Behavioral Health Disparities Research Articles

Speaker Abstracts

The Deaf community consists of a diverse group of individuals with varied languages (i.e. American Sign Language, English, etc.), community affiliations (i.e. Deaf culture, general community, etc.), and sociocultural norms (Anderson et al., 2018). Despite evidence of higher rates of victimization, behavioral health disorders, and hazardous drinking among Deaf individuals, they remain one of the most understudied populations in behavioral health research (Anderson et al., 2018;Fellinger et al., 2012). Significant disparities exist in access to and utilization of behavioral health services among Deaf individuals due to limited access to health information, fear and mistrust in healthcare settings, cultural and linguistic oppression, fear of stigmatization within the Deaf community, communication barriers, and a lack of culturally appropriate services (Barnett et al., 2011;Fellinger et al., 2012). CBT for Treatment Seeking (CBT-TS) has shown promise as an intervention to promote the use of treatment services among hearing individuals (Stecker et al., 2012), but it is unknown whether the intervention would be effective with Deaf individuals and what modifications might be necessary to increase its accessibility and applicability. This paper will present an ongoing project funded by an NIAAA diversity supplement [R01AA026815-03S1] to adapt CBT-TS for Deaf individuals using the ADAPT-ITT model, a pragmatic framework for adapting evidence-based interventions (Wingood & DiClemente, 2008). The first part of this project involves elicitation interviews with members of the new target population regarding their attitudes and beliefs about treatment, facilitators and barriers to treatment seeking, and the impact of COVID-19 on treatment seeking. The second part involves soliciting feedback of the materials, content, and delivery of CBT-TS from the target population and key stakeholders in the community via a pretesting methodology called “theater testing.” Finally, data from the elicitation interviews and the theater testing sessions will be combined to produce an adapted version of CBT-TS for Deaf individuals. This paper will present background information about behavioral health disparities among Deaf individuals and the rationale, plan, progress, and initial data of the ongoing project. An adaptation of CBT-TS for Deaf individuals would benefit a historically underserved community with potentially higher rates of hazardous drinking and behavioral health disorders and lower rates of treatment use.

Scaling Up and Out HIV Prevention and Behavioral Health Services to Latino Sexual Minority Men in South Florida: Multi-Level Implementation Barriers, Facilitators, and Strategies

Latino sexual minority men (LSMM) are disproportionately affected by HIV in the United States. Concurrently, behavioral health disparities, including mental health and substance use concerns, worsen HIV disparities affecting LSMM. Yet, evidence-based HIV prevention and behavioral health services are insufficiently scaled up and out to this population, perpetuating health disparities, thwarting efforts to control the HIV epidemic, and highlighting the need for culturally relevant evidence-based implementation strategies that address these disparities. Participants included 28 LSMM with varying degrees of engagement in HIV prevention and behavioral health services, and 10 stakeholders with experience delivering HIV prevention and behavioral health services to LSMM in South Florida, an HIV epicenter in general and in particular for LSMM. Participants completed semistructured interviews (English/Spanish) regarding LSMM's barriers and facilitators to engaging in HIV prevention and behavioral health services. Interviews were audio recorded and analyzed using thematic analysis. The 16 themes that emerged from the qualitative analysis were consistent with the consolidated framework for implementation research, an implementation research framework that articulates barriers and facilitators to implementing clinical interventions. Findings suggested the need for implementation strategies that simplify and reduce costs of HIV prevention and behavioral health services, address syndemic challenges impacting service use among LSMM, reduce stigma about service utilization, leverage peer networks, increase provider and community knowledge about services, and build LSMM's readiness and motivation to engage in services. Such strategies may ultimately address HIV and behavioral health disparities among LSMM and facilitate achievement of ending the HIV epidemic goals in this disproportionally affected population.

Integrating Cultural Relevance into a Behavioral mHealth Intervention for Native American Youth.

Native American communities are disproportionately affected by a number of behavioral health disparities, including higher rates of depression, substance abuse, and suicide. As mobile health (mHealth) interventions gain traction as methods for addressing these disparities, they continue to lack relevance to Native American youth. In an effort to explore the design of relevant behavioral mHealth intervention for Native American communities, we have developed ARORA (Amplifying Resilience Over Restricted Internet Access), a prototype behavioral mHealth intervention that has been co-designed with Native American youth, a community advisory board, and a clinical psychologist. In this paper, we qualitatively analyze our co-design and focus group sessions using a grounded theory approach and identify the key themes that Native American community members have identified as being critical components of relevant mHealth designs. Notably, we find that the Native American youth who participated in our focus groups desired a greater level of didactic interaction with cultural and behavioral health elements. We conclude with a discussion of the significant challenges we faced in our efforts to co-design software with Native American stakeholders and provide recommendations that might guide other HCI researchers and designers through challenges that arise during the process of cross-cultural design.

