Center Core. There are pervasive ethnic and racial disparities in mental health service utilization and in mental health status yet the underlying causes of these disparities are poorly understood. This application seeks to establish an Advanced Center for Latino and Mental Health Systems Research (Advanced Latino Disparities Center) that focuses on understanding the factors affecting mental health service disparities in Latinos and generating research and knowledge to eliminate them. This Center will be part of the Cambridge Health Alliance (CHA), Center for Multicultural Mental Health Research (CMMHR) and is built on the strengths and learning experiences of our ongoing NIMH-funded Latino Research Program Project (LRPP). The proposed Center is a five-year project, structured around two large (R01) and two smaller (pilot) projects. We support the research with an Administrative and Methods Core led by experienced, multidisciplinary investigators, build on the collaborative partnerships that characterize our past work, and mentor and develop junior investigators to become new experts in health disparities research. The overall aims of the Advanced Latino Disparities Center are to: (1) Establish an administrative structure that supports a synergistic core of researchers to conduct mental health service disparities research;(2) Institute a methodological and statistical component as an integral part of the proposed program;(3) Formulate and conduct an interdisciplinary mental health services disparity research program with a focus on four program areas: (a) Improving Clinical Assessment of Diagnosis for Latinos;(b) Identifying Sources Linked to Differential Assertive Community Treatment (ACT) Outcomes for Latinos;(c) Ethnic Differences in Perceived Impairment and Need for Care;and (d) Dialog with the Latino Community and Healthcare System Stakeholders for Identifying Quality Improvements;(4) Continue developing a cadre of young investigators committed to mental health service disparities research with Latino populations;and (5) Disseminate the research findings to inform policy decisions and practice, contribute to stakeholders'knowledge, and encourage future disparities research in Latino communities. Project 1: Improving Clinical Assessment of Diagnosis for Latinos. The goal of this project is to develop and test a mixed methods approach to helping clinicians in public health psychiatric settings decrease clinical uncertainty by more accurately diagnosing patients with diverse cultural backgrounds and improving the matching of clinical services to the needs of Latinos. Our approach combines methods from cultural anthropology with statistical methods and psychiatric epidemiology.
The specific aims of this study focus on generating improved cultural formulations and diagnostic accuracy using information from qualitative and quantitative perspectives, iterating between the methods in a complementary fashion.
The specific aims are to:
Aim 1 : Identify the information about symptoms and cultural and social context gathered in the initial diagnostic interview, that clinicians use to make determinations about three disorders: major depression, drug abuse and alcohol abuse;
Aim 2 : Use data from an epidemiological survey to assess the potential sensitivity and specificity of the clinical determinations identified in Aim1 in detecting the underlying diagnosis. We will test the hypothesis that clinical diagnosis is less accurate for Latino than non-Latino white patients;
Aim 3 : Assess clinician and patient reactions to the recommended improvements to diagnostic assessments developed in Aim 2. Using focus groups and consensus panels, prioritize the kinds of information to be collected to improve diagnostic determinations in safety net settings.
