Mental Health & Latino Kids

In September 2017, Salud America! Published an issue brief that reviewed the evidence related to the mental health of Latino youth. Findings from the research included:

Latino children suffer alarming mental health issues.

  • 22% of Latino youth have depressive symptoms, a rate higher than any minority group besides Native American youth.
  • More than 1 in 4 Latina high-schoolers have thought about committing suicide.
  • Latina high-schoolers are more likely to attempt suicide than their white peers (15.1% to 9.8%).
  • 32.6% of Latino students say they feel hopeless and sad, and participate less in things they enjoy as a result (vs. 27.2% of whites, 24.7% of blacks).

Latino children do not access mental health services as much as their peers.

  • Only 8% of Latinos say their child has ever used mental health care services (vs. 14% of whites).
  • Latino children had half of the outpatient mental health visits that their white peers had.
  • One study found 38.3% of school-aged Latino children and 37.2% of Latino preschoolers had a clinical need for mental health services; yet only 17.3% of school-aged Latino children and 10.8% of Latino preschoolers had received mental health services in the past year.
  • Despite the higher rates of suicide attempts among Latino youth, these children are less likely to be identified as suicidal, and less likely to receive crisis intervention services than others.

The migration experience causes stress, anxiety, and depression in Latino children.

  • Before migrating to the U.S., 38% of Latino children are separated from their parents for up to a year and 32% of Latino children are separated for longer than a year.
  • Latino families face economic hardships, difficult travel conditions, and stressful family separations during migration to the U.S.
  • After migrating to the U.S., Latinos are stressed by social status changes, language issues, discrimination, and immigration status questions.
  • For instance, compared to peers in their native land, Puerto Rican youth living in New York were lonelier and more depressed, anxious, exposed to more violence, and more likely to be discriminated against.

 

See the full report.

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New Publication: Consolidating the Academic End of a Community-Based Participatory Research Venture to Address Health Disparities

A recent article published in the Journal of Higher Education Outreach and Engagement explores the development of the Health Disparities Research Group (HDRG) at the University of South Alabama.  Written by a team led by Dr. Martha Arrieta, the article discusses

  • the formation process of the HDRG
  • Activities leading to the promotion of group identity and permanence
  • Activities to Foster Health Disparities Research Capacity
  • Activities Leading to Engagement in Participatory Research
  • Activities Leading to the Dissemination of CBPR Principles and Practice
  • Keys to Success in the Consolidation of HDRG
  • Challenges Encountered and Responses Devised

Read the full article.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

The following excerpt comes from the Issue Brief written by Susan L. Hayes, Pamela Riley, David Radley, and Douglas McCarthy.  It was originally posted to the Commonwealth Fund website on August 24, 2017.


Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.

Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA, but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.

We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:

  • the share of uninsured working-age adults ages 19 to 64
  • the share of adults age 18 and older who went without care because of costs in the past year
  • the share of adults age 18 and older without a usual source of care.

These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.

As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.

Findings include:

  • Racial and Ethnic Disparities in Adult Uninsured Rates Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Who Went Without Care Because of Costs Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Without a Usual Source of Care Narrowed After the ACA’s Major Coverage Expansions
  • Disparities Between Hispanic and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Without a Usual Source of Care in Medicaid Expansion States vs. Nonexpansion States, 2013–2015

Download the full issue brief.

I Had to ‘Unlearn’ Medicine to Treat Vulnerable Patients

The following excerpt comes from an August 14, 2017, posting written by Anita Ravi in the Fresh Perspectives: New Docs in Practice section of the AAFP website.


Two years ago, I started the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health, a federally qualified health center in New York, N.Y. We offer a health home for people who have been victims of human trafficking and other trauma, and I meet patients of all genders, ages, documentation statuses and backgrounds who are encountering a range of medical issues.   

…. When I prescribed medications such as ibuprofen, reminding people to “avoid taking these on an empty stomach” was reflexive — until last year. A PurpLE Clinic patient seeking asylum after being tortured while living in his native country had an appointment to address ongoing pain related to his injuries. As I was prescribing him an anti-inflammatory medication, I didn’t think twice about saying, “Make sure you take this with food,” until I noticed his blank stare.

