Tetine Sentell

Access to Mental Health Treatment by English Language Proficiency and Race/Ethnicity

BackgroundLimited English proficiency (LEP) may contribute to mental health care disparities, yet empirical data are limited.ObjectiveTo quantify the language barriers to mental health care by race/ethnicity using a direct measure of LEP is the objective of the study.DesignCross-sectional analysis of the 2001 California Health Interview Survey is the study’s design.ParticipantsAdults aged 18 to 64 who provided language data (n = 41,984) were the participants of the study.MeasurementParticipants were categorized into three groups by self-reported English proficiency and language spoken at home: (1) English-speaking only, (2) Bilingual, and (3) Non-English speaking. Mental health treatment was measured by self-reported use of mental health services by those reporting a mental health need.ResultsNon-English speaking individuals had lower odds of receiving needed services (OR: 0.28; 95% CI: 0.17–0.48) than those who only spoke English, when other factors were controlled. The relationship was even more dramatic within racial/ethnic groups: non-English speaking Asian/PIs (OR = 0.15; 95% CI: 0.30–0.81) and non-English speaking Latinos (OR: 0.19; 95% CI: 0.09–0.39) had significantly lower odds of receiving services compared to Asian/PIs and Latinos who spoke only English.ConclusionsLEP is associated with lower use of mental health care. Since LEP is concentrated among Asian/PIs and Latinos, it appears to contribute to racial/ethnic disparities in mental health care. Heightened attention to LEP is warranted in both mental health practice and policy.

Impact of Health Literacy on Socioeconomic and Racial Differences in Health in an Elderly Population

BACKGROUND: Differences in health literacy levels by race and education are widely hypothesized to contribute to health disparities, but there is little direct evidence.OBJECTIVE: To examine the extent to which low health literacy exacerbates differences between racial and socioeconomic groups in terms of health status and receipt of vaccinations.DESIGN: Retrospective cohort study.PARTICIPANTS (OR PATIENTS OR SUBJECTS): Three thousand two hundred and sixty noninstitutionalized elderly persons enrolling in a Medicare managed care plan in 1997 in Cleveland, OH; Houston, TX: South Florida; and Tampa, FL.MEASUREMENTS: Dependent variables were physical health SF-12 score, mental health SF-12 score, self-reported health status, receipt of influenza vaccine, and receipt of pneumococcal vaccine. Independent variables included health literacy, educational attainment, race, income, age, sex, chronic health conditions, and smoking status.RESULTS: After adjusting for demographic and health-related variables, individuals without a high school education had worse physical and mental health and worse self-reported health status than those with a high school degree. Accounting for health literacy reduced these differences by 22% to 41%. Black individuals had worse self-reported health status and lower influenza and pneumococcal vaccination rates. Accounting for health literacy reduced the observed difference in self-reported health by 25% but did not affect differences in vaccination rates.CONCLUSIONS: We found that health literacy explained a small to moderate fraction of the differences in health status and, to a lesser degree, receipt of vaccinations that would normally be attributed to educational attainment and/or race if literacy was not considered.

Importance of Adult Literacy in Understanding Health Disparities

AbstractBACKGROUND: In several recent studies, the importance of education and race in explaining health-related disparities has diminished when literacy was considered. This relationship has not been tested in a nationally representative sample of U.S. adults. OBJECTIVE: To understand the effect of adult literacy on the explanatory power of education and race in predicting health status among U.S. adults. DESIGN: Using the 1992 National Adult Literacy Survey, logistic regression models predicting health status were estimated with and without literacy to test the effect of literacy inclusion on race and education. SUBJECTS: A nationally representative sample of 23,889 noninstitutionalized U.S. adults. MEASURES: Poor health status was measured by having a work-impairing condition or a long-term illness. Literacy was measured by an extensive functional skills test. RESULTS: When literacy was not considered, African Americans were 1.54 (95% confidence interval, 1.29 to 1.84) times more likely to have a work-impairing condition than whites, and completion of an additional level of education made one 0.75 (0.69 to 0.82) times as likely to have a work-impairing condition. When literacy was considered, the effect estimates of both African-American race and education diminished 32% to the point that they were no longer significantly associated with having a work-impairing condition. Similar results were seen with long-term illness. CONCLUSIONS: The inclusion of adult literacy reduces the explanatory power of crucial variables in health disparities research. Literacy inequity may be an important factor in health disparities, and a powerful avenue for alleviation efforts, which has been mistakenly attributed to other factors.

