Developmental Psychopathology and Ethnicity I: The Young Adulthood Assessment of the Boricua Youth Study.

OBJECTIVE: Developmental psychopathology processes pertinent to underserved ethnically diverse youths may not always coincide with those relevant to youths from nondisadvantaged groups. This article reports on the young adulthood assessment (fourth wave; April 2013 to August 2017) of the Boricua Youth Study, which includes 2 population-based samples of children of Puerto Rican background (N = 2,491) aged 5-13 years (recruited in 2000), in the South Bronx, New York, and San Juan, Puerto Rico. METHOD: Study procedures included intensive participant tracking and in-person interviews of young adults and, when possible, their parents. Study participation rates, measures, and weights are described. RESULTS: At Boricua Youth Study wave 4 (on average 11.3 years since last wave of participation), we reassessed 2,004 young adults (mean age = 22.9 years, range = 15-29 years; 51% women; retention rate adjusted for ineligibility = 82.7%) and available parents (n = 1,180). Nonparticipation was due to inability to locate/contact participants (8.6%); refusal (4.7%); and ineligible status (2.8%) owing to cognitive impairment, incarceration, or death. Among participants originally from Puerto Rico, 91% stayed in Puerto Rico during young adulthood. Of participants from the South Bronx, 52.4% remained in the area (85.8% within 100 miles). Most study measures had good internal consistency (Cronbach α ≥ .70). CONCLUSION: Our results support the viability of retaining a population-based cohort of children from the same ethnic group across 2 contexts during a life stage when individuals are likely to move. Longitudinal samples that are generalizable to underserved populations can elucidate developmental processes of relevance for curtailing the risk of psychopathology in disadvantaged contexts.

A comparison of the prevalence of psychiatric disorders in Puerto Rico with the United States and the Puerto Rican population of the United States.

PURPOSE: The manuscript compares the rates of psychiatric disorder among island Puerto Ricans, the US population and US Puerto Ricans in order to examine whether social support explains differences in psychiatric disorder among these three groups. METHODS: Unadjusted and adjusted rates for sociodemographic factors and social support of main psychiatric disorders are compared among three population-based psychiatric epidemiology studies carried in Puerto Rico (PR) and the United States (US) as part of the NCS-R and NLAAS studies. RESULTS: Comparison of adjusted rates showed island Puerto Ricans had similar overall rates of psychiatric disorder as those of the US, lower rates of anxiety disorders, but higher rates of substance use disorders. US Puerto Ricans had higher rates of adjusted anxiety and depression but not of overall psychiatric disorder, as compared to the island. When the rates of disorder were adjusted also for social support, the differences between these two groups disappeared. CONCLUSIONS: The findings suggest that social support is a variable worthy of further exploration for explaining differences in disorder prevalence particularly among Puerto Ricans depending on where they live.

Effectiveness of a multi-level asthma intervention in increasing controller medication use: a randomized control trial.

INTRODUCTION: Poor self-management by families is an important factor in explaining high rates of asthma morbidity in Puerto Rico, and for this reason we previously tested a family intervention called CALMA that was found effective in improving most asthma outcomes, but not effective in increasing the use of controller medications. CALMA-plus was developed to address this issue by adding to CALMA, components of provider training and screening for asthma in clinics. METHODS: Study participants were selected from claims Medicaid data in San Juan, Puerto Rico. After screening, 404 children in eight clinics were selected after forming pairs of clinics and randomizing the clinics) to CALMA-only or CALMA-plus. RESULTS: For all three primary outcomes at 12 months, the mean differences between treatment arms were small but in the predicted direction. However, after adjusting for clinic variation, the study failed to demonstrate that the CALMA-plus intervention was more efficacious than the CALMA-only intervention for increasing controller medication use, or decreasing asthma symptoms. Both groups had lower rates of asthma symptoms and service utilization, consistent with previous results of the CALMA-only intervention. CONCLUSIONS: Compliance of providers with the intervention and training, small number of clinics available and the multiple barriers experienced by providers for medicating may have been related to the lack of difference observed between the groups. Future interventions should respond to the limitations of the present study design and provide more resources to providers that will increase provider participation in training and implementation of the intervention.

