from all six sources at grade 6 was strongly predictive of grade 7 drinking and grade 7 intentions to drink. Youth in the 75th percentile of alcohol marketing exposure had a predicted probability of drinking that was 50% greater than that of youth in the 25th percentile. Conclusions: Although causal effects are uncertain, policy makers should consider limiting a variety of marketing practices that could contribute to drinking in early adolescence. © 2007 Society for Adolescent Medicine. All rights reserved.

The present study assesses current drinking behavior in a representative sample of Cambodian refugees. Earlier estimates of alcohol use in this population suggest that Cambodian refugees are at elevated risk for alcohol-use problems, but these studies have relied on convenience samples and may not reflect current consumption patterns.A cross-sectional, face-to-face interview was conducted in Khmer on a household probability sample of Cambodian refugees residing in the largest such community in the United States. The overall response rate was 87% and yielded 490 respondents in the current analyses.Rates of consumption and alcohol-use problems were low in this population. Few participants (26%) reported any alcohol consumption in the 30 days preceding the interview, and only 2% reported any heavy drinking in the last 30 days. Multivariate analyses indicated that younger participants and men were more likely to report any recent drinking, and men were more likely to report any heavy drinking. Notably, recent consumption was not related to degree of trauma exposure or extent of psychiatric distress when controlling for age and gender.These data contrast dramatically with the widespread belief that Cambodian refugees are at elevated risk for problem drinking. Findings highlight the pitfalls of drawing population-based conclusions from data based on nonrepresentative samples or from nonstandard measures of alcohol consumption.

HIV/AIDS increasingly affects women, and housing status is important to understanding HIV risk behaviors among women. The goal of this study is to enhance understanding of the association between housing status and a key sexual risk behavior, having multiple sex partners, by investigating the extent to which housing status differences can be accounted for by hypothesized explanatory factors. In a probability sample of 833 women in Los Angeles, results indicated that homeless African American and Hispanic women had from two to almost five times greater odds than low-income housed women of having multiple sex partners in the past 6 months. These disparities in risk behavior were accounted for by housing status differences in perceived susceptibility to HIV/AIDS, recent victimization by physical violence, drug use severity, and avoidant coping. Findings provide further evidence that interventions should address a multifaceted context of HIV risk for impoverished women.

Asian Americans encounter barriers to mental health care, some of which are structural, whereas others may be cultural. Using data from a probability sample (N = 490) drawn from the largest Cambodian refugee community in the United States, the authors assessed the extent to which structural and cultural barriers were experienced. Surprisingly, a relatively small proportion endorsed commonly cited cultural barriers such as distrust of Western care (4%) and greater confidence in alternative care (5%), whereas most endorsed structural barriers such as high cost (80%) and language (66%). Among those with a probable diagnosis, a similar pattern was found. Findings suggest that structural, not culturally based, barriers are the most critical obstacles to care in this U.S. Cambodian refugee community.

The CAHPS® hospital project is an effort jointly sponsored by the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality to collect data that objectively measure patients' perceptions of hospital care and services. The CAHPS consortium has developed a standardized survey instrument for collecting information from recently discharged adult patients about care they received in medical, surgical, or obstetric sections of acute care hospitals. In this paper, we describe unit and item nonresponse patterns in the pilot version of the CAHPS Hospital Survey, which was conducted in Arizona, Maryland, and New York. A subset of items on the pilot survey will be used in national implementation (see Goldstein et al. 2005). Surveys generally do not yield complete responses from every individual sampled from the population. In certain situations, nonresponse can bias the survey findings if appropriate adjustments are not made. There are two basic types of survey nonresponse. Unit nonresponse is the failure of a member of the sample to respond to the survey as a whole. Item nonresponse is the failure of a unit respondent to answer one or more survey items that the respondent is eligible to answer. In this analysis, we examine and model patterns of both unit and item nonresponse to the pilot CAHPS Hospital Survey to assess the potential impacts of nonresponse bias and the corresponding adjustments. (Throughout this paper, nonresponse and nonresponse bias refer to unit nonresponse unless otherwise specified.) There are other sources of bias that have the potential to affect analyses of the CAHPS hospital data. In particular, the mix of services and patient characteristics often varies significantly among hospitals. Thus, comparisons of CAHPS Hospital Survey data across hospitals or across different groups of patients may be biased unless case-mix adjustments are made to take such differences into account. It is important that nonresponse analyses of the CAHPS Hospital Survey data be made in conjunction with case-mix analyses, as one type adjustment may affect biases targeted by the other. Thus, once eligible discharges have been selected from each hospital, there are at least two links from this targeted group of patients to the data ultimately obtained, each of which can threaten equitable comparisons among hospitals. Case-mix adjustments attempt to account for response bias among respondents—i.e., the systematic lack of correspondence between actual health care experiences and reports thereof among respondents (see O'Malley et al. 2005). Nonresponse analyses, the subject of the present manuscript, attempt to account for nonresponse bias resulting from differences between respondents and the full set of those targeted by the survey. Together, case-mix adjustment and nonresponse analyses enable survey estimates to more accurately reflect consumer experience of hospital performance and to provide more informative comparisons with consumers, hospitals, and other stakeholders engaging in quality improvement efforts.