Colorectal Cancer Screening: Low Health Literacy and Limited English Proficiency Among Asians and Whites in California

The authors examined the relationship between low health literacy (LHL), limited English proficiency (LEP), and meeting current U.S. Preventive Service Task Force colorectal cancer (CRC) screening guidelines for Asians and Whites in California. For 1,478 Asian and 14,410 White respondents 50–75 years of age in the 2007 California Health Interview Survey, the authors examined meeting CRC screening guidelines using multivariable logistic models by LEP and LHL separately and in combination. Analyses were run with the full sample, then separately for Whites and Asians controlling for demographics and insurance. For those with LEP, patient-provider language concordance and CRC screening was examined. Overall, respondents with LEP and LHL were the least likely to meet CRC screening guidelines (36%) followed by LEP-only (45%), LHL-only (51%), and those with neither LHL nor LEP (59%), a hierarchy that remained significant in multivariable models. For Whites, LHL-only was associated with screening, whereas LEP-only and LEP and LHL were significant for Asians. Having a language concordant provider was not significantly associated with CRC screening among those with LEP. Health literacy is associated with CRC screening, but English proficiency is also critical to consider. Asians with both LEP and LHL appear particularly vulnerable to cancer screening disparities.

Comparison of potentially preventable hospitalizations related to diabetes among Native Hawaiian, Chinese, Filipino, and Japanese elderly compared with whites, Hawai'i, December 2006-December 2010.

Introduction Approximately 25% of individuals aged 65 years or older in the United States have diabetes mellitus. Diabetes rates in this age group are higher for Asian American and Pacific Islanders (AA/PI) than for whites. We examined racial/ethnic differences in diabetes-related potentially preventable hospitalizations (DRPH) among people aged 65 years or older for Japanese, Chinese, Filipinos, Native Hawaiians, and whites. Methods Discharge data for hospitalizations in Hawai‘i for people aged 65 years or older from December 2006 through December 2010 were compared. Annual rates of DRPH by patient were calculated for each racial/ethnic group by sex. Rate ratios (RRs) were calculated relative to whites. Multivariable models controlling for insurer, comorbidity, diabetes prevalence, age, and residence location provided final adjusted rates and RRs. Results A total of 1,815 DRPH were seen from 1,515 unique individuals. Unadjusted RRs for DRPH by patient were less than1 in all AA/PI study groups compared with whites, but were highest among Native Hawaiians and Filipinos. In fully adjusted models accounting for higher diabetes prevalence in AA/PI groups, Native Hawaiian (adjusted rate ratio [aRR] = 1.59), Filipino (aRR = 2.26), and Japanese (aRR = 1.86) men retained significantly higher rates of diabetes-related potentially preventable hospitalizations than whites, as did Filipino women (aRR = 1.61). Conclusion Native Hawaiian, Filipino, and Japanese men and Filipino women aged 65 years or older have a higher risk than whites for DRPH. Health care providers and public health programs for elderly patients should consider effective programs to reduce potentially preventable hospitalizations among Native Hawaiian, Filipino, and Japanese men and Filipino women aged 65 years or older.

