Defining, Estimating, and Communicating Overdiagnosis in Cancer Screening.

The toll of inadequate health care is well-substantiated, but recognition is mounting that "too much" is also possible. Overdiagnosis represents one harm of too much medicine, but the concept can be confusing: It is often conflated with related harms (such as overtreatment, misclassification, false-positive results, and overdetection) and is difficult to measure because it cannot be directly observed. Because the U.S. Preventive Services Task Force (USPSTF) issues screening recommendations aimed largely at healthy persons, it has a particular interest in understanding harms related to screening, especially but not limited to overdiagnosis. In support of the USPSTF, the authors summarize the knowledge and provide guidance on defining, estimating, and communicating overdiagnosis in cancer screening. To improve consistency, thinking, and reporting about overdiagnosis, they suggest a specific definition. The authors articulate how variation in estimates of overdiagnosis can arise, identify approaches to estimating overdiagnosis, and describe best practices for communicating the potential for harm due to overdiagnosis.

Conflicts of Interest in Clinical Guidelines: Update of U.S. Preventive Services Task Force Policies and Procedures.

The U.S. Preventive Services Task Force (USPSTF) provides independent, objective, and scientifically rigorous recommendations for clinical preventive services. A primary concern is to avoid even the appearance of members having special interests that might influence their ability to judge evidence and formulate unbiased recommendations. The conflicts of interest policy for the USPSTF is described, as is the formal process by which best practices were incorporated to update the policy. The USPSTF performed a literature review, conducted key informant interviews, and reviewed conflicts of interest policies of ten similar organizations. Important findings included transparency and public accessibility; full disclosure of financial relationships; disclosure of non-financial relationships (that create the potential for bias and compromise a member's objective judgment); disclosure of family members' conflicts of interests; and establishment of appropriate reporting periods. Controversies in best practices include the threshold of financial disclosures, ease of access to conflicts of interest policies and declarations, vague definition of non-financial biases, and request for family members' conflicts of interests (particularly those that are non-financial in nature). The USPSTF conflicts of interest policy includes disclosures for immediate family members, a clear non-financial conflicts of interest definition, long look-back period and application of the policy to prospective members. Conflicts of interest is solicited from all members every 4 months, formally reviewed, adjudicated, and made publicly available. The USPSTF conflicts of interest policy is publicly available as part of the USPSTF Procedure Manual. A continuous improvement process can be applied to conflicts of interest policies to enhance public trust in members of panels, such as the USPSTF, that produce clinical guidelines and recommendations.

Evaluating Feasible and Referable Behavioral Counseling Interventions.

The U.S. Preventive Services Task Force (USPTF) recognizes that behaviors have a major impact on health and well-being. Currently, the USPSTF has 11 behavioral counseling intervention (BCI) recommendations. These BCIs can be delivered in a primary care setting or patients can be referred to other clinical or community programs. Unfortunately, many recommended BCIs are infrequently and ineffectually delivered, suggesting that more evidence is needed to understand which BCIs are feasible and referable. In response, the USPSTF convened an expert forum in 2013 to inform the evaluation of BCI feasibility. This manuscript reports on findings from the forum and proposes that researchers use several frameworks to help clinicians and the USPSTF evaluate which BCIs work under usual conditions. A key recommendation for BCI researchers is to use frameworks whose components can support dissemination and implementation efforts. These frameworks include the Template for Intervention Description and Replication (TIDieR), which helps describe the essential components of an intervention, and pragmatic frameworks like Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) or Pragmatic-Explanatory Continuum Indicator Summary (PRECIS), which help to report study design elements and outcomes. These frameworks can both guide the design of more-feasible BCIs and produce clearer feasibility evidence. Critical evidence gaps include a better understanding of which patients will benefit from a BCI, how flexible interventions can be without compromising effectiveness, required clinician expertise, necessary intervention intensity and follow-up, impact of patient and clinician intervention adherence, optimal conditions for BCI delivery, and how new care models will influence BCI feasibility.

Understanding Research Gaps and Priorities for Improving Behavioral Counseling Interventions: Lessons Learned From the U.S. Preventive Services Task Force.

Behavioral counseling interventions can address significant causes of preventable morbidity and mortality. However, despite a growing evidence base for behavioral counseling interventions, there remain significant research gaps that limit translating the evidence into clinical practice. Using U.S. Preventive Services Task Force (USPSTF) examples, we address how researchers and funders can move the research portfolio forward to achieve better application of behavioral counseling interventions to address substantial health burdens in the U.S. This paper describes the types of gaps that the USPSTF encounters across its behavioral counseling intervention topics and provides suggestions for opportunities to address these gaps to enhance the evidence base for primary care-based behavioral counseling recommendations. To accomplish this, we draw from both the USPSTF experience and issues identified by researchers and clinicians during the USPSTF-sponsored Behavioral Counseling Intervention Forum. We also discuss the dilemma posed by having "insufficient" evidence with which to make a behavioral counseling intervention-related recommendation, and describe two case examples (screening for alcohol misuse in adolescence and screening for child maltreatment), detailing the research gaps that remain. Recommendations are outlined for researchers, funders, and practice implementers to improve behavioral counseling intervention research and application.