To evaluate the need for survey mode adjustments to hospital care evaluations by discharged inpatients and develop the appropriate adjustments.A total of 7,555 respondents from a 2006 national random sample of 45 hospitals who completed the CAHPS Hospital (HCAHPS [Hospital Consumer Assessments of Healthcare Providers and Systems]) Survey.We estimated mode effects in linear models that predicted each HCAHPS outcome from hospital-fixed effects and patient-mix adjustors.Patients randomized to the telephone and active interactive voice response (IVR) modes provided more positive evaluations than patients randomized to mail and mixed (mail with telephone follow-up) modes, with some effects equivalent to more than 30 percentile points in hospital rankings. Mode effects are consistent across hospitals and are generally larger than total patient-mix effects. Patient-mix adjustment accounts for any nonresponse bias that could have been addressed through weighting.Valid comparisons of hospital performance require that reported hospital scores be adjusted for survey mode and patient mix.

This study examined U.S. Cambodian refugees' use of complementary and alternative medicine and Western sources of care for psychiatric problems. Analyses assessed the extent to which complementary and alternative medicine was used in the absence of Western mental health treatment and whether use of complementary and alternative medicine was associated with decreased use of Western services.Face-to-face interviews were conducted with a representative sample drawn from the largest Cambodian refugee community in the United States. The sample included 339 persons who met criteria in the past 12 months for posttraumatic stress disorder, major depression, or alcohol use disorder. Respondents described contact with complementary and alternative medicine and Western service providers for psychological problems in the preceding 12 months. Bivariate and multivariate logistic regression analyses were used.Seventy-two percent of the sample sought Western mental health services, and 34% relied on complementary and alternative medicine in the past year. Seeking complementary and alternative medicine was strongly and positively associated with seeking Western services, contrary to the hypothesis that use of complementary and alternative medicine inhibits seeking Western mental health treatment.Only a small percentage of Cambodian refugees used complementary and alternative medicine exclusively (5%), and utilization of complementary and alternative medicine was positively associated with seeking Western sources of care for mental health problems. Complementary and alternative medicine use does not appear to be a significant barrier to mental health treatment in this population, contrary to the Surgeon General's conclusion that Asian Americans' use of alternative resources may inhibit their utilization of Western mental health care.

Consumer Assessment of Health Care Providers and Systems (CAHPS) is an organized effort to provide consumers with standardized, comprehensible, and usable data regarding consumers' experiences with health care. In its Medicare and other summary reports, CAHPS emphasizes the frequency of the most positive experiences. Cognitive models of survey response combined with attitude theory suggest that performance measurement might be further improved by the addition of problem-oriented reporting, which highlights the frequency of negative experiences. We propose criteria and use them to assess whether problem-oriented reporting provides valid, precise, and complementary information. Analysis of the 2000 CAHPS Medicare Fee-For-Service and 2001 CAHPS Medicare Advantage survey data shows that problem-oriented reporting (1) is viable, interpretable, and unlikely to represent noise; (2) has statistical power sufficient to capture important differences of magnitudes commonly observed; and (3) provides information that complements standard reporting.

