A Socio Cultural Framework for A Socio Cultural Framework for Mental Health and Substance Mental Health and Substance

Abuse Service Disparities Abuse Service Disparities Research with Multicultural Research with Multicultural

PopulationsPopulations

Margarita Alegria, Ph.D.Margarita Alegria, Ph.D.Glorisa Canino, Ph.D.Glorisa Canino, Ph.D.

Harvard Medical School and Cambridge Harvard Medical School and Cambridge Health AllianceHealth Alliance

Complexities of Co-Occurring Conditions Complexities of Co-Occurring Conditions Conference Conference

June 25, 2004 June 25, 2004

AcknowledgementsAcknowledgements

Funding for this project was Funding for this project was provided byprovided by

NIMH -Latino Research Program NIMH -Latino Research Program Project (LRPP) (P01 MH 59876)Project (LRPP) (P01 MH 59876)

NIDA (DA A09438).NIDA (DA A09438).

Why a Framework for Why a Framework for Mental Health and Mental Health and

Substance Abuse Service Substance Abuse Service Disparities Research with Disparities Research with

Multicultural Populations?Multicultural Populations?

Racial and ethnic disparities in Racial and ethnic disparities in health care exist and are health care exist and are associated with worse associated with worse outcomes, making them outcomes, making them unacceptable. Many sources – unacceptable. Many sources – including health systems, including health systems, health care providers, patients, health care providers, patients, and utilization managers – and utilization managers – contribute to racial and ethnic contribute to racial and ethnic disparities in health care.disparities in health care. (IOM (IOM

Report , 2002)Report , 2002) That is why we need an That is why we need an approach for reducing racial and ethnic approach for reducing racial and ethnic disparities in health caredisparities in health care. .

MotivationMotivation There are pervasive ethnic and racial disparities There are pervasive ethnic and racial disparities

in mental health and substance abuse service in mental health and substance abuse service utilization. Yet the underlying causes of these utilization. Yet the underlying causes of these disparities are poorly understood. The disparities are poorly understood. The importance of obtaining a clearer understanding importance of obtaining a clearer understanding of the factors accounting for the ethnic/racial, of the factors accounting for the ethnic/racial, cultural and contextual differences in sa/mh cultural and contextual differences in sa/mh service utilization is critical due to the rapid service utilization is critical due to the rapid growth of ethnic/racial minority populations in the growth of ethnic/racial minority populations in the United States (U.S.). Census projections estimate United States (U.S.). Census projections estimate that Latinos will comprise nearly one-fourth of our that Latinos will comprise nearly one-fourth of our nation’s population by 2050. The service needs of nation’s population by 2050. The service needs of multicultural populations are of national interest, multicultural populations are of national interest, particularly because of the documented pattern particularly because of the documented pattern of health care service inequities and potential of health care service inequities and potential negative consequences of these inequities for this negative consequences of these inequities for this population. population.

Racial and ethnic minorities have less access to Racial and ethnic minorities have less access to substance abuse and mental health services substance abuse and mental health services than Whites, are less likely to receive needed than Whites, are less likely to receive needed care and are more likely to receive poor quality care and are more likely to receive poor quality care when needed. care when needed.

Higher risk of being misdiagnosed

Less likely than whites to receive evidence based Tx

Less likely to receive proper medication when first diagnosed

Motivation for FrameworkMotivation for Framework Lacked models to facilitate understanding of mh Lacked models to facilitate understanding of mh

and substance abuse disparities for ethnic and and substance abuse disparities for ethnic and racial minoritiesracial minorities

Evidence of sociocultural and contextual Evidence of sociocultural and contextual elements having role in service delivery and how elements having role in service delivery and how minorities interface with servicesminorities interface with services

Interactive and reciprocal dynamics of patient, Interactive and reciprocal dynamics of patient, provider, community and service systems that provider, community and service systems that adds layers of complexity to identifying service adds layers of complexity to identifying service disparities disparities

Absence of frameworks to develop public policies, Absence of frameworks to develop public policies, systematic guidelines, training of professional or systematic guidelines, training of professional or restructuring of mental health system to be restructuring of mental health system to be responsive to multicultural populationsresponsive to multicultural populations

How do we define Service Disparities?How do we define Service Disparities?

