Mildred Vera

Social Networks and Patterns of Use Among the Poor with Mental Health Problems in Puerto Rico

OBJECTIVES This study uses the recently developed Network-Episode Model (NEM) to examine the nature and correlates of utilization among Puerto Ricans reporting mental health problems. The NEM highlights two issues: (1) examining the patterns or combinations of lay and formal use that individuals employ and (2) reformulating how the availability and content of social networks influences patterns of care. METHODS Using data from the 1989 Mental Health Care Utilization Among Puerto Ricans Study (probability sample of 1,777 individuals living in low-income areas of the island), the authors focus on the patterns and correlates of use for 365 Puerto Ricans reporting service use for mental health problems in the previous year. RESULTS A combination of clustering and multinomial logit techniques indicates that there are six unique care patterns. Two patterns include the use of mental health providers and are associated with different contingencies. CONCLUSIONS In general, patterns of use are shaped by age, education, gender, and illness severity. Larger, more supportive networks decrease the use of patterns of care that include formal health care providers, and decrease direct entry into the mental health sector. These results are in line with NEMs predictions for lower class populations and help clarify inconsistencies in previous research on social networks. The implications of this perspective for health services research and treatment are discussed.

HIV infection, risk behaviors, and depressive symptoms among Puerto Rican sex workers.

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.

Gender and health services use for a mental health problem

This study addresses whether the predictors of seeking help for a mental health problem differ by gender. An adaptation of Andersens Socio-Behavioral Model is used to identify factors associated with seeking care for a mental health problem. Data are derived from two waves of a community survey undertaken in 1992-1993 and in 1993-1994 among a probability sample of adults (18-69 years), residing in poor areas of Puerto Rico. Paired data was used from those individuals who responded to both waves of the survey for a total of 3221 community respondents. Responses from wave 1 were used to predict mental health service use in wave 2. The dependent variable is any use of outpatient mental health services in the year preceding the second interview. Logistic regression was used to model the effects of the independent variables on use. Males and females were found to use mental health services in nearly equal proportions. Gender did not have a main effect on use when other covariates were controlled. Significant interactions with gender were found for several predictors of use. The largest intervention effects were encountered in our need for care indicators. Having a definite need for mental health care and poor self-rated mental health had a larger effect on predicting use of services for men than they do for women. It is concluded that strategies designed to improve access to mental health services for minority disadvantaged populations ought to take into account gender differences in the predictors of use. Studies addressing factors influencing health services utilization for a mental health problem should consider stratifying their sample by gender. Future research should establish whether or not these findings are sustained with other population groups.

Patterns of mental health utilization among Island Puerto Rican poor

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.

Changes in Access to Mental Health Care Among the Poor and Nonpoor: Results From the Health Care Reform in Puerto Rico

OBJECTIVES Health care reforms associated with managed care may adversely affect the health care safety net for disadvantaged populations. This study compared changes in health care use among poor and nonpoor individuals enrolled in managed care. METHODS Data from 3 waves of a random community sample were collected on approximately 3,000 adults. Changes in use of mental health services were assessed in a pretest-posttest, quasi-experimental design. RESULTS Managed care increased use of specialty services among the nonpoor while maintaining the same level of use for the poor in the public sector. CONCLUSIONS Reallocation of mental health services may be a result of expanding Medicaid eligibility.

Does managed mental health care reallocate resources to those with greater need for services

Evidence points to the existence of two coexisting inefficiencies in mental health care resource allocation: those with need receive too limited or no care while those with no apparent need receive services. In addition to reducing costs, managed mental health care is expected to reallocate treatment resources to those with greater need for services. However, there are no empirical findings regarding this issue. This study tests whether managed mental health care has had a differential impact by level of need. Data consist of three waves of a community sample with a control group. The study finds that managed care has not succeeded in reallocating resources from the unlikely to the definite “needers.”