The development of a community-based family asthma management intervention for Puerto Rican children.

BACKGROUND: Puerto Rican children maintain disproportionately high asthma prevalence rates and effective asthma management interventions are needed. OBJECTIVES: This article describes how community-based participatory research (CBPR) was implemented in the development of a culturally tailored family asthma management intervention for Puerto Rican children: CALMA (a Spanish acronym for Take Control, Empower Yourself, and Achieve Asthma Management). METHOD: CALMA was developed according to CBPR principles and contemporary asthma guidelines through the collaboration of diverse members of the local, professional, and medical communities, academia, and local government. All group members contributed unique perspectives, making CALMA's development a collaborative effort. LESSONS LEARNED: The CALMA community dealt with challenges in both incorporating and managing a diverse group of stakeholders and maintaining equity in decision making power. However, the community maintained strengths, such as incorporating culturally accepted remedies and addressing culturally specific myths in the intervention, as well as having the medical community directly involved in overseeing the accuracy of the intervention. CONCLUSION: A CBPR approach enhanced the cultural sensitivity of the intervention as well as its potential for sustainability.

Disparities in asthma medication dispensing patterns: the case of pediatric asthma in Puerto Rico.

BACKGROUND: Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico. OBJECTIVES: Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children. METHODS: Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM). RESULTS: Private insurance families (n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of ß-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect. CONCLUSION: Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits. CAPSULE SUMMARY: A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed.

Barriers to Prescribing Controller Anti Inflammatory Medication among Puerto Rican Asthmatic Children with Public Insurance: Results of National Survey of Pediatricians.

BACKGROUND: There are substantial disparities in dispensing patterns of long term control medications for asthma among children in Puerto Rico with public insurance as compared to those with private insurance. Public health insurance policy in Puerto Rico includes the cost of medications in the capitation paid to the primary care physicians and clinics. METHODS: Survey questionnaires were mailed to all pediatricians enrolled in the Puerto Rico College of Physicians (n=798) in addition to some pediatricians not enrolled in the College (n=25) for a total of 823 pediatricians. Of these, 722 were eligible pediatricians with 458 responding to the survey for a response rate of 63.4%. RESULTS: Most of the respondents expressed being moderately to very familiar with the National Asthma Education and Prevention Program (NAEPP) guidelines (71.7%) and with the NAEPP recommendations for controller asthma medication use (73.5%). Inadequate capitation to cover asthma medication (86.2%) and lack of adequate health insurance coverage of the patient (83.2%) however, were the most frequent barriers reported by pediatricians for prescribing controller asthma medication to children with public health insurance. The most frequent strategies used to provide controller asthma medication to these children were prescription of oral medications (59.5%) and giving away samples (44.7%). CONCLUSIONS: Current public health insurance policy in Puerto Rico creates a disincentive to the appropriate prescription of long term control medication for children with asthma. To improve the quality of asthma care of children in Puerto Rico, revision of this public health insurance policy is necessary.

Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups.

OBJECTIVE: Although widely reported among Latino populations, contradictory evidence exists regarding the generalizability of the immigrant paradox, i.e., that foreign nativity protects against psychiatric disorders. The authors examined whether this paradox applies to all Latino groups by comparing estimates of lifetime psychiatric disorders among immigrant Latino subjects, U.S-born Latino subjects, and non-Latino white subjects. METHOD: The authors combined and examined data from the National Latino and Asian American Study and the National Comorbidity Survey Replication, two of the largest nationally representative samples of psychiatric information. RESULTS: In the aggregate, risk of most psychiatric disorders was lower for Latino subjects than for non-Latino white subjects. Consistent with the immigrant paradox, U.S.-born Latino subjects reported higher rates for most psychiatric disorders than Latino immigrants. However, rates varied when data were stratified by nativity and disorder and adjusted for demographic and socioeconomic differences across groups. The immigrant paradox consistently held for Mexican subjects across mood, anxiety, and substance disorders, while it was only evident among Cuban and other Latino subjects for substance disorders. No differences were found in lifetime prevalence rates between migrant and U.S.-born Puerto Rican subjects. CONCLUSIONS: Caution should be exercised in generalizing the immigrant paradox to all Latino groups and for all psychiatric disorders. Aggregating Latino subjects into a single group masks significant variability in lifetime risk of psychiatric disorders, with some subgroups, such as Puerto Rican subjects, suffering from psychiatric disorders at rates comparable to non-Latino white subjects. Our findings thus suggest that immigrants benefit from a protective context in their country of origin, possibly inoculating them against risk for substance disorders, particularly if they emigrated to the United States as adults.