Ten minutes earlier, he had told me he had no income and relied on a friend who worked in a restaurant to bring leftovers to eat; sometimes there were none. I realized that what I was actually telling him with my prescription instructions was that I had been hearing but not listening. I needed to unlearn the idea that common medical advice has universal applicability, and instead learn that some prescriptions need their own treatment — such as assisting with food access — to help a patient.  

My assumptions regarding food have been tested in other ways, too. One patient called to let me know she was running late because she had a chance to get food and hadn’t eaten in three days. This was not an uncommon reason for patients to be delayed, so I said I completely understood, envisioning a very specific scenario.

When she arrived that evening, I asked what she had eaten, and she responded, “Nothing,” because she had only “collected $3.83 worth.” This patient was paying for food by collecting cans and bottles to recycle, and she had come up short.

Hunger is frequently addressed during PurpLE Clinic appointments because they are typically on weekends, when there is limited access to assistance such as food pantries.

“When was the last time you ate?” is something physicians ask when we order labs that require fasting. I’ve unlearned the purpose of this question. Having implemented a way to provide point-of-care access to food, I now ask “When was the last time you ate?” to ensure no one leaves the clinic hungry.

As I mentioned, patients at our clinic often come in later than scheduled for many reasons. Life is unpredictable. Some undocumented patients rely on informal networks for jobs and may find out the night before that a hair-braiding, construction or housekeeping job has become available. Some patients, however, always make it on time and never miss an appointment.

Other patients said they had to decide between eating a meal or paying subway fare — making appointment days particularly difficult. In New York City, where issues such as turnstile-hopping were resulting in arrest,(gothamist.com) it was troubling that attending appointments could be a link in the cycle of poverty and incarceration. To address this, I needed to unlearn that on-time appointments were a measure of success in health care delivery, and our team implemented a system that made subway cards available to patients.

Read the full post.

The Interplay of Community Trauma, Diet, and Physical Activity

The following excerpt comes from the Discussion Paper by Howard Pinderhughes* posted August 7. 2017 on the National Academy of Medicine website.


Diet- and activity-related illnesses—such as heart disease, stroke, cancer, and type 2 diabetes—can shorten life spans and adversely impact quality of life. Over the past 15 years, the public health field has made important progress in addressing these illnesses by shifting the focus from individual behavior to the broader social and economic forces that shape health. There is now widespread agreement among experts in the field that in order to improve health outcomes and reduce the impact of these illnesses, we must pursue strategies, practices, and policies that are multifaceted, comprehensive, and focused on community- and institutional-level change.

There is a growing understanding that community conditions—the places where we live, work, and play—have a significant impact on our health and that adverse community experiences (community trauma) affect our food and activity behaviors. Advances in understanding the connection between adverse childhood experiences and health have revolutionized the field of trauma-informed care, which has now become an important standard practice in communities across the country. But we must also seek to illuminate how adverse community experiences impact healthy eating and activity, and to develop integrated solutions. Adverse community experiences are destructive factors—such as racial, residential, and economic segregation; violence; structural racism and discrimination; intergenerational poverty; and public and private disinvestment—that traumatize entire communities. For example, experiencing and witnessing community violence can negatively impact the ability to eat healthfully and be active. Violence and fear of violence reduce social interactions that would otherwise contribute to community cohesion, thus reducing support for healthy eating and active living. The pervasive presence of community trauma can become a significant barrier to efforts to improve population health and health equity, including those that address eating- and activity-related diseases. When people don’t feel safe in their communities, they are less likely to walk to the grocery store, use local parks, access public transportation, and let their children play outside. Healthy food retailers and recreation businesses are less likely to invest in communities perceived as unsafe.

