Racial/ethnic disparities in the use of mental health services in poverty areas.
Journal: 2003/May - American Journal of Public Health
ISSN: 0090-0036
PUBMED: 12721146
Abstract:
OBJECTIVE
This study examined racial/ethnic disparities in mental health service access and use at different poverty levels.
METHODS
We compared demographic and clinical characteristics and service use patterns of Whites, Blacks, Hispanics, and Asians living in low-poverty and high-poverty areas. Logistic regression models were used to assess service use patterns of minority racial/ethnic groups compared with Whites in different poverty areas.
RESULTS
Residence in a poverty neighborhood moderates the relationship between race/ethnicity and mental health service access and use. Disparities in using emergency and inpatient services and having coercive referrals were more evident in low-poverty than in high-poverty areas.
CONCLUSIONS
Neighborhood poverty is a key to understanding racial/ethnic disparities in the use of mental health services.
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Am J Public Health 93(5): 792-797

Racial/Ethnic Disparities in the Use of Mental Health Services in Poverty Areas

Julian Chun-Chung Chow is with the School of Social Welfare, University of California at Berkeley. Kim Jaffee is with the College of Human Services and Health Professions, School of Social Work, Syracuse University, Syracuse, NY. Lonnie Snowden is with the Center for Mental Health Services Research, School of Social Welfare, University of California at Berkeley.
Requests for reprints should be sent to Julian Chun-Chung Chow, PhD, School of Social Welfare, University of California at Berkeley, 209 Haviland Hall, No. 7400, Berkeley, CA 94720-7400 (e-mail: ude.yelekreb.knilcu@99wohcj).
Requests for reprints should be sent to Julian Chun-Chung Chow, PhD, School of Social Welfare, University of California at Berkeley, 209 Haviland Hall, No. 7400, Berkeley, CA 94720-7400 (e-mail: ude.yelekreb.knilcu@99wohcj).
Accepted July 1, 2002.

Abstract

Objectives. This study examined racial/ethnic disparities in mental health service access and use at different poverty levels.

Methods. We compared demographic and clinical characteristics and service use patterns of Whites, Blacks, Hispanics, and Asians living in low-poverty and high-poverty areas. Logistic regression models were used to assess service use patterns of minority racial/ethnic groups compared with Whites in different poverty areas.

Results. Residence in a poverty neighborhood moderates the relationship between race/ethnicity and mental health service access and use. Disparities in using emergency and inpatient services and having coercive referrals were more evident in low-poverty than in high-poverty areas.

Conclusions. Neighborhood poverty is a key to understanding racial/ethnic disparities in the use of mental health services.

Abstract

Racial/ethnic disparities in health and mental health status have received increasing attention. Well-documented gaps in health status are believed to reflect, among other factors, underlying differences in access to care. In the mental health arena, researchers have repeatedly demonstrated differences in rates and patterns of mental health treatment for African Americans, Latinos, and Asian Americans.1–10

The surgeon general’s report on mental health noted that the needs of minority racial/ethnic groups remain largely unmet.11 Among minority persons who have received mental health treatment, premature termination has been especially problematic.3,11,12 Several factors appear to explain the observed disparities, including lack of insurance coverage, a tendency to attribute mental health problems to religious and other culturally sanctioned belief systems, and lack of access to receptive and culturally compatible providers.

Troubling patterns of participation in treatment include underrepresentation in outpatient care and, for certain groups, overrepresentation in inpatient and emergency treatment.1,2,6 Failure to receive outpatient care early during episodes of mental illness appears to play a role in increasing rates of hospitalization and lengths of stay.

Geographic differences and residential patterns contribute to health and mental health disparities.13 Since the seminal work of William Julius Wilson,14 researchers have paid considerable attention to understanding the impact of living in neighborhoods with high concentrations of poor people. These neighborhoods tend to have high rates of unemployment, homelessness, crime, and substance abuse.14 There is high residential turnover and little opportunity for the development of informal mechanisms of social control that some researchers have called collective efficacy.15 These factors create unfavorable social conditions that individual residents cannot control personally and that exacerbate the impact of personal vulnerabilities and problems in living.16

People with mental illness are overrepresented in high-poverty neighborhoods. Early ecological studies of the geographic distribution of people with mental illness17,18 and more recent studies of the displacement of the mentally ill19,20 indicate that people with mental illness, and members of minority racial/ethnic populations in particular, are disproportionately concentrated in high-poverty areas.

The relationship between race/ethnicity, poverty, and mental health service use is complex. Poor areas with a high proportion of minority residents generally lack the resources needed to maintain community services at a minimum level. This dearth of services decreases access to mental health treatment and exacerbates mental health problems for minority and other residents in those communities.21 Safety-net providers—public hospitals and mental health centers22—are the primary source of care in low-income and immigrant communities. Safety-net providers are too few and struggle to provide a level of care adequate to meet the needs of the most vulnerable populations.

At the same time, racial/ethnic disparities in access are less pronounced among clients of safety-net providers. Several studies suggest that these programs, which sometimes even target minority communities and specialize in treating ethnic minority populations, are especially adept at recruiting and retaining minorities.23–25 Many are financed by Medicaid—a payment source associated with negligible Black–White disparities in outpatient treatment.26

Another reason that racial disparities between minorities and Whites may be less within high-poverty neighborhoods than elsewhere is predicted by social selection theory. This theory postulates that Whites have a greater propensity to avoid living in poverty communities because they are more likely to enjoy social and economic advantages.27 Only seriously mentally ill Whites suffer from steep downward mobility and come to reside in high-poverty neighborhoods. Minorities come to high-poverty communities through immigration and other routes and accordingly are more heterogeneous. As a consequence, we would expect minority residents to have less severe mental illness than Whites and to require less hospitalization and emergency care.

Our study examined patterns of mental health service use among Whites, Blacks, Hispanics, and Asians in high- and lowpoverty areas. It was conducted in New York City and represents one of the few studies of mental health service use, minority status, and poverty level conducted outside California. The purpose was to evaluate whether welldocumented minority–White disparities would vary with residence in communities with different poverty levels.

Acknowledgments

This research was supported in part by a grant awarded to J. C.-C. Chow, by the Center for the Study of Issues in Public Mental Health.

J. C.-C. Chow was responsible for the conception, plan, and design of the study and was the principal writer of this article. K. Jaffee analyzed the data and contributed to the writing of the article. L. Snowden contributed to the interpretation of the data and the writing of the article.

Human Participant Protection
The New York State Office of Mental Health institutional review board approved the access of the anonymous Patient Characteristics Survey data.

Acknowledgments

Notes

Peer Reviewed

Notes
Peer Reviewed

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