A Model for Addressing Behavioral Health Disparities Impacting HBCU students

A Model for Addressing Behavioral Health Disparities Impacting HBCU students

Reducing racial/ethnic disparities in mental health service use among emerging adults: community-level supply factors

ABSTRACT Objectives: Emerging adulthood—spanning 18–29 years of age—is associated with the highest risk for onset of certain behavioral health disorders (e.g. major depression, bipolar disorder, psychosis, substance use disorders) and high prevalence of many behavioral health disorders. Yet, rates of mental health service use remain low in this age range. Racial/ethnic minorities are particularly impacted by individual, cultural/linguistic, and community-level barriers to mental health care. This study examined community-level factors associated with mental health service use and investigated whether these associations varied by race/ethnicity. Design: This study analyzed individual- and county-level data for emerging adults in the United States (N=3,294) from the nationally representative Collaborative Psychiatric Epidemiological Surveys (CPES). Using the Andersen Model of Health Care Utilization, analyses examined predisposing, enabling, and need factors utilized in prior studies with adult samples as well as novel community characteristics hypothesized to impact service use among emerging adults of diverse racial/ethnic backgrounds. Past-year use of both specialty and any mental health services were assessed, controlling for individual- and community-level variables, and adjusting for presence of past-year mental health disorder, overall health status, and functional impairment. Differences between racial/ethnic minority groups and Non-Latino Whites were tested through a multilevel model incorporating random intercepts logistic regression, with analysis focusing on the interaction between race/ethnicity and community-level supply variables. Results: For past-year use of specialty mental health services, density of hospitals with child wellness programs was linked to service use among Black emerging adults, whereas density of hospitals with linguistic/translation services was linked to service use among Latino emerging adults. Conclusions: This study expands on previous research in behavioral health disparities to examine ways to improve behavioral health services for an emerging adult population with unmet service needs and identifies specific community-level factors that can improve mental health for racial/ethnic minority emerging adults.

Gender and Sexual Identities Predicting Patterns of Co-occurring Health Risks Among Sexual Minority Youth: a Latent Class Analysis Approach.

Behavioral health disparities (e.g., substance use, mental health) exist for gender nonconforming (GNC) and sexual minority youth; however, there is limited knowledge on disparities that may be unique among youth who identify as both a sexual and gender minority. This study utilized a diverse sample of GNC and cisgender sexual minority youth seeking crisis services to examine co-occurrence of behavioral health outcomes. Surveys were administered with youth (aged 12-24, N = 592), and latent class analyses were applied. Two latent class regression models were conducted to examine how gender and sexual identity separately (independent effect; Model 1) and configurations of gender and sexual identity (Model 2) predicted class membership. Analyses resulted in a four-class solution: High All (17.6%), High Substance Use and Moderate Mental Health (10.6%), Low All (20.1%), and High Suicide and High Mental Health (51.7%). In our first model, youth who identified as GNC had 2.11 higher odds of being in the High Suicide and High Mental Health class compared to the Low All class; however, sexual identity was not a significant predictor. In the second model, individuals identifying as GNC gay or lesbian or GNC pansexual had 1.95 and 2.57 higher odds, respectively, of being in the High Suicide and High Mental Health class compared to the Low All class. Our study suggests the information on gender and sexual identities together are more helpful in identifying youth at risk for co-occurring negative health outcomes. Implications for prevention approaches are described.

Examination of Group-Based Behavioral Skills Training for Parents of Children with Intellectual and Neurodevelopmental Disorders

Children with intellectual and neurodevelopmental disabilities are likely to present with behavioral and academic difficulties. Behavioral skills training to train parents to improve their children’s outcomes has garnered a great deal of support for improving parents’ use of evidence- based behavior management strategies. Unfortunately, children with intellectual and neurodevelopmental disabilities often experience behavioral health disparities due to lengthy wait lists for services. One solution for this problem is to train multiple caregivers in behavior management strategies at the same time. This study evaluated the effectiveness of group-based behavioral skills training for teaching parents of children with intellectual and neurodevelopmental disabilities to accurately implement effective instruction delivery and their children’s response to instructions. Results indicated that parents’ effective instruction delivery integrity improved and maintained over time, with concomitant improvements in children’s response to instructions. Brief performance feedback was necessary for one parent to maintain increases in effective instruction delivery integrity. Results are discussed in terms of this study’s outcomes, implications, and limitations.

Using integrated behavioral healthcare to address behavioral health disparities in underserved populations.