An analysis of the production of health inequities across multiple determinants of health revealed that adverse community factors—which decrease opportunities for healthy eating and activity—are rooted in structural violence in the form of government policies and business practices. These policies and practices have led, for example, to the over concentration of unhealthy food outlets in communities of color and communities with low to average household incomes. In the case of food retail, public policies such as those of the Federal Housing Administration incentivized suburban home ownership, which resulted in white middle-class flight to the suburbs and a concentration of poverty in the inner cities. Supermarkets, grocery stores, and many other businesses followed the white middle-class population in migrating to the suburbs. This flight (along with financial policies and practices, including redlining) left a void for unhealthful food outlets to fill. The high cost and scarce availability of land in dense urban areas contributed to the migration of businesses out of the cities and resulted in loss of jobs and tax revenues, and has influenced decisions about the siting of grocery stores and supermarkets. Additionally, there has been limited availability of loans for local residents in underserved neighborhoods so that they might open businesses that sell and promote healthy food options. These adverse community experiences have resulted in limited economic opportunities for residents and a poor food system in which chain restaurants and stores fill the gap with less healthy or unhealthful food options.

Read the full Discussion Paper.

*References have been removed from the excerpt. Please visit the full paper for more details.

Medicine Is Getting More Precise … For White People

The following excerpt is from an article by Rob Arthur published August 2, 2017, on FiveThirtyEight.


Every human on earth is unique — our genes are different, we eat different things, we live in different places. As a result, medical treatments tend to work differently on different people. Depending on your genes, a drug might cure your sickness — or it might cause a side effect that makes you sicker.

In the past, many of humanity’s individual variations were invisible to us, but today, new technology offers us a way to peer into each person’s genome, allowing doctors to personalize treatments for each patient. This approach, called precision medicine, has been a major focus of research and investment in the last few years.

But precision medicine only works if scientists have studied people who are similar to you. If your genes are rare or unusual compared to those researchers have examined in the past, you could end up getting the wrong treatment. Since the vast majority of genetics studies are done on people of European ancestry, members of other racial groups may lose out on the benefits of precision medicine entirely. Those same groups already often receive worse health care in the United States than people of European descent get, and personalized medical treatment could make the gap in care larger.

Precision medicine is based on the idea that genes can be linked to diseases. To study this, scientists assemble a group of people, some with a disease and some without, and identify their genetic differences. If particular differences are common among the people who have the disease and absent from the people without it, then scientists can infer that those genetic patterns might be involved in the disease.

But each person has their own catalogue of genetic characteristics. Some are common in people of certain ancestral backgrounds and rare in those from other backgrounds. If scientists exclusively study individuals of one ethnic group, they may not know how to refine their treatments for a person from a different group.

A 2009 analysis of the studies that can link a genetic variant to a disease or trait showed that fully 96 percent of participants were of European descent. In a 2016 commentary in the journal Nature, Alice Popejoy and Stephanie Fullerton, respectively a graduate student and a professor at the University of Washington, showed that these studies had grown more diverse and people of European ancestry now account for 81 percent of research subjects. “Things are getting better, and it’s still pretty darn slow,” Fullerton said in an interview. And of the progress that has been made, much of it is attributable not to an increase in diversity in U.S. research but to studies conducted in Asian countries, which involve local participants.

Disparities in biomedical research exacerbate an existing gap in U.S. health care. African-Americans and Latinos are less likely to have health insurance and more likely to suffer from chronic diseases. Even controlling for wealth differences between populations, African-Americans receive worse health care.

The science underlying precision medicine threatens to make these disparities worse because it could leave any genetic differences that primarily affect non-white groups unstudied. Some genetic differences are prevalent in one population and rare in another. A prominent example is a gene called APOL1. Differences in this gene are common in people whose ancestors are from sub-Saharan Africa but rare in those of other backgrounds. Some of these variations increase the risk of developing kidney disease more than sevenfold, but they also seem to confer protection against African sleeping sickness. Knowing a patient’s APOL1 genetic makeup might be useful for guiding kidney disease treatment, and APOL1 is likely one of many genes that must be studied within a nonwhite population.

It’s possible to solve the problem of underrepresentation. The National Institutes of Health fund a number of large-scale genetic research projects in the United States, and scientists there consider this a major issue. “We are aware of this situation, and work is being funded to rectify the situation,” said Charles Rotimi, an investigator at NIH. He pointed to initiatives like Human Heredity and Health in Africa and the Population Architecture using Genomics and Epidemiology Consortium. These projects are developing more diverse study populations to address the underrepresentation of people of non-European ancestries, in some cases going to African countries to collect genetic data. In the United States, individual investigators can also apply for smaller-scale NIH grants to study particular diseases.

Read the full article.

