Characterizing the Mental Health Care of U.S. Cambodian Refugees.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Cambodian refugees' rates of mental health service utilization and minimally adequate care were comparable to those of individuals in the general U.S. POPULATION: 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.

The unusually poor physical health status of Cambodian refugees two decades after resettlement.

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.

Mental health service utilization after physical trauma: the importance of physician referral.

BACKGROUND: Despite the availability of effective treatments for posttraumatic stress reactions after serious physical injuries, many sufferers do not use mental health services. Attempts to understand the factors that facilitate mental health service use have often focused on patient-related factors without assessing provider behavior. OBJECTIVES: To examine the relative influence of patient-related factors and physician referral on mental health service utilization among patients after a traumatic physical injury. DESIGN: A fully structured interview was administered prospectively by trained lay persons to Los Angeles Country trauma center injury patients. A total of 677 patients completed an initial interview. Of those who completed an initial interview, 70% (n = 476) completed a 6-month follow-up interview and 68% (n = 462) completed a 12-month interview. MEASURES: We examined 3 classes of patient characteristics hypothesized to be related to mental health service use: need (eg, posttraumatic stress symptoms), predisposing factors (eg, gender), and enabling resources (eg, health insurance). Additionally, we looked at physician referral to mental health treatment as a provider behavior hypothesized to predict service use. RESULTS: Age, posttraumatic stress disorder symptom severity, previous mental health treatment, and physician referral were all associated with mental health service use. Physician referral demonstrated the strongest relationship with mental health service utilization. While controlling for other factors, the odds of mental health service use were nearly 8 times higher for those respondents receiving a physician referral than for those without a referral. CONCLUSIONS: Findings highlight the importance of physician referral in facilitating access to mental health services for trauma injury survivors.

Alcohol abuse and illegal drug use among Los Angeles County trauma patients: prevalence and evaluation of single item screener.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Effects of survey mode, patient mix, and nonresponse on CAHPS hospital survey scores.

OBJECTIVE: To evaluate the need for survey mode adjustments to hospital care evaluations by discharged inpatients and develop the appropriate adjustments. DATA SOURCE: 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. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: We estimated mode effects in linear models that predicted each HCAHPS outcome from hospital-fixed effects and patient-mix adjustors. PRINCIPAL FINDINGS: 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. CONCLUSIONS: Valid comparisons of hospital performance require that reported hospital scores be adjusted for survey mode and patient mix.

USE OF EXPERT RATINGS AS SAMPLING STRATA FOR A MORE COST-EFFECTIVE PROBABILITY SAMPLE OF A RARE POPULATION.

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%, and ideally at least 80%, 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 ½ the rate of likely strata.This approach was applied to a survey of Cambodian immigrants in which the 82% of households rated "unlikely" were sampled at » the rate as "likely" households, reducing screening from 9.4 to 4.0 approaches per complete. Sensitivity and specificity were 86% and 91% respectively. Weighted estimation had a design effect of 1.26 so screening costs per effective sample size were reduced 47%. We also note that in this instance, expert classification appeared to be uncorrelated with survey outcomes of interest among eligibles.

How do proxy responses and proxy-assisted responses differ from what Medicare beneficiaries might have reported about their health care?

OBJECTIVE: Assess proxy respondent effects on health care evaluations by Medicare beneficiaries. DATA SOURCE: 110,215 respondents from the nationally representative 2001 CAHPS((R)) Medicare Fee-for-Service Survey. STUDY DESIGN/DATA COLLECTION/EXTRACTION METHODS: We compare the effects of both proxy respondents and proxy assistance (reading, writing, or translating) on 23 "objective" report items and four "subjective" global measures of health care experiences using propensity-score-weighted regression. We assess whether proxy effects differ among spouses, other relatives, or nonrelatives. PRINCIPAL FINDINGS: Proxy respondents provide less positive evaluations of beneficiary health care experiences than otherwise similar self-reporting beneficiaries for more subjective global ratings (average effect of 0.21 standard deviations); differences are smaller for relatively objective and specific report items. Proxy assistance differences are similar, but about half as large. Reports from spouse proxy respondents are more positive than those from other proxies and are similar to what would have been reported by the beneficiaries themselves. Standard regression techniques may overestimate proxy effects in this instance. CONCLUSIONS: One should treat proxy responses to subjective ratings cautiously. Even seemingly innocuous reading, writing, and translation by proxies may influence answers. Spouses may be accurate proxies for the elderly in evaluations of health care.

U.S. Cambodian refugees' use of complementary and alternative medicine for mental health problems.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Problem-oriented reporting of CAHPS consumer evaluations of 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.

Early adolescent exposure to alcohol advertising and its relationship to underage drinking.

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.

Sexual risk among impoverished women: understanding the role of housing status.

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.

Problem drinking among Cambodian refugees in the United States: how big of a problem is it?

OBJECTIVE: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Barriers to mental health care utilization for U.S. Cambodian refugees.

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.

Rates and correlates of seeking mental health services among Cambodian refugees.

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.

Patterns of unit and item nonresponse in the CAHPS Hospital Survey.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Trauma, depression, coping, and mental health service seeking among impoverished women.

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.

Do Medicaid and commercial CAHPS scores correlate within plans?: a New Jersey case study.

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 organizations that 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.

Saturated in beer: awareness of beer advertising in late childhood and adolescence.

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.

Does alcohol advertising promote adolescent drinking? Results from a longitudinal assessment.

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.

Prevalence and co-occurrence of violence, substance use and disorder, and HIV risk behavior: a comparison of sheltered and low-income housed women in Los Angeles County.

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.