Objectives. We assessed the rates and correlates of seeking mental health services among a probability sample of Cambodian refugees who needed such services. Methods. Interviewers conducted face-to-face interviews with a representative sample drawn from the largest US community of Cambodian refugees. The analytic sample included 339 persons who met past 12-month criteria for posttraumatic stress disorder, major depression disorder, or alcohol use disorder. Respondents described contact with service providers for psychological problems during the preceding 12 months. We examined bivariate and multivariate predictors of seeking services. Results. Respondents reported high rates of contact with both medical care providers (70%) and mental health care providers (46%). Seeking services from both types of providers was associated with lack of English-speaking proficiency, unemployment, 3 or fewer years of preimmigration education, and being retired or disabled. Women, individuals with health insurance, and persons receiving government assistance also were more likely to seek services. Conclusions. Cambodian refugees with mental health problems had high rates of seeking service for psychological problems during the preceding 12 months. Research is needed to examine the effectiveness of services received by Cambodian refugees.

To examine the predictors of unit and item nonresponse, the magnitude of nonresponse bias, and the need for nonresponse weights in the Consumer Assessment of Health Care Providers and Systems (CAHPS) Hospital Survey.A common set of 11 administrative variables (41 degrees of freedom) was used to predict unit nonresponse and the rate of item nonresponse in multivariate models. Descriptive statistics were used to examine the impact of nonresponse on CAHPS Hospital Survey ratings and reports.Unit nonresponse was highest for younger patients and patients other than non-Hispanic whites (p.001); item nonresponse increased steadily with age (p.001). Fourteen of 20 reports of ratings of care had significant (p.05) but small negative correlations with nonresponse weights (median -0.06; maximum -0.09). Nonresponse weights do not improve overall precision below sample sizes of 300-1,000, and are unlikely to improve the precision of hospital comparisons. In some contexts, case-mix adjustment eliminates most observed nonresponse bias.Nonresponse weights should not be used for between-hospital comparisons of the CAHPS Hospital Survey, but may make small contributions to overall estimates or demographic comparisons, especially in the absence of case-mix adjustment.

The authors examined the relationship among trauma, coping, depression, and mental health service seeking in a probability sample of sheltered homeless and low-income housed women. Results highlight the diversity of trauma. In a longitudinal analysis, women who lived in shelters or experienced major violence had a twofold increase in their risk of depression over the 6-month follow-up. In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health service seeking among traumatized women. Modifying coping strategies may ameliorate some of the negative impact of trauma and potentially enhance mental health service use among at-risk women.

Background: The Consumer Assessment of Health Plans Study (CAHPS) health plan survey is currently administered to large independent samples of Medicaid beneficiaries and commercial enrollees for managed care organizationsthat serve both populations. There is interest in reducing survey administration costs and sample size requirements by sampling these 2 groups together for health plan comparisons. Plan managers may also be interested in understanding variability within plans. Objective: The objective of this study was to assess whether the within plan correlation of CAHPS scores for the 2 populations are sufficiently large to warrant inferences about one from the other, reducing the total sample sizes needed. Research Design: This study consisted of an observational cross-sectional study. Subjects: Subjects were 3939 Medicaid beneficiaries and 3027 commercial enrollees in 6 New Jersey managed care plans serving both populations. Measures: Outcomes are 4 global ratings and 6 report composites from the CAHPS 1.0 survey. Results: Medicaid beneficiaries reported poorer care than commercial beneficiaries for 6 composites, but none of the 4 global ratings. Controlling for these main effects, variability between commercial enrollees and Medicaid beneficiaries within plans exceeded variability by plans for commercial enrollees for 4 of the 10 measures (2 composites, 2 global ratings). Conclusions: Within-plan variability in evaluations of care by Medicaid and commercial health plan member evaluations is too great to permit meaningful inference about plan performance for one population from the other for many important outcomes; separate surveys should still be fielded.