Using integrated behavioral healthcare to address behavioral health disparities in underserved populations.

Individuals with spinal cord injury have greater odds of substance use disorders than non-sci comparisons

BackgroundIndividuals with spinal cord injury (SCI) are disproportionately affected by numerous physical and behavioral health disparities, but the literature lacks a clear understanding of the association between SCI and substance use disorders. Identifying such behavioral health disparities in persons with disabilities is an increasingly central focus for public health researchers and represents a critical first step for prevention. MethodThe present study utilized a large database of deidentified electronic health records to examine the association between SCI and substance use disorders related to alcohol, cannabis, opioid, and nicotine. Examining data from patients 16 years or older who had patient encounters at the Penn State Hershey Medical Center from January 1, 1997 to April 30, 2018, the current study included data from 1,466,985 unique patients – 6192 of which held SCI diagnoses. Age-adjusted odds ratios were calculated using logistic regression. ResultsCompared to non-SCI patients, individuals with SCI were at increased odds of having alcohol use disorder (OR: 4.19, 95% CI [3.67, 4.80]), cannabis use disorder (OR: 7.83, 95% CI [6.32, 9.69]), opioid use disorder (OR: 7.97, 95% CI [6.59, 9.66]), and nicotine use disorder (OR: 4.66, 95% CI [4.40, 4.94]). Patient sex did not moderate any of the four associations. ConclusionThis study provides early indication that individuals with SCI may be disproportionately at-risk for substance use disorders and provides a foundation for future mechanistic and translational research. This evidence is a valuable step towards improving the health and quality of life for individuals with SCI.

TRANSFORMING TRAUMATIC IMPACTS FOR LGBTQ YOUTH

LGBTQ youth experience significantly greater rates of family rejection, societal prejudice, and various traumas, and they have significantly greater risk for developing MDD, suicidality, and/or PTSD than their straight peers. This Symposium describes trauma-related behavioral health disparities of LGBTQ youth and 3 effective interventions to address related negative mental health outcomes in LGBTQ youth.

20.1 THE FAMILY ACCEPTANCE PROJECT'S MODEL FOR LGBTQ YOUTH

Historically, families were not included in interventions to decrease risk for LGBTQ youth. The Family Acceptance Project (FAP) was founded to study LGBTQ youth and families and to develop an evidence-grounded family support model to decrease family-rejecting behaviors and increase family-supportive and -accepting behaviors to reduce behavioral health disparities and increase connectedness. Family rejection is traumatic and must be addressed directly to reduce risk.

20.4 BEHAVIORAL HEALTH DISPARITIES IN LGBTQ YOUTH

Many child and adolescent psychiatrists are aware of studies suggesting that LGBTQ youth have significantly increased risk for adverse mental health outcomes relative to their heterosexual, cisgender peers. Such awareness represents a good starting point when working with LGBTQ and gender-diverse youth, but child and adolescent psychiatrists often receive little training in methods or approaches specific to helping these youth. In addition to the same types of trauma experienced by other youth, LGBTQ youth are at elevated risk for traumas related to their sexual orientation and/or gender identity, with differing levels of stigma, trauma, and disparities in care experienced by those within the LGBTQ community. A review of relevant studies can provide crucial information to guide in clinical decision making. Attendees will leave with an increased knowledge of the behavioral health disparities experienced by LGBTQ youth, as well as factors that can help decrease their risk and mitigate negative outcomes.

Transforming through leadership: a qualitative study of successful American Indian Alaska Native behavioral health leaders

BackgroundEffective leadership is vital in the struggle to decrease the behavioral health disparities between the US population and American Indian Alaska Native (AIAN) communities. AIAN communities have a pre-colonization history of highly effective leadership, yet some AIAN leadership traditions have been eradicated through decades of trauma and genocidal efforts. There is a paucity of research on AIAN public health leadership, and most existing research relies on samples of individuals holding leadership positions rather than individuals purposely selected because of their effectiveness. The aim of the study was to investigate the experiences of successful AIAN behavioral health leaders and present an emerging AIAN public health leadership model.MethodsThirty-eight public health leaders in the Substance Abuse and Mental Health Service Administration (SAMHSA) funded Circles of Care project were observed over the course of their three-year leadership role. Stringent criteria for successful community participatory leadership resulted in the selection of 11 of the 38 leaders for inclusion in the study. Ultimately eight leaders (21% of the population of observed leaders) participated in the study. Semi-structured, one-on-one qualitative interviews were conducted. The methods were informed by phenomenology and the data were analyzed using a thematic content analysis approach.ResultsThe analysis resulted in ten themes: Hopeful Vision for the People, Cultural Humility, Awareness of Historical Context, Purpose Driven Work Behavior, Cultural and Bi-Cultural Knowledge, Trusting a Broader Process, Caring Orientation, Holistic Supervision, Community Centered, and Influence Through Education. Respondents were strongly motivated by a desire to help future generations. They described their success in terms of the application of traditional AIAN values such as cultural humility and community orientation, but also relied heavily on task orientation. An emerging AIAN leadership model is presented.ConclusionsIt is important to encourage AIAN public health leaders to employ leadership research and models conducted or developed in the context of AIAN communities. The emerging model presented in this study could serve as an initial basis for AIAN leadership training. Given the challenging context of AIAN leadership, the lessons taught by these successful leaders could be adapted for use by leaders in non AIAN settings.