Start by expanding IOM’s definition as “racial Start by expanding IOM’s definition as “racial and ethnic differences in the access, quality and ethnic differences in the access, quality and outcomes of health/sa/mh care that are and outcomes of health/sa/mh care that are not due to clinical needs, preferences and not due to clinical needs, preferences and appropriateness of intervention.”appropriateness of intervention.”

Difference from IOM’s definition: we postulate Difference from IOM’s definition: we postulate 6 rather than 2 sources of service disparities 6 rather than 2 sources of service disparities and include rather than exclude access related and include rather than exclude access related factors as service disparities factors.factors as service disparities factors.

Factors that may influence MH and Factors that may influence MH and SA Service Disparities:SA Service Disparities:

The operation of the health care system and The operation of the health care system and provider organizationprovider organization (e.g. structure of incentives and (e.g. structure of incentives and supports for servicing multicultural populations [mcp], diversity in supports for servicing multicultural populations [mcp], diversity in workforce, design of services for mcp, provider burden)workforce, design of services for mcp, provider burden)

Health care policies and regulations at the Health care policies and regulations at the state and federal levelstate and federal level (e.g. budgetary allocations to (e.g. budgetary allocations to serve mcp, state eligibility thresholds for public insurance serve mcp, state eligibility thresholds for public insurance coverage of mcp, state and federal cost-sharing for attracting coverage of mcp, state and federal cost-sharing for attracting diverse work force) diverse work force) and market forcesand market forces (e.g. # of HMO’s and (e.g. # of HMO’s and pharmacies in ethnic/racial minority neighborhoods)pharmacies in ethnic/racial minority neighborhoods)

The operation of the community systemThe operation of the community system (e.g. (e.g. community norms to sa & mh, receptivity to sa & mh community norms to sa & mh, receptivity to sa & mh services, access to public transportation)services, access to public transportation)

Factors that may influence MH and Factors that may influence MH and SA Service Disparities:SA Service Disparities:

Biases, uncertainty and stereotyping in the Biases, uncertainty and stereotyping in the provider-patient interactionprovider-patient interaction (e.g. statistical (e.g. statistical discrimination, misdiagnoses, mistrust, lack of therapeutic discrimination, misdiagnoses, mistrust, lack of therapeutic alliance)alliance)

Patient and Family level factorsPatient and Family level factors (e.g. health (e.g. health literacy, unrealistic expectations about substance abuse literacy, unrealistic expectations about substance abuse and mental health treatments, lack of adherence to Tx, and mental health treatments, lack of adherence to Tx, lack of problem recognition, negative attitudes, stigma)lack of problem recognition, negative attitudes, stigma)

The changing socio-contextual, cultural, and The changing socio-contextual, cultural, and political forces affecting Multicultural political forces affecting Multicultural populationspopulations

The operation of the health care system and The operation of the health care system and provider organizationprovider organization

The climate and culture of provider The climate and culture of provider organizations-racial minorities as less organizations-racial minorities as less appealing to service organizations appealing to service organizations (higher illness severity and (higher illness severity and prematurely terminating Tx)prematurely terminating Tx)

Institutional racismInstitutional racism Commitment of allocating providers Commitment of allocating providers

to minority Medicaid beneficiaries to minority Medicaid beneficiaries (competing for physician services)(competing for physician services)

The climate and culture of provider The climate and culture of provider organizationsorganizations