Στόχοι: Να διερευνηθεί η σχέση ανάμεσα στη χρήση αλκοόλ από εφήβους και στην έκθεση σε διαφημίσεις για το αλκοόλ, στις Ηνωμένες Πολιτείες. Να αξιολογηθεί, εάν η συμμετοχή σε κάποιο πρόγραμμα πρόληψης για τη χρήση αλκοόλ και ναρκωτικών ουσιών μπορεί να μετριάσει αυτή τη σχέση. Σχεδιασμός: Μοντέλα παλινδρόμησης με πολλαπλές μεταβλητές ελέγχου, οι οποίες διερεύνησαν τη σχέση ανάμεσα στην έκθεση των εφήβων σε διαφημίσεις για το αλκοόλ στη δεύτερη τάξη του γυμνασίου και στην κατανάλωση αλκοόλ στην τρίτη τάξη του γυμνασίου, σε δύο ομάδες εφήβων από τη Νότια Ντακότα: (1) μαθητές στην πρώτη τάξη του γυμνασίου που δεν κατανάλωναν αλκοόλ (n= 1206) και (2) μαθητές στην πρώτη τάξη του γυμνασίου που κατανάλωναν αλκοόλ (n= 1905). Διερευνήθηκε η αλληλεπίδραση ανάμεσα στο πρόγραμμα παρέμβασης και στους σημαντικούς παράγοντες πρόβλεψης της χρήσης αλκοόλ που σχετίζονται με τις διαφημίσεις. Χώρος: Σαράντα ένα σχολεία μέσης εκπαίδευσης στην Νότια Ντακότα στις ΗΠΑ. Συμμετέχοντες: Συνολικά 3.111 μαθητές της πρώτης τάξης του γυμνασίου, οι οποίοι ακολουθήθηκαν μέχρι την τρίτη τάξη του γυμνασίου. Μετρήσεις: Διαμορφώθηκαν μεταβλητές, για τα τέσσερα είδη διαφημίσεων αλκοόλ τα οποία προβλήθηκαν στην τηλεόραση, σε μαγαζιά, σε περιοδικά και σε σημεία πώλησης μπύρας. Άλλοι παράγοντες πρόβλεψης που ελέγχθηκαν, περιελάμβαναν τις κοινωνικές επιρροές, τους κοινωνικούς δεσμούς, τις προβληματικές συμπεριφορές, τις αντιλήψεις σχετικά με το αλκοόλ, την έκθεση στην τηλεόραση και τα δημογραφικά χαρακτηριστικά. Ευρήματα: Για τους μαθητές της πρώτης τάξης του γυμνασίου που δεν κατανάλωναν αλκοόλ, η έκθεση σε διαφημίσεις μπύρας σε μαγαζιά και σε σημεία πώλησης μπύρας σε χώρους μουσικών και αθλητικών εκδηλώσεων, προέβλεπε τη συχνότητα κατανάλωσης αλκοόλ στην τρίτη τάξη του γυμνασίου. Αν και η έκθεση σε διαφημίσεις μπύρας στην τηλεόραση είχε σημαντική διμεταβλητή σχέση με τη χρήση αλκοόλ από τους μαθητές της πρώτης τάξης του γυμνασίου που δεν κατανάλωναν αλκοόλ, δεν αποτέλεσε σημαντικό παράγοντα πρόβλεψης για την κατανάλωση αλκοόλ για καμία από τις δύο ομάδες στην ανάλυση των πολλαπλών μεταβλητών. Η συμμετοχή στο πρόγραμμα πρόληψης ALERT Plus περιόρισε τη μελλοντική κατανάλωση αλκοόλ και στις δύο ομάδες και εξουδετέρωσε την επιρροή από την έκθεση σε διαφημίσεις μπύρας σε μαγαζιά. Συμπεράσματα: Οι διάφορες μορφές διαφήμισης του αλκοόλ μπορούν να προβλέψουν την κατανάλωση αλκοόλ από εφήβους. Όσον αφορά ωστόσο το ποιες πηγές θα επικρατήσουν εξαρτάται από την προηγούμενη εμπειρία-σχέση του παιδιού με το αλκοόλ. Τα προγράμματα και οι πολιτικές πρόληψης θα μπορούσαν να βοηθήσουν τα παιδιά να αντιδράσουν στις διαφορετικού τύπου διαφημίσεις αλκοόλ και να περιορίσουν την έκθεση σε αυτές. Λέξεις κλειδιά: υγεία στην εφηβεία, αλκοόλ, μέσα μαζικής ενημέρωσης.