Reducing asthma health disparities in poor Puerto Rican children: the effectiveness of a culturally tailored family intervention.

BACKGROUND: Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. OBJECTIVE: We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma. METHODS: Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group. RESULTS: No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma. CONCLUSION: A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.

Understanding differences in past year psychiatric disorders for Latinos living in the US.

This study seeks to identify risk factors for psychiatric disorders that may explain differences in nativity effects among adult Latinos in the USA. We evaluate whether factors related to the processes of acculturation and enculturation, immigration factors, family stressors and supports, contextual factors, and social status in the US account for differences in 12-month prevalence of psychiatric disorders for eight subgroups of Latinos. We report results that differentiate Latino respondents by country of origin and age at immigration (whether they were US-born or arrived before age 6: In-US-as-Child [IUSC]; or whether they arrived after age 6: later-arrival immigrants [LAI]). After age and gender adjustments, LAI Mexicans and IUSC Cubans reported a significantly lower prevalence of depressive disorders than IUSC Mexicans. Once we adjust for differences in family stressors, contextual factors and social status factors, these differences are no longer significant. The risk for anxiety disorders appears no different for LAI compared to IUSC Latinos, after age and gender adjustments. For substance use disorders, family factors do not offset the elevated risk of early exposure to neighborhood disadvantage, but coming to the US after age 25 does offset it. Family conflict and burden were consistently related to the risk of mood disorders. Our findings suggest that successful adaptation into the US is a multidimensional process that includes maintenance of family harmony, integration in advantageous US neighborhoods, and positive perceptions of social standing. Our results uncover that nativity may be a less important independent risk factor for current psychiatric morbidity than originally thought.

Considering context, place and culture: the National Latino and Asian American Study.

This paper provides a rationale for, and overview of, procedures used to develop the National Latino and Asian American Study (NLAAS). The NLAAS is nationally representative community household survey that estimates the prevalence of mental disorders and rates of mental health service utilization by Latinos and Asian Americans in the US. The central aims of the NLAAS are to: 1) describe the lifetime and 12-month prevalence of psychiatric disorders and the rates of mental health services use for Latino and Asian American populations using nationwide representative samples of Latinos and Asian Americans, 2) assess the associations among social position, environmental context, and psychosocial factors with the prevalence of psychiatric disorders and utilization rates of mental health services, and 3) compare the lifetime and 12-month prevalence of psychiatric disorders, and utilization of mental health services of Latinos and Asian Americans with national representative samples of non-Latino whites (from the National Comorbidity Study-Replication) (NCS-R) and African Americans (from the National Survey of American Life) (NSAL). This paper presents new concepts and methods utilized in the development of the NLAAS to capture and investigate ethnic, cultural and environmental considerations that are often ignored in mental health research.

Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos.

This paper describes the development, translation and adaptation of measures in the National Latino and Asian American Study (NLAAS). We summarize the techniques used to attain cultural relevance; semantic, content and technical equivalency; and internal consistency of the measures across languages and Latino sub-ethnic groups. We also discuss some of the difficulties and thallenges encountered in doing this work. The following three main goals are addressed in this paper: (1) attaining cultural relevance by formulating the research problem with attention to the fundamental cultural and contextual differences of Latinos and Asians as compared to the mainstream population; (2) developing cultural equivalence in the standardized instruments to be used with these populations; and (3) assessing the generalizability of the measures - i.e., that the measures do not fluctuate according to culture or translation. We present details of the processes and steps used to achieve these three goals in developing measures for the Latino population. Additionally, the integration of both the etic and emic perspectives in the instrument adaptation model is presented.