Promoting Enrollment in Parenting Programs Among a Filipino Population: A Randomized Trial.

Evidence-based parenting programs prevent the onset and escalation of youth conduct problems. However, participation rates in such programs are low among hard-to-reach populations, including Filipino individuals. Compared with other ethnic groups, Filipino adolescents have significant mental health disparities. We evaluated the effectiveness of a theory-based, culturally tailored video versus a usual-care mainstream video on enrollment in an evidence-based parenting program among Filipino caregivers of children ages 6 to 12 years and tested theoretical mediators of intervention effect. We randomly assigned 215 Filipino participants to view either a theory-based, culturally tailored video based on the Health Belief Model and Theory of Planned Behavior or a control video. The primary outcome was actual enrollment in an evidence-based parenting intervention. Mediators (knowledge and perceived susceptibility) were modeled as latent variables in a structural equation model. After the intervention, participants in the intervention group had significantly higher knowledge of Filipino adolescent behavioral health disparities and higher perceived susceptibility to adolescent risky sexual activity and illegal drug use. Controlling for child sex, parents in the intervention group had significantly greater odds of actual enrollment in the Incredible Years program (odds ratio = 2.667; 95% confidence interval: 1.328-5.354; P = .006). The intervention effects were mediated by increased knowledge and perceived susceptibility. Results demonstrated the effectiveness of a theory-based, culturally tailored intervention aimed at increasing participation of a hard-to-engage population in parenting interventions. Videos that include parents and health professionals with whom audiences can identify can be used to produce shifts in knowledge and behavior.

Community-Engaged and Culturally Relevant Research to Develop Behavioral Health Interventions with American Indians and Alaska Natives.

American Indians and Alaska Natives experience pervasive mental, behavioral, and physical health disparities, yet access to culturally relevant and evidenced-based programs (EBPs) are severely limited. The purpose of this research is to describe the process of conducting a rigorous and culturally sensitive research approach, which was used to inform the development of a family-based substance abuse and violence prevention program that promotes resilience. The focus of this article is on the process of this development, rather than the intervention itself. We utilize a convergent mixed-methods design with distinct tribes in the Southeast that included 436 research participants across individual, family, and focus group interviews, field notes and existing data, and a quantitative survey (n = 127). This community-engaged, culturally sensitive, and rigorous research methodology provides a road-map for developing culturally relevant interventions.

The use of an educational video to increase suicide awareness and enrollment in parenting interventions among Filipinos.

Filipino American adolescents are at higher risk for suicidal ideation and attempts compared to other ethnic subgroups. Results of prior studies suggest the need to engage Filipino parents in the use of culturally tailored, best-practice child rearing strategies. The Incredible Years® is an evidence-based preventive parenting intervention for the school-age years that can reduce children's high risk behaviors. Qualitative research methods and community advisory board meetings were primarily used during the formative research phases in producing a theory-based, culturally-tailored video to increase awareness about adolescent suicide and promote enrollment in the Incredible Years® among Filipino American parents. A 14-minute video was created to increase knowledge about adolescent risky behaviors among Filipino American youth (i.e., suicidal behavior, drug use) and to motivate Filipino parents using constructs from the Health Belief Model and Theory of Planned Behavior. The video presented parent and grandparent testimonials with whom a target audience can identify and health and mental health providers who discussed behavioral health disparities. The content and format of the video included culturally-tailored cues and modeling to influence Filipinos decision to enroll in a parenting intervention. Perceived susceptibility to future adolescent risky behaviors, perceived benefits and barriers to participate in parenting interventions, and knowledge of behavioral health disparities can be effectively targeted in a video format in order to promote enrollment of Filipino parents in evidence-based parenting interventions.

"Living off the Land": How Subsistence Promotes Well-Being and Resilience among Indigenous Peoples of the Southeastern United States.