Aims To examine the relationship between exposure to different forms of alcohol advertising and subsequent drinking among US adolescents and assess whether exposure to an alcohol and drug prevention program mitigates any such relationship. Design Regression models with multiple control variables examined the relationship between exposure to alcohol advertising in grade 8 and grade 9 drinking for two groups of South Dakotan adolescents: (1) seventh-grade non-drinkers (n = 1206) and (2) seventh-grade drinkers (n = 1905). Interactions between the intervention program and the significant advertising predictors were tested. Setting Forty-one middle schools in South Dakota, USA. Participants A total of 3111 seventh-graders followed through grade 9. Measurements Advertising variables were constructed for four types of alcohol advertising—television, in-store displays, magazines and concession stands. Other predictors tested included measures tapping social influences, social bonds, problem behavior, alcohol beliefs, television exposure and demographics. Findings For seventh-grade non-drinkers, exposure to in-store beer displays predicted drinking onset by grade 9; for seventh-grade drinkers, exposure to magazines with alcohol advertisements and to beer concession stands at sports or music events predicted frequency of grade 9 drinking. Although exposure to television beer advertising had a significant bivariate relationship with alcohol use for grade 7 non-drinkers, it was not a significant predictor of drinking for either group in multivariate analyses. Participation in the prevention program, ALERT Plus, reduced future drinking for both groups and counteracted the effect of in-store beer displays. Conclusions Several forms of alcohol advertising predict adolescent drinking; which sources dominate depends on the child's prior experience with alcohol. Alcohol prevention programs and policies should help children counter alcohol advertising from multiple sources and limit exposure to these sources.

BACKGROUND: Violence against women, substance use and disorder, and HIV represent three significant threats to the health of women, yet little is known about the extent of these epidemics among indigent women. This study investigates and documents differences in the prevalence and co-occurrence of physical and sexual violence, substance use and disorder, and HIV risk behavior in sizable probability samples of sheltered homeless and low-income housed women. METHODS: Retrospective self-reports were obtained through structured interviews with stratified random samples of women residing in shelters (N = 460) and low-income housing (N = 438) in Los Angeles County, California. RESULTS: Sheltered women were more likely than housed women to report experiencing physical and sexual violence, substance use and disorder, HIV risk behavior, and co-occurrence of these problems in the past year. Differences remained when propensity weights were used to equate the groups on demographic and background characteristics. CONCLUSIONS: Findings suggest remarkable need for services among communities of indigent women. Higher rates of problems among women in shelters highlight the importance of differentiating among subgroups of indigent women in community-based prevention and intervention activities and tentatively suggest a protective influence of housing. Language: en

Purpose The purpose of this study was to examine exposure, response to, and awareness of beer advertising in 2 age groups, including awareness of a Budweiser advertisement (ad) that portrayed lizards and an animated ferret. Methods In the spring of 2000, 1,996 fourth graders and 1,525 ninth graders attending 1 of 60 South Dakota schools participated in an in-school survey. Several indicators of advertising awareness, exposure, and response were assessed: recognition, product naming, brand naming, and liking in response to stills drawn from 4 masked television beer ads, listing of beer brands, exposure, attention to, and skepticism toward television beer ads. Results Fourteen percent of 4th graders and 20% of 9th graders recognized at least 3 of 4 sample beer ads. Seventy-five percent of 4th graders and 87% of 9th graders recognized the Budweiser ferret ad; about one in three 4th graders could name the brand it advertised, whereas more than three in four 9th graders could do so. When asked to list as many beer brands as they could, almost 29% of 4th graders listed 3 or more beer brands and 82% of 9th graders did so. Ninth graders liked beer advertisements more and paid greater attention to them, but 4th graders were exposed to them more often. Conclusion Television beer ads result in high levels of beer advertising awareness in children as young as age 9, and even higher awareness among 14-year-olds. Practices that expose or appeal to youth, including use of animated characters, should be avoided by beer advertisers.