Assessing Preferences for Schizophrenia Outcomes: Comprehension and Decision Strategies in Three Assessment Methods

Quantifying the importance of treatment outcomes by measuring preferences allows construction of aggregate outcome indicators that reflect the relative importance of multiple outcomes, trade-offs between outcomes, and the perspectives of different stakeholders. However, standard preference assessment methods are cognitively complex and may be particularly challenging for persons with schizophrenia and other serious mental illnesses. Preferences may not be meaningful or comparable across stakeholder groups if the groups do not use the methods in similar ways. This study combined qualitative and quantitative methods to compare comprehension and decision strategies across three standard preference assessment methods (Rating Scale, Time Tradeoff, and Paired Comparison) in 2 stakeholder groups (consumers of schizophrenia treatment and clinicians). Results indicate that the Rating Scale method is likely to yield the most valid and comparable preference values because it is well understood and acceptable to both consumers and clinicians. Both groups found the Time Tradeoff method difficult to use and poorly suited to evaluating schizophrenia outcomes.

Low literacy and mental illness in a nationally representative sample

Low literacy is a recognized barrier to efficient and effective health care (Ad Hoc Committee on Health Literacy, 1999). In mental health care, low literacy may have additional detrimental effects, diminishing comprehension of written and verbal diagnostic and assessment measures (Grace and Christensen, 1998), and complicating cognitive impairments associated with mental illness (Miles and Davis, 1995). Furthermore, chronic mental illness may lead to deterioration in literacy by limiting opportunities for reading and writing (Tfouni and Seidinger, 1997), as well as opportunities for formal education and vocational training (Frankie et al., 1996). Recent evidence from small studies in specific treatment settings suggests that low literacy is particularly common among adults with mental illness. In a study of 100 patients admitted to a state psychiatric hospital, 54% scored below the seventh-grade level, compared with 20% of the general population (Berg and Hammtt, 1980). In a sample of 45 homeless adults receiving outpatient psychiatric services, 76% read below an eighth-grade level and 27% read at or below a fourth-grade level (Christensen and Grace, 1999). A study of 48 long-term hospitalized patients in a state hospital found that almost half scored below a fourth-grade reading level (Coles et al., 1978). Some of the association between mental illness and literacy may be due to lower educational attainment among adults with mental illness. Yet these studies also confirm that, among adults with mental illness, literacy attainment is not identical to educational attainment. The study of 45 homeless adults found an almost a 4-year gap between average reading level (seventh grade) and average last grade completed in school (eleventh grade) (Christensen and Grace, 1999). In both the study of 100 patients admitted to a state psychiatric hospital (Berg and Hammitt, 1980) and in a study of 53 adults seen in a psychiatric emergency service (Currier et al., 2001), reading comprehension was not even correlated with educational attainment. Though existing studies indicate that mental illness is significantly associated with literacy even when education is controlled, this relationship has only been tested in small samples in specific treatment settings. Thus, the relationship of literacy to mental illness may be misrepresented. For instance, adults in treatment may not be representative of the general population, especially because less than half of persons with a diagnosable mental health disorder seek treatment of it (Kessler et al., 1994). Furthermore, the specific treatment settings sampled in most of the existing research on literacy and mental illness have been public health settings. The relationship of literacy and mental illness among adults in public care may vary from those who do not receive public care. Specifically, adults in public care may have lower literacy than other adults because poverty is associated with lower literacy (Kirsch et al., 1993). Also, minority adults may be overrepresented in public health settings. Minority race is also associated with lower literacy when education is controlled (Kirsch et al., 1993). One study of American adults assessed both mental illness and literacy in a nationally representative sample. The National Adult Literacy Survey (NALS), found that adults with a self-reported mental health problem (MHP) did have lower literacy skills than the general public (Kirsch et al., 1993). Approximately 75% of adults with a MHP were either functionally illiterate or marginally literate, compared with approximately 50% of the general population (Kirsch et al., 1993). However, in published results, these researchers did not control for other associated factors that might explain the relationship of literacy and mental illness, particularly education, poverty, and race. The current study extends analyses of the NALS, the most comprehensive assessment of adult literacy in the United States, to examine whether mental illness is associated with low literacy in a nationally representative sample after education, demographic, and socioeconomic factors are taken into account. Also, this study investigates whether mental illness is associated with reductions in literacy activities such as reading and writing that may lead to the deterioration of literacy skills and contribute to increased disability.