For example, minorities are described as coming For example, minorities are described as coming to health care with higher levels of illness severity to health care with higher levels of illness severity (Vega and Alegría, 2001) and of prematurely (Vega and Alegría, 2001) and of prematurely terminating treatment (Sue, 1994). In similar terminating treatment (Sue, 1994). In similar fashion, minority Medicaid managed care fashion, minority Medicaid managed care beneficiaries are seen as having increased beneficiaries are seen as having increased probability for missing appointments (Majeroni et probability for missing appointments (Majeroni et al., 1996) which, in a capitated managed care al., 1996) which, in a capitated managed care environment, might make them less attractive for environment, might make them less attractive for physicians. Recent efforts to weave cultural and physicians. Recent efforts to weave cultural and linguistic competence requirements in the health linguistic competence requirements in the health care system have been met with concern by care system have been met with concern by medical associations (Flores et al., 2003) because medical associations (Flores et al., 2003) because physicians may be required to cover the costs of physicians may be required to cover the costs of non-reimbursable interpreter services non-reimbursable interpreter services

Decreased odds of specialty care use for poor Latinos Decreased odds of specialty care use for poor Latinos as compared to poor whites: effect of poverty and as compared to poor whites: effect of poverty and minority status minority status ((Inequalities in Specialty Care, Alegria et al., Psychiatric Inequalities in Specialty Care, Alegria et al., Psychiatric

Services, 2002 )Services, 2002 )

Poor Poor

(Income<$15,000)(Income<$15,000)

Any Specialized Any Specialized Mental Mental

Health/Substance Health/Substance Use CareUse Care

LatinosLatinos 0.18 (0.04-0.81)*0.18 (0.04-0.81)*

African African AmericansAmericans

0.53 (0.21-1.32)0.53 (0.21-1.32)

Non-Non-Latino Latino WhitesWhites

1.001.00

TANF/AFDC Medicaid Patients (18 or older) with New TANF/AFDC Medicaid Patients (18 or older) with New Episodes of DepressionEpisodes of Depression

WhiteWhite

(N=7,752)(N=7,752)Afr AmerAfr Amer

(N=2685)(N=2685)LatinoLatino

(N=4564)(N=4564)AsianAsian

(N=1102)(N=1102)

% SSRI’s 6mo. % SSRI’s 6mo. Follow up Follow up

56.8%56.8% 42.5%**42.5%** 43.4%**43.4%** 52.4%**52.4%**

% psychotherapy % psychotherapy Tx 6mo followup Tx 6mo followup

9.08%9.08% 8.9%8.9% 1.14%**1.14%** 0.64%**0.64%**

% any MD% any MD

Office visitOffice visit72.9%72.9% 69.6%69.6% 71.2%71.2% 73.3%73.3%

% any MH% any MH

visitvisit43.8%43.8% 35.8%35.8% 47.2%47.2% 36.9%36.9%

% any ER visit% any ER visit 36.02%36.02% 38.32%38.32% 29.1%**29.1%** 20.69%**20.69%**

% any MH% any MH

ER visitER visit8.91%8.91% 8.98%8.98% 8.06%8.06% 5.54%**5.54%**

% any psych % any psych hospitalizationhospitalization

5.65%5.65% 10.1%**10.1%** 4.47%**4.47%** 3.81%**3.81%**

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign o f services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizationa l c lim ate Process o f C are

Access totreatm ent forLatinos

Q uality o f careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality o f L ife

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

Health care policies and regulations at the Health care policies and regulations at the state and federal levelstate and federal level

Organization and financing at Organization and financing at state/county level affects access to state/county level affects access to specialty/substance abuse carespecialty/substance abuse care

Policies of direct public mh/sa provision Policies of direct public mh/sa provision of behavioral servicesof behavioral services

Distribution of HMO’s plans by areaDistribution of HMO’s plans by area Assurances of geographic distribution Assurances of geographic distribution

of specialty/sa providersof specialty/sa providers Policies to require in contracts design of Policies to require in contracts design of

targeted services for mcpstargeted services for mcps

Health Care Policies and Regulations at Health Care Policies and Regulations at the State and Federal level and Market the State and Federal level and Market