Indigenous peoples of the United States tend to experience the most severe social, behavioral, and physical health disparities of any ethnic minority. This critical ethnography uses the framework of historical oppression, resilience, and transcendence to examine indigenous peoples' perspectives on and experiences with subsistence living, investigating how subsistence living may contribute to well-being and resilience by promoting physical exercise, a healthy diet, and psychological health. Thematic analysis of data from 436 participants across two southeastern tribes reveals three overarching themes: fostering fond memories and family bonding through "living off the land," enabling experiential intergenerational teaching and learning, and promoting resourcefulness and offsetting economic marginalization. Results indicate that subsistence is an important avenue to promote sustainable and organic approaches to health and well-being within indigenous communities by facilitating positive nutrition and diet, exercise, and subjective well-being.

Alcohol and drug use among deaf and hard-of-hearing individuals: A secondary analysis of NHANES 2013–2014

ABSTRACTBackground: Within the field of behavioral health research, one of the most understudied populations is the US deaf and hard-of-hearing (D/HH) population—a diverse group of individuals with hearing loss that have varied language and communication preferences, community affiliations, and sociocultural norms. Recent research identified concerning behavioral health disparities experienced by the D/HH population; yet, little research has been conducted to extend these findings to the topic of substance use disorder. Methods: To begin to fill this gap, the authors conducted a secondary analysis of data from the 2013–2014 administration of the National Health and Nutrition Examination Survey, comparing alcohol and drug use between participants based on their reported hearing status, i.e., D/HH or hearing. Results: Findings suggest that the overall lifetime prevalence of alcohol and drug use does not differ based on hearing status, and that D/HH and hearing adolescents begin using cannabis on a similar timeline. However, findings also revealed that D/HH respondents were more likely to have been regular cannabis users and heavy alcohol users than hearing respondents. In other words, when D/HH individuals use substances, they tend to be heavy users. Conclusions: These findings stress the importance of directing resources to the prevention and treatment of heavy alcohol use in the D/HH population, given that binge drinking is associated with a number of health problems and social consequences. Additionally, the continuation of this empirical work is rather urgent given recent legislative changes regarding cannabis use. D/HH individuals possess a number of risk factors for substance use disorder and, as such, may be more greatly impacted by these legislative changes than individuals from the general US population. It is imperative that this impact be captured by future research efforts in order to inform the development of prevention and intervention efforts for the traditionally underserved D/HH population.

Recruiting Filipino Immigrants in a Randomized Controlled Trial Promoting Enrollment in an Evidence-Based Parenting Intervention.

Filipinos, the second largest Asian subgroup in the U.S., experience significant youth behavioral health disparities but remain under-represented in health research. We describe lessons learned from using the Matching Model of Recruitment to recruit 215 Filipinos to participate in a large, randomized controlled trial of a culturally tailored video aimed at increasing enrollment in the Incredible Years® Parent Program. We recruited participants from schools, churches, clinics, community events, and other community-based locations. Facilitators of participation included: partnership with local community groups, conducting research in familiar settings, building on existing social networks, and matching perspectives of community members and researchers. Findings suggest recruitment success occurs when there is a match between goals of Filipino parents, grandparents and the research community. Understanding the perspectives of ethnic minority communities and effectively communicating goals of research studies are critical to successful recruitment of hard-to-reach immigrant populations in randomized controlled trials.

Sexual and behavioral health disparities among African American sexual minority men and women

ABSTRACT Introduction: Sexual and behavioral health disparities have been consistently demonstrated between African American and White adults and between sexual minority and heterosexual communities in the United States; however, few studies using nationally representative samples have examined disparities between sexual minority and heterosexual adults within African American populations. The purpose of this study was to examine the prevalence of sexual and behavioral health outcomes between sexual minority and heterosexual African American adults and to examine whether there were different patterns of disparities for African American sexual minority men and women, respectively. Methods: We analyzed data from 4502 African American adults who participated in the 2001–2015 waves of the National Health and Nutrition Examination Survey. Using multivariable analyses, we examined differences in HIV, sexually transmitted infections, mental health, and substance use among African American sexual minority and heterosexual men and women. Results: After adjusting for sociodemographic variables, African American sexual minority men had significantly higher odds of HIV, sexually transmitted infections, and poor mental health compared to their heterosexual male counterparts, whereas African American sexual minority women had significantly higher odds of Hepatitis C, poor mental health, and substance use compared to their heterosexual female counterparts. Conclusions: These findings demonstrate notable sexual orientation disparities among African American adults. Disparities persisted beyond the role of sociodemographic factors, suggesting that further research utilizing an intersectional approach is warranted to understand the social determinants of adverse health outcomes among African American sexual minority men and women.