Health Literacy, Health Communication Challenges, and Cancer Screening Among Rural Native Hawaiian and Filipino Women

Native Hawaiians and Filipinos are disproportionately impacted by cancer and are less likely to participate in cancer screening than whites. Limited information exists about health information pathways and health communication challenges as they relate to cancer screening in these groups. Six focus groups (n = 77) of Native Hawaiian and Filipino women age 40 + years were conducted to investigate these research gaps. Participants noted many health information challenges. Challenges were both practical and interpersonal and included both written and oral health communication. Practical challenges included “big” words, complexity of terms, and lack of plain English. Interpersonal issues included doctors rushing, doctors not assessing comprehension, and doctors treating respondents as patients not people. Women noted that they would often not ask questions even when they knew they did not understand because they did not want the provider to think negatively of them. Overarching themes to improve cancer communication gaps included: (1) the importance of family and community in health information dissemination, (2) the key role women play in interpreting health information for others, (3) the importance of personal experience and relationships to the salience of health information, and (4) the desire for local cultural relevance in health communication. Findings are discussed in light of the 2010 National Action Plan for Health Literacy.

Illness Severity and Psychiatric Hospitalization Rates Among Asian Americans and Pacific Islanders

OBJECTIVE The study objective was to fill research gaps about inpatient psychiatric service utilization among Asian Americans and Pacific Islanders (AA/PIs). METHODS Rates of psychiatric hospitalization, illness severity, and length of stay were compared among AA/PI adults overall and across diagnoses (schizophrenia, depression, bipolar, anxiety, and other psychiatric disorders identified by All Patient Refined Diagnosis Related Groups) by using discharge data from all hospitalizations in Hawaii from December 2006 to 2010. Multivariable models adjusted for gender, age, payer, and residence. RESULTS In multivariable analyses of total psychiatric hospitalizations, Chinese (rate ratio [RR]=.22), Japanese (RR=.23), Filipinos (RR=.30), and Native Hawaiians (RR=.37) had significantly lower rates than whites. Native Hawaiians had significantly higher hospitalization rates compared with other AA/PI groups. Length of stay was significantly longer for Chinese (length of stay ratio [LOSR]=1.53), Filipinos (LOSR=1.20), and Japanese (LOSR=1.19) compared with whites, whereas severity of illness was significantly higher for Japanese (odds ratio [OR]=1.36) and Filipinos (OR=1.30). Within specific diagnoses, Native Hawaiians had higher hospitalization rates than other AA/PI groups for depression, bipolar disorder, and anxiety disorder. Chinese, Japanese, and Filipinos had significantly higher illness severity or longer stays than whites for at least one diagnostic category. CONCLUSIONS AA/PI subgroups had lower psychiatric hospitalization rates than whites, but rates varied across AA/PI subgroups. Native Hawaiians had higher hospitalization rates for many diagnoses. Chinese, Japanese, and Filipinos had greater illness severity or longer stays than whites overall and for some diagnoses, whereas Native Hawaiians did not. Disaggregating AA/PI groups provides important insight into mental health services utilization and need.

Gender Differences in Practice Patterns and Income Among Psychologists in Professional Practice

Income, an important facet of professional psychological practice, differs by gender. The potential sources of income differences among California clinical psychologists were investigated. Full-time female psychologists earned significantly less income on average than full-time male psychologists, despite similar patient demographics, caseloads, practice profiles, and payment sources. In separate regression models, professional experience increased income more for men than for women, whereas greater psychologist supply decreased income for both groups. According to the regression model, if female psychologists were paid like male psychologists, they would receive, on average,