ForcesForces For example, state of residence of the child appears to For example, state of residence of the child appears to

influence the likelihood of receiving mental influence the likelihood of receiving mental health/substance abuse care, even after controlling for health/substance abuse care, even after controlling for ethnic and racial differences in the population of children ethnic and racial differences in the population of children and the level of need (Sturm, Ringel and Andreyeva, 2003). and the level of need (Sturm, Ringel and Andreyeva, 2003). This study found that Latino children had the greatest level This study found that Latino children had the greatest level of unmet need, and that the states of California, Florida, of unmet need, and that the states of California, Florida, Texas, Mississippi and Alabama exceeded the national Texas, Mississippi and Alabama exceeded the national average of unmet mental health/substance abuse need for average of unmet mental health/substance abuse need for children 6-17. Geographic differences in mental children 6-17. Geographic differences in mental health/substance abuse care disparities, particularly among health/substance abuse care disparities, particularly among children in poor families suggest that state policies and children in poor families suggest that state policies and health care market characteristics impact which children health care market characteristics impact which children get health care. A crucial component seems to be played by get health care. A crucial component seems to be played by State Children’s Health Insurance Programs (SCHIP) State Children’s Health Insurance Programs (SCHIP) designed to make free or low-cost health insurance designed to make free or low-cost health insurance available to uninsured children not eligible under Medicaid. available to uninsured children not eligible under Medicaid.

Health Care Policies and Regulations at Health Care Policies and Regulations at the State and Federal level and Market the State and Federal level and Market

ForcesForces The structure of the Medicaid contracts The structure of the Medicaid contracts

with independent practice associations with independent practice associations (IPAs) who service minority Medicaid (IPAs) who service minority Medicaid beneficiaries may also indirectly impact beneficiaries may also indirectly impact service disparities. Contracts with IPAs service disparities. Contracts with IPAs that do not include a sufficient pool of that do not include a sufficient pool of providers with language or cultural providers with language or cultural competencies to service non-English competencies to service non-English populations, or that do not have practices populations, or that do not have practices located near residential areas where located near residential areas where ethnic and racial minority enrollees live, ethnic and racial minority enrollees live, may lead to service disparities (Sue et al., may lead to service disparities (Sue et al., 1991). 1991).

Twelve-Month Rates of Utilization of Health Care Twelve-Month Rates of Utilization of Health Care Services by Mexican Americans with Mental and Services by Mexican Americans with Mental and

Substance Use DisordersSubstance Use Disorders

0%

5%

10%

15%

20%

25%

Mental HealthSpecialist

General Medical OtherProfessional

Informal Care

Mood DisorderAnxiety DisorderSubstance Use DisorderDual

Vega WA, et al. Gaps in service utilization by Mexican Americans with mental health problems. Am J Psychiatry

1999;156:928-34.

H ealth C arePolic ies

R egulations ats tate and

federa l level

M arket forces

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign of services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizational c lim ate Process of C are

Access totreatm ent forLatinos

Q uality of careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality of L ife

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

The changing socio-contextual, cultural, and The changing socio-contextual, cultural, and political forces affecting Multicultural populationspolitical forces affecting Multicultural populations

EducationEducation EmploymentEmployment HousingHousing Political relationships Political relationships

between country of exit between country of exit and the US may determine and the US may determine eligibility for government eligibility for government aid and health benefitsaid and health benefits

Political conditions in the Political conditions in the USUS

Private Insurance Among Latinos is Private Insurance Among Latinos is DecreasingDecreasing

Ruiz P. Issues in the psychiatric care of Hispanics. Psychiatric Services 1997;48:539-40.