Annual Report on Healthcare Quality and Disparities

In July, the Agency for Healthcare Research and Quality (AHRQ) posted the 2016 National Healthcare Quality and Disparities Report on its website. Mandated by Congress, this annual report “provides a comprehensive overview of the quality of healthcare received by the general US population and disparities in care experienced by different racial and socioeconomic groups.”  Based on over 250 quality measures, the report covers a wide range of healthcare services and settings. The key findings from the report were:

Access: While most access measures (65%) tracked in this report did not demonstrate significant improvement (2000-2014), uninsurance rates (measured as uninsured at the time of interview) decreased from 2010 to 2016.

Quality: Quality of health care improved overall from 2000 through 2014-2015 but the pace of improvement varied by priority area:

  • Person-Centered Care: About 80% of person-centered care measures improved overall.
  • Patient Safety: Almost two-thirds of patient safety measures improved overall.
  • Healthy Living: About 60% of healthy living measures improved overall.
  • Effective Treatment: More than half of effective treatment measures improved overall.
  • Care Coordination: About half of care coordination measures improved overall.
  • Care Affordability: About 70% of care affordability measures did not change overall.  

Disparities: Overall, some disparities were getting smaller from 2000 through 2014-2015, but disparities persist, especially for poor and uninsured populations in all priority areas:

  • While 20% of measures show disparities getting smaller for Blacks and Hispanics, most disparities have not changed significantly for any racial and ethnic groups.
  • More than half of measures show that poor and low-income households have worse care than high-income households; for middle-income households, more than 40% of measures show worse care than high-income households.
  • Nearly two-thirds of measures show that uninsured people had worse care than privately insured people.

See the table of contents and description of the report.

Download the full report.

Working with Communities to Improve Health

The following excerpt comes from an article that first appeared May 1, 2017, on the NIMHD website under NIMHD Community Health and Population Sciences Feature Articles


Improving health is not always a matter of prescribing the right medicine. Sometimes the environment needs to change. Many Americans live in neighborhoods that lack safe walking routes, grocery stores, and health facilities.

“Are there places for kids to play? Are there good farmers markets or grocery stores?” asks Irene Dankwa-Mullan, M.D., M.P.H., formerly of NIMHD and now deputy chief health officer of IBM Watson Health. Such features help people in a neighborhood live healthier lives. Along with NIMHD director Eliseo Pérez-Stable, Dr. Dankwa-Mullan wrote an editorial in the April 2016 issue of the American Journal of Public Health, “Addressing Health Disparities Is a Place-Based Issue.”

Efforts to address these problems in particular communities are called “place-based interventions.” Ideally, these interventions come from a collaboration among community members, businesses, and other stakeholders, working together with police, urban planners, and other groups to improve their neighborhood. Community members are involved to make sure the interventions are based on their values.

Examples of place-based interventions include an effort to bring a farmers market to a neighborhood without a grocery store or promoting public safety so that residents feel safe walking on the street. Walking is a simple way to improve health, but there can be many barriers to walking, a fact highlighted in the Surgeon General’s Call to Action on walking.

Place-based interventions have been used successfully in rural areas, disadvantaged urban neighborhoods, and Indian reservations. People who live in such places tend to have particular health problems, such as diabetes and heart disease, and working to change the place-based conditions may help address health disparities.

Communities are complicated, and figuring out the best way to improve the health of all residents in a particular place can be a daunting task. “Part of the issue is that we do not have a best practices model for place-based interventions,” Dr. Dankwa-Mullan says. The editorial in the American Journal of Public Health was part of a new series on best practices for place-based interventions. Through this series, public health professionals will be able to learn how to develop place-based interventions.

One key to success of place-based interventions is involving the community. This is similar to community-based participatory research, a way of doing research in which the community sets priorities, ensuring that communities that are asked to participate in research get answers to the questions that are most important to them.

Read the full article.

 

Talking about Health Equity

Recently, the Health Policy Research Consortium create a YouTube Series, Conversations on Health Equity,  exploring health equity with leading experts. Available videos include

 

Examining Provider Bias In Health Care Through Implicit Bias Rounds

The following comes from the July 17, 2017, article by Vidya Viswanathan, Matthew Seigerman, Edward Manning, and Jaya Aysola on the Health Affairs Blog.


