Disparities in Mental Health Service Utilization between Native American and White Adults Open Access

Gleason, Lacey (Summer 2018)

Permanent URL: https://etd.library.emory.edu/concern/etds/zw12z5353?locale=en
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Abstract

Despite the high risk of behavioral health conditions and poor outcomes among non-Hispanic American Indians and Alaska Natives (AI/ANs), little is known about current patterns of mental health (MH) service utilization in this population. This study aimed to examine rates of MH service utilization in a nationally representative sample of AI/ANs and identify if there is a disparity between AI/ANs and non-Hispanic whites. Data from the 2014-2016 National Survey on Drug Use and Health were used to examine differences in any MH service use, any outpatient MH service use, and any prescription medication use for MH in the past year between non-elderly adults (18-64 years old) who identified as AI/AN or non-Hispanic white. Differences in probability of MH service utilization were assessed using logistic regression models that were sequentially adjusted for relevant predisposing, enabling, and need-based factors. The unadjusted, weighted proportions of any MH service use in the past year were 14.4% among AI/ANs and 19.3% among non-Hispanic whites (p<0.01). On average, AI/ANs were less likely to have used any MH services than non-Hispanic whites. The results differed by treatment type as a significant AI/AN-white disparity was observed for any MH service use (AI/ANs had a 4.6 percentage point lower likelihood of service use, p<0.001) and prescription medication use for MH (AI/ANs had a 4.2 percentage point lower likelihood of service use, p<0.001) but not for outpatient MH service use. Population density had a significant moderating effect on the relationship between AI/AN race/ethnicity and MH service utilization. Significant AI/AN-white disparities in any MH service use and prescription medication use for MH were found among those living in moderately populated areas (AI/ANs had a 7.6 percentage point and 7.2 percentage point lower likelihood of utilizing these services, respectively, p<0.001 for both) but not among those living in densely populated areas or outside of core-based statistical areas. The majority of AI/ANs (55%) lived in moderately populated areas where these clinically and statistically significant disparities were observed. Future interventions aimed at improving MH among AI/ANs should consider how access to and uptake of MH services varies by treatment type and population density.

Table of Contents

Chapter I. Introduction. 1

Chapter II. Background and Review of the Literature. 3

A.     Mental Health of American Indians and Alaska Natives 3

B.     Access to Mental Health Services among American Indians and Alaska Natives. 5

C.     Previous Literature. 9

Chapter III. Methodology. 12

D.     Conceptual Framework. 12

Focal Relationship. 14

Confounders. 17

Contextual Characteristics 18

E.     Hypotheses. 20

F.     Data Source. 21

G.    Analytic Sample. 22

Figure 2. Analytic Sample. 23

H.    Constructs and Measures. 23

Mental Health Service Utilization. 23

Race and Ethnicity. 25

Predisposing Characteristics – Demographic. 25

Enabling Characteristics. 26

Need-based Characteristics 29

Unmeasured Constructs. 31

Table 1. Constructs and Measures 31

I.      Data Analysis. 34

Chapter IV. Results. 35

A.     Descriptive Statistics. 35

Table 2. Predisposing Characteristics, Need-based Characteristics, Enabling Characteristics, and Past Year Mental Health Service Use of Study Sample, by Race/Ethnicity. 36

Table 2. Continued. 37

B.     Results of Logistic Regression Model Predicting Any Mental Health Service Use in Past Year 39

Table 3. Logit Analysis of Probability of Any Mental Health Service Use in Past Year among Non-Hispanic AI/AN and Non-Hispanic White Adults. 39

Figure 3: Adjusted Predicted Probabilities of Any Mental Health Treatment in Past Year by Race/Ethnicity and Population Density. 43

C.     Results of Logistic Regression Model Predicting Any Outpatient Mental Health Service Use in Past Year 44

Table 4. Logit Analysis of Probability of Any Past Year Outpatient Mental Health Service Use among Non-Hispanic AI/AN and Non-Hispanic White Adults. 44

Figure 4: Adjusted Predicted Probabilities of Any Outpatient Mental Health Service Use in Past Year by Race/Ethnicity and Population Density. 47

D.     Results of Logistic Regression Model Predicting Any Prescription Medication Use for Mental Health in Past Year. 48

Table 5. Logit Analysis of Probability of Any Past Year Prescription Medication Use for Mental Health among Non-Hispanic AI/AN and Non-Hispanic White Adults. 48

Figure 5: Adjusted Predicted Probabilities of Any Prescription Medication Use for Mental Health in Past Year by Race/Ethnicity and Population Density. 52

Chapter V. Discussion. 53

A.     Key Findings. 53

B.     Strengths and Limitations. 59

C.     Policy Implications. 63

D.     Future Directions. 67

Chapter VI. Conclusion. 69

References. 71

Appendix A.. i

Table 6. Full Results of Logit Analysis of Probability of Any Past Year Mental Health Service Use among Non-Hispanic AI/AN and Non-Hispanic White Adults. i

Table 6. Continued. ii

Table 7. Full Results of Logit Analysis of Probability of Any Past Year Outpatient Mental Health Service Use among Non-Hispanic AI/AN and Non-Hispanic White Adults. iii

Table 7. Continued. iv

Table 8. Logit Analysis of Probability of Any Past Year Prescription Medication Use for Mental Health among Non-Hispanic AI/AN and Non-Hispanic White Adults. v

Table 8. Continued

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