0%

10%

20%

30%

40%

50%

60%

1977 1987 1997

Private Health Insurance Medicaid or Medicare Uninsured

H ealth C arePolic ies

R egulations a ts tate and

federa l leve l

M arket forces

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign o f services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizationa l c lim ate Process o f C are

Access totreatm ent forLatinos

Q uality o f careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality o f L ife

C hanging

soc io-contextua l,

cu ltura l,

and

politica l forces

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

The operation of the community systemThe operation of the community system

Support and availability of CBO’s at the Support and availability of CBO’s at the neighborhood levelneighborhood level

Level of community mistrust in health, sa and Level of community mistrust in health, sa and mh care providersmh care providers

Community social and contextual problems Community social and contextual problems that compete for attention (housing, jobs)that compete for attention (housing, jobs)

Neighbors and extended family’s willingness Neighbors and extended family’s willingness to intervene-community cohesion to intervene-community cohesion

High tolerance for untreated mental illnessHigh tolerance for untreated mental illness Community’s poor perception of the Community’s poor perception of the

effectiveness of sa and mh care effectiveness of sa and mh care

Community Mistrust in MH/SA Community Mistrust in MH/SA CareCare

Mistrust in Service Providers and Medical Mistrust in Service Providers and Medical Institutions: in NLAAS, about 20% of Institutions: in NLAAS, about 20% of respondents indicate having negative respondents indicate having negative experience w service providersexperience w service providers

Experience that Tx does not help a lot: only Experience that Tx does not help a lot: only 50% rated psychiatric/substance abuse Tx 50% rated psychiatric/substance abuse Tx as helping them a lot.as helping them a lot.

Dropping out of Tx: only 57.14% of Dropping out of Tx: only 57.14% of respondents in NLAAS say they completed respondents in NLAAS say they completed the treatment.the treatment.

Mode number of visits is 1 and median is 3 Mode number of visits is 1 and median is 3 to both psychiatrists and psychologists.to both psychiatrists and psychologists.

Received Active Received Active Tx=Any Tx=Any pharmacotherapy, pharmacotherapy, counseling or counseling or psychotherapypsychotherapy

OROR LB 95%LB 95%

CICIUB 95%UB 95%

CICI

African African AmericanAmerican

0.580.58 0.530.53 0.630.63

LatinoLatino 0.550.55 0.520.52 0.590.59

AsianAsian 1.031.03 0.900.90 1.171.17

OtherOther 0.930.93 0.670.67 1.281.28

WhiteWhite 1.001.00 ---------- ----------

Logit Model for Received Active Tx (TANF/AFDC Sample (N=17,772) for those w New Depression

H ealth C arePolic ies

R egulations a ts tate and

federa l level

M arket forces

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign o f services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizationa l c lim ate Process o f C are

Access totreatm ent forLatinos

Q uality o f careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality o f L ife

C om m unity System

O peration of C om m unitySystem

C om m unity perceptionsof services

Socia l cap ita l Level o f com m unity

m istrust in hea lth careproviders

Level o f cohesion

C hanging

socio-contextua l,

cu ltura l,

and

politica l forces

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

Biases, uncertainty and stereotyping in the Biases, uncertainty and stereotyping in the provider-patient interactionprovider-patient interaction

Bias by providers in the clinical Bias by providers in the clinical encounter (e.g. negative encounter (e.g. negative attitudes)attitudes)

Problems in the therapeutic Problems in the therapeutic alliance due to stereotypingalliance due to stereotyping

Miscommunication in the clinical Miscommunication in the clinical encounter leading to uncertaintyencounter leading to uncertainty

Bringing past experiences of Bringing past experiences of racist Tx (patient side) or racist Tx (patient side) or negative experiences w/ negative experiences w/ minority patients (provider side)minority patients (provider side)

Uncertainty may lead Providers to Uncertainty may lead Providers to adopt stereotypesadopt stereotypes

Cooper’s data in studying patient-provider Cooper’s data in studying patient-provider communication showed that providers may communication showed that providers may unintentionally incorporate racial and unintentionally incorporate racial and ethnic stereotypes into their ethnic stereotypes into their interpretations of patients’ symptoms, interpretations of patients’ symptoms, prediction of patients’ behaviors and prediction of patients’ behaviors and medical decision-making.medical decision-making.