How have researchers studied multiracial populations? A content and methodological review of 20 years of research.

The U.S. Census shows that the racial-ethnic makeup of over 9 million people (2.9% of the total population) who self-identified as multiracial is extremely diverse. Each multiracial subgroup has unique social and political histories that may lead to distinct societal perceptions, economic situations, and health outcomes. Despite the increasing academic and media interest in multiracial individuals, there are methodological and definitional challenges in studying the population, resulting in conflicting representations in the literature. This content and methods review of articles on multiracial populations provides a comprehensive understanding of which multiracial populations have been included in research and how they have been studied, both to recognize emerging research and to identify gaps for guiding future research on this complex but increasingly visible population. We examine 125 U.S.-based peer-reviewed journal articles published over the past 20 years (1990 to 2009) containing 133 separate studies focused on multiracial individuals, primarily from the fields of psychology, sociology, social work, education, and public health. Findings include (a) descriptive data regarding the sampling strategies, methodologies, and demographic characteristics of studies, including which multiracial subgroups are most studied, gender, age range, region of country, and socioeconomic status; (b) major thematic trends in research topics concerning multiracial populations; and (c) implications and recommendations for future studies.

'I didn't feel like any of those things were me': results of a qualitative pilot study of race/ethnicity survey items with minority ethnic adolescents in the USA.

OBJECTIVE: The present study is a qualitative exploration of the thought processes of minority ethnic adolescents in responding to standard epidemiologic survey questions about racial/ethnic group membership in the USA. DESIGN: Fifteen minority ethnic adolescents (ages 15-21) were enrolled in a pilot qualitative study using a cognitive processing interview technique to elicit their understanding and interpretation of race/ethnicity survey items. RESULTS: Findings from this pilot study indicated that racial/ethnic classification survey items commonly used in the USA were susceptible to a number of item performance problems, including participant confusion, and misreported or insufficient responses. Additionally, item wording elicited intense affective reactions among participants. Results suggest the need for careful review of current US race/ethnic classifications systems, as standard survey measures are likely to provide an incomplete demographic characterization of minority ethnic adolescents. CONCLUSIONS: Recommendations are provided for improving procedures for collecting race and ethnicity data from youth in the USA.

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.

Prevalence and correlates of eating disorders in Latinos in the United States.

OBJECTIVE: To present national estimates and correlates of lifetime and 12-month DSM-IV eating disorders for Latinos. METHOD: Data come from the National Latino and Asian American Study (NLAAS), a national epidemiological household survey of Latinos in the United States. RESULTS: Latinos have elevated rates of any binge eating and binge eating disorder but low prevalence of anorexia nervosa and bulimia nervosa. The US born and those living a greater percentage of their lifetime in the US evidenced higher risk for certain eating disorders while severe obesity and low levels of education were significant correlates. Rates of treatment utilization were exceedingly low. CONCLUSION: Standard eating disorder criteria may not be appropriate for understanding psychological morbidity of eating disorders for Latinos, particularly less acculturated Latinos, due to cultural differences in the presentation of eating disorder symptoms. Criteria for disturbed eating patterns that are more reflective of the illness experience of Latinos should be developed.

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.

Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study.

OBJECTIVES: We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States. METHODS: We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos. RESULTS: Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non-Puerto Ricans and foreign-born Latinos. CONCLUSIONS: Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria.

Looking Beyond Nativity: The Relation of Age of Immigration, Length of Residence, and Birth Cohorts to the Risk of Onset of Psychiatric Disorders for Latinos.

Past studies yield inconsistent results regarding risk of psychopathology for U.S. Latinos by nativity possibly due to differences across immigrants in their age of arrival to the U.S., their length of residence in the U.S., or birth-cohort differences. This paper seeks to document the relation of age of arrival, time in the U.S., and cohort effects on the risk of onset of psychiatric disorders using a nationally representative sample of 2554 Latinos in the coterminous United States. Risk of onset of psychiatric disorders was assessed using the World Health Organization Composite International Diagnostic Interview (WMH-CIDI, Kessler & Ustun, 2004). Findings indicate that Latino immigrants have lower risks of onset for some psychiatric disorders in their country of origin, but once in the U.S., Latino immigrants appear to experience similar risks of onset as U.S.-born Latinos of the same age. The longer Latino immigrants remain in their country of origin, the less cumulative risk of onset they experience, resulting in lower lifetime rates of disorders. These findings could potentially be due to variation in cultural and social norms and expectations across geographical contexts, differences in family structure and gender roles, as well as artifactual-level explanations.

Health insurance coverage for vulnerable populations: contrasting Asian Americans and Latinos in the United States.

This paper examines the role that population vulnerabilities play in insurance coverage for a representative sample of Latinos and Asians in the United States. Using data from the National Latino and Asian American Study (NLAAS), these analyses compare coverage differences among and within ethnic subgroups, across states and regions, among types of occupations, and among those with or without English language proficiency. Extensive differences exist in coverage between Latinos and Asians, with Latinos more likely to be uninsured. Potential explanations include the type of occupations available to Latinos and Asians, reforms in immigration laws, length of time in the United States, and regional differences in safety-net coverage. Policy implications are discussed.

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.