Aim 4 : Apply the findings of Aim 3 to make concrete recommendations to improve the efficiency and fairness of diagnostic decisions for Latino and non-Latino white population groups. Project 2: Identifying Sources Linked to Differential Assertive Community Treatment (ACT) Outcomes for Latinos. In this research we propose to conduct statistical analyses of data from a large quasi-experimental project (ACCESS) and a 2-stage modified Delphi technique to generate recommendations for the modification of assertive community treatment (ACT) when applied to Latino and other severely mentally ill homeless (SMIH) minority populations. The ACCESS study compared the outcome effects of """"""""augmented"""""""" ACT (i.e., ACT + quality improvement intervention) and standard ACT, and found no evidence of differences. Utilizing a disparities framework, advanced statistical methods, and a 2-stage Delphi method, we propose to conduct service and outcomes disparities research aimed at generating information with clinical or programmatic utility for Latinos. The proposed analyses will generate new evidence on service use and outcomes for Latino SMIH persons treated with ACT, and will broaden our understanding of the effects of quality improvement interventions for Latinos. Findings will be integrated with expert opinion to generate recommendations regarding ACT for Latino SMIH persons. The study has four aims: 1. To test for disparities in service use for Latino and African American as compared to white SMIH persons served by standard and augmented ACT 2. To test for outcome disparities for Latino and African American as compared to white SMIH persons served by standard and augmented ACT 3. To estimate the impact of observed service disparities on observed outcome disparities for Latino and African American as compared to white SMIH persons 4. To integrate results from analyses of service and outcome disparities for Latinos, a literature review, and expert opinion, and generate recommendations to improve ACT for Latino SMIH persons. Pilot 1: Ethnic Differences in Perceived Impairment and Need for Care. Parental belief that the child needs mental health care has been found to be the most significant factor associated with service use in non-minority populations. The results of several studies suggest that Latino parents are less likely than European Americans to recognize and/or label their children's behavior as a mental health problem requiring intervention. It is not clear which factors explain this lower recognition of mental health problems by Latino parents, and consequently the lower utilization of mental health services by this group. Differences between providers and parents in their views of children's impairments and/or the kind of problems that require treatment may also explain some of the lower utilization of mental health services among Latino children. There is some evidence that providers from different cultures differ in their impairment ratings of children. However, there is no research that examines whether non-Latino white providers as compared to Latino providers are more likely to rate the same children as impaired, nor is there any research that assesses the extent to which parents and providers from different cultures differ in their ratings of children's impairment. This pilot aims to investigate parental and provider beliefs about what is impaired behavior, the severity of the behavior, and the need for treatment in a sample of Mexican Americans, island Puerto Rican and non-Latino providers and parents. We will examine the ratings of providers and parents from the three ethnic groups using case vignettes of children with different levels of impairment and internalizing and externalizing symptoms. Vignettes will be developed utilizing information obtained through secondary analyses of two clinical data sets. We will test the hypothesis that Puerto Rican and Mexican American parents and providers rate the children described in the vignettes as less impaired as compared to non-Latino white parents and providers. We further hypothesize that greater acculturation in Mexican American parents will be associated with less variation between Mexican American and non- Latino white parents in their impairment ratings of the vignettes. We also expect greater congruence in the impairment ratings and perceptions of need for services among parents and providers within the same ethnic group. Pilot 2: Dialogue with the Latino Community and Healthcare System Stakeholders for Identifying Quality Improvements. A disproportionate number of Latinos rely on free or reduced price care making them more vulnerable to the impact of shrinking resources on the quality of care at safety net healthcare systems. The main goal of this pilot is to identify quality improvements by increasing the Latino community voice in a safety net mental healthcare system. We will explore system concerns (disproportionate impact of economic constraints on quality of care and low levels of participation in mental health services among Latinos) by including members of the Latino community in a participatory research process together with representatives of a healthcare system (i.e., psychiatrists, nurses, social workers, senior hospital administrators, clinic coordinators). In addition, this resulting collaborative stakeholder group will jointly identify leverage points in the community and health care system to launch quality improvements.
The aims of the pilot are to: 1. Consult multiple stakeholders to identify community, client, administrative, provider and mental health care system barriers to access and quality mental health services for Latino patients. 2. Selecting barriers identified from Aim 1, conduct policy implementation analyses that ground the participatory process in a clear, shared understanding of the legal, administrative and fiscal constraints on efforts aimed at quality improvements. 3. Use the information generated in Aims 1 and 2 to launch a participatory process with multiple stakeholders to identify leverage points for mental health care system change. As part of this research, we will generate hypotheses to be tested in the context of community and/or systems interventions and their prospective evaluation in R01 applications. We intend to use qualitative methods and policy implementation analysis to address these aims. We will build a collaborative, multidisciplinary community and mental health systems advisory group to assist in the identification and design of these quality improvements. By the end of this pilot, we will have a sustainable group of advisors who will work together in the future implementation of the quality improvements identified through this pilot work. Center Core:
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