Short cuts may be necessary given limited Short cuts may be necessary given limited exposure or experience w/ particular exposure or experience w/ particular population. population.

Unsuccessful Provider-patient InteractionUnsuccessful Provider-patient Interaction

Studies emphasize that racial and cultural Studies emphasize that racial and cultural differences between patient and provider differences between patient and provider may affect the patient’s satisfaction with may affect the patient’s satisfaction with and continuation in care (Saha, and continuation in care (Saha, Komaromy, Koepsell et al., 1999). Having Komaromy, Koepsell et al., 1999). Having a successful interaction between caregiver a successful interaction between caregiver and clinician has an effect on the degree and clinician has an effect on the degree of resistance or cooperation, the level of of resistance or cooperation, the level of disclosure (Chiu, 1994), and the rejection disclosure (Chiu, 1994), and the rejection of treatment options (Temkin-Greener and of treatment options (Temkin-Greener and Clark, 1988). Clark, 1988).

H ealth C arePolic ies

R egulations a ts tate and

federa l level

M arket forces

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign o f services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizationa l c lim ate

Provider/C lin ic ianS tereotyp ing

T reatm ent, uncerta in tyand s tereotyp ing o fLatinos

Attitudes towards Latinos C lin ic ian 's sex, e thnic ity/

race, and tra in ing

Process o f C are Access to

treatm ent forLatinos

Q uality o f careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality o f L ife

C om m unity System

O peration of C om m unitySystem

C om m unity perceptionsof services

Socia l cap ita l Level o f com m unity

m istrust in hea lth careproviders

Level o f cohesion

C hanging

socio-contextua l,

cu ltura l,

and

politica l forces

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

Patient and Family level factorsPatient and Family level factors

Low priority to MH/SA Tx Low priority to MH/SA Tx Multiple jobs of minorities and Multiple jobs of minorities and

importance of retaining a jobimportance of retaining a job Family and social networks Family and social networks

against mh Txagainst mh Tx Limited knowledge of MH/SA and of MH/SA Limited knowledge of MH/SA and of MH/SA

sector, including use of alternative sources sector, including use of alternative sources (clergy)(clergy)

Difficulty in communicating Difficulty in communicating need and goals of TXneed and goals of TX

HOW MANY PEOPLE W/ PTSD RECOGNIZE HOW MANY PEOPLE W/ PTSD RECOGNIZE PROBLEM BY RACEPROBLEM BY RACE

   LATINOLATINO ASIANASIAN

YOU THOUGHT YOU HAD YOU THOUGHT YOU HAD NERVOUS/EMOTION/DRUG/ALC NERVOUS/EMOTION/DRUG/ALC PROBLEMPROBLEM 34.88%34.88% 16.00%16.00%

OTHER PERSON THOUGHT YOU HAD OTHER PERSON THOUGHT YOU HAD NERV/EMTN/DRUG/ALC PROBLEMNERV/EMTN/DRUG/ALC PROBLEM 30.23%30.23% 16.67%16.67%

YOU THOUGHT YOU SHOULD TALK TO YOU THOUGHT YOU SHOULD TALK TO DOCTORDOCTOR 59.30%59.30% 40.00%40.00%

FAM MEMBER/FRIEND/OTHER TELL YOU FAM MEMBER/FRIEND/OTHER TELL YOU TO TALK TO DOCTORTO TALK TO DOCTOR 47.67%47.67% 36.00%36.00%