In 2015, a 27-year-old patient presented to our primary care resident practice in intractable pain, having been recently discharged from the hospital following surgery for a complex shoulder fracture. The orthopedic surgeons evaluated him the day before and scheduled a second surgery but did not adequately treat his pain. The inpatient nurse had told him he would be discharged with the oral pain regimen he had been taking for the past day or so within the hospital. But upon discharge, he found himself without those prescriptions and came to our primary care practice in severe pain. When we reviewed his inpatient record to determine the reason for this discrepancy, the attending physician discovered the phrase “drug-seeking” in the record. The rationale for this statement was not provided, nor the context. When questioned by his new primary care provider about this, the patient was shocked. He tried to recollect what he may have said to result in that assumption. He had no prior history of documented substance or prescription drug abuse.

The patient in question was a young black male and the victim of a drive-by shooting by a stranger. He had been sitting in the passenger seat of a stationary car when it happened. Standard practice in this type of case involves long-acting oral opioid medication, with gradual adjustments of a medication regimen tailored to meet the needs of the patient. But the patient didn’t receive the standard of care, and we naturally wondered why. The answer may be implicit bias.

The literature suggests that he would be more likely to be perceived as drug-seeking when requesting pain relief, compared to his white counterpart. Bias is particularly well-documented in pain management, with black children and adults receiving less adequate pain treatment than their white counterparts in the emergency department for the same presenting condition, even when accounting for insurance status and severity of pain. Longitudinal, national data on 156,729 pain-related emergency department visits found that even among those presenting with the same condition, non-Hispanic white patients were significantly more likely to receive an opioid than all other ethnic minorities examined. Researchers using an instrument to assess implicit bias in more than 2,500 physicians found a significant implicit preference for white Americans relative to black Americans among physicians of all racial/ethnic groups except for black physicians. Another study found that physicians were twice as likely to underestimate pain in black patients compared with all other ethnicities combined and also more likely to overestimate pain in nonblack patients than in black patients.

To address the case of our patient who was inadequately treated for pain based on apparently false assumptions—and other patients who have experienced a different standard of care due to implicit bias—we believe there needs to be formal discussion of this source of clinical errors at institutions. We propose the initiation of a new kind of case conference—“Implicit Bias Rounds”—to specifically identify and discuss these cases.

How Does Bias Occur?

We conceptualized Implicit Bias Rounds based on theories on why disparities in care occur despite well-intentioned providers and despite the recognition of the importance of cognitive error as a source of diagnostic error. Providers, when faced with the need to make complicated judgments quickly and with insufficient and imperfect information, may rely on assumptions associated with a patient’s social categories to fill in the gaps with information that may be relevant to diagnosis and treatment. Physicians are at risk for relying on stereotypes or assumptions for efficient decision making, even when attempting to be objective. In addition to the assumptions providers may make about patients that are dissimilar to them, they may also unconsciously favor patients whose identity they relate to. Such affinity bias may cause a provider not to consider the possibility of a drug problem in an adolescent that appears similar to him, despite a positive urine screen for marijuana. Current efforts in medicine to combat bias may also serve to perpetuate them: Physician-anthropologist Arthur Kleinman states that one problem with traditional cultural competency training is that it may erroneously characterize culture as static and cultural understanding as a technical skill.

It is not enough to merely consider potential sources of provider bias without considering proposed strategies to mitigate that bias. Evidence tells us that simply adjusting the explicit medical curricula is not enough to change implicit bias; increasing positive role modeling for medical trainees is more effective. Strategies proposed to combat implicit bias include consciously thinking of the patient’s perspective and approaching each provider-patient interaction as a shared negotiation between worldviews. Focusing on specific and unique details about an individual, instead of his or her social category, serves to combat biases by diminishing stereotyping and promoting empathy building. Clinicians who are trained to consider the unique perspectives and experiences of their patients are more likely to show empathy toward them, the study suggests. Priming physicians with information about the relevance or irrelevance of sociocultural factors in medical care can combat cognitive errors that stem from stereotyping. A regular intervention such as Implicit Bias Rounds would serve to implement these strategies on a consistent basis.

Read the full article.