Street-Based Female Adolescent Puerto Rican Sex Workers: Contextual Issues and Health Needs

This study examines the motivations social context and health needs of street-based adolescent sex workers in Puerto Rico. Data were collected from 78 female adolescents aged 13-18 years who traded sex for money drugs or other goods. The results showed that the most important factor driving adolescents into sex work is their financial situation wherein three-fourths of the sample stated money as their primary motivation. Although some respondents perceived sex work as a source of income most of them considered sex work as a means to fulfill their need for material things. Social context and exposure bring about this desire for material possessions to media that are filled with images of material wealth and beauty. Furthermore having friends or relatives who are also sex workers contributed to adolescents perception of sex work as a viable alternative for them. With regards to the health status of Hispanic adolescent sex workers 15 participants (19.2%) were tested positive for sexually transmitted infections while almost two-thirds of them displayed high levels of depressive symptoms. Moreover 44.9% reported drug use during the 6 months prior to the study and 69.2% reported having a nonpaying sexual partner during the same period of time. These findings suggest the need for comprehensive programming to include individual interpersonal and greater environmental interventions.

CAN WE CONCEPTUALIZE AND MEASURE CONTINUITY OF CARE IN INDIVIDUAL EPISODES? THE CASE OF MENTAL HEALTH SERVICES IN PUERTO RICO*

Abstract While continuity of care becomes a more pressing issue given changes in the locus of medical care under reform initiatives, our ability to understand how socio-medical factors shape the continued use of medical care services is limited by current conceptual and measurement tools. In this paper, we reconsider the possibility of measuring continuity of care for individuals during the course of an episode of illness. We recognize the inherent heterogeneity in the notion of “continuity” and suggest that different scenarios produce breaks in the use and delivery of services. We lay out two crucial distinctions. The first targets the type of breaks in continuous care, distinguishing among provider, sector and system continuity. Second, we examine the source of provider continuity, separating breaks in health service use that result from the clients failure to remain in treatment and the health care systems failure to provide for continuous care. We suspect that these scenarios represent different soc...

A note on implementation of a random-walk design to study adolescent social networks☆

Abstract Starting with adolescents residing in an inner-city neighborhood, a random-walk sampling design was implemented with the aim of examining the socioecological context of behaviors pertinent to HIV transmission. A three-step, four-node random walk was attempted for each initial respondent, n = 43, of a probability sample of 12–15-year-old boys and girls who resided in a census-tract delimited area. The success rate in identifying and locating named associates was approximately 62%. The response rate of locatable associates exceeded 90%. No systematic item non-response or refusal was apparent in the interview process. The major obstacle to implementation was difficulty locating named associates and not, as anticipated, nonresponse or refusal to disclose sensitive information.

Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico

Background: Little is known about suicidal ideation among general practice patients in Puerto Rico. In this study we examined the rates, severity, and correlates of suicidal ideation, plans, and attempts among general practice patients with chronic illnesses. This is important in targeting appropriate interventions and management approaches to minimize and prevent suicide. Methods: We screened patients with chronic physical conditions at general practices. Suicidal ideation was assessed with the suicidality module of the Mini International Neuropsychiatric Interview. Major depression was assessed with the Patient Health Questionnaire depression module. The relationship between sociodemographic factors, depression and suicidal ideation was examined with multiple logistic regression analysis. Among the subgroup that acknowledged suicidal ideation, we used multinomial logistic regression analysis to estimate simultaneously the multivariate associations of depression and sociodemographic factors with suicidality risk levels. Results: Of the 2068 patients screened, 15.4% acknowledged recent suicidal ideation. Among this group, 8.6% reported passive ideation, 3.7% active ideation without a plan, and 3.1% active ideation with a plan or attempt. According to multivariate logistic regression, suicidal ideation was higher among patients with moderately severe depression and severe depression than for those with milder symptoms. Patients aged 64 years or younger were over one and a half times more likely to acknowledge suicidal ideation than those aged 65 years and older. Compared with patients having a college degree, those with lower education had a twofold higher risk of suicidal ideation. Multinomial logistic regression analysis indicated that severe depression was associated with a higher likelihood of having a suicide plan or attempt. Conclusion: The findings of this study suggest that public health strategies focusing on the systematic identification of patients with increased depression severity and the implementation of evidence-based depression treatments are relevant for minimizing and preventing suicidal behavior among general practice patients with chronic health conditions.