Patient and Family level factorsPatient and Family level factors

Disparities in health care show that some ethnic Disparities in health care show that some ethnic minority children have also been tied to parental minority children have also been tied to parental knowledge of available treatments (Bussing, knowledge of available treatments (Bussing, Schoenberg and Perwien, 1998). Bussing and Schoenberg and Perwien, 1998). Bussing and colleagues’ results (1998) reveal significant colleagues’ results (1998) reveal significant differences among African American and white differences among African American and white parents in their knowledge of attention deficit parents in their knowledge of attention deficit hyperactivity disorder (ADHD). Only 36% of African hyperactivity disorder (ADHD). Only 36% of African American parents reported that they knew some or a American parents reported that they knew some or a lot about ADHD in contrast to 70% of white parents. lot about ADHD in contrast to 70% of white parents. Recent data suggests that increased parental Recent data suggests that increased parental knowledge about ADHD increases the likelihood of knowledge about ADHD increases the likelihood of enrollment in both pharmacological treatments and enrollment in both pharmacological treatments and non-pharmacological treatments (Corkunu, Rimer and non-pharmacological treatments (Corkunu, Rimer and Schachar, 1999).Schachar, 1999).

H ealth C arePolic ies

R egulations a ts tate and

federa l level

M arket forces

H ealth C are System

O peration of H ealth C are System C ultura l and linguis tic

requirem ents Structure of incentives to

service Latinos W ork force d ivers ity D esign o f services for Latinos

Provider O rganization Level o f Institu tional R acism Provider burden O rganizationa l c lim ate

Provider/C lin ic ianS tereotyp ing

T reatm ent, uncerta in tyand s tereotyp ing o fLatinos

Attitudes towards Latinos C lin ic ian 's sex, e thnic ity/

race, and tra in ing

Process o f C are Access to

treatm ent forLatinos

Q uality o f careonce in treatm entfor Latinos

D ifferentia l treatm entservice outcom es

Function ing Burder o f illness Q uality o f L ife

C om m unity System

O peration of C om m unitySystem

C om m unity perceptionsof services

Socia l cap ita l Level o f com m unity

m is trust in hea lth careproviders

Level o f cohesion

Fam ily/F riend/Lay Sector C aregiver's recognition of

m enta l health problem sor inh ib iting help seek ing

Perc ieved effectivenessof m enta l hea lth system

M enta l hea lth lite racy

Patient Sex, race/ethn ic ity Problem recognition M igration h is tory T reatm ent h is tory Level o f need Severity o f sym ptom s

C hanging

soc io-contextua l,

cu ltura l,

and

politica l forces

T he Socio-C ultura l F ram ework of Service D isparities (SC FSD )

Recommended mechanisms to deal w Recommended mechanisms to deal w MH/SA Service DisparitiesMH/SA Service Disparities

Restructuring of Service Sectors and Restructuring of Service Sectors and Changing Recertification of Provider Changing Recertification of Provider Organizations for Public contractsOrganizations for Public contracts

Reforming health policies to make them Reforming health policies to make them sensitive to needs of mcpssensitive to needs of mcps

Training and monitoring to avoid stereotypes, Training and monitoring to avoid stereotypes, prejudice and clinical uncertainty (e.g. cultural prejudice and clinical uncertainty (e.g. cultural liaisons)liaisons)

Augmenting information exchange between Augmenting information exchange between client and provider (more time in clinical client and provider (more time in clinical encounter, required assessment) for mcpencounter, required assessment) for mcp

Recommended mechanisms to deal with Recommended mechanisms to deal with MH/SA Service DisparitiesMH/SA Service Disparities

Evaluate service procedures to see how can you do Evaluate service procedures to see how can you do better treatment matching (who, when, how)better treatment matching (who, when, how)

Increased client/patient activation or Increased client/patient activation or empowerment (e.g. RQP)empowerment (e.g. RQP)

Review institutional policies in health care systems Review institutional policies in health care systems and implement changes to provider organizations and implement changes to provider organizations to reduce service disparitiesto reduce service disparities

Consider regulating marketsConsider regulating markets Create annual report card on service disparities at Create annual report card on service disparities at

state and county levelstate and county level