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I remember once during my PhD at Zurich University in Switzerland my Professor telling me I would do a post doc at Harvard. At that time I thought, this would be a dream though I was not sure if I could fulfill it. Life went on, I moved to other three different European countries and one day I was introduced to Professor Margarita Alegria by Professor Myron Belfer, also from Harvard Medical School. I remember the first words of Dr. Alegria when I entered CMMHR for the first time this September “congratulations for not having given up such a long bureaucratic process”. It has been now five months that I have been spending five days a week at the CMMHR. And exactly one month before my visa expires I have to confess “I want to stay”. This group of people is amazing. I have lived and worked in six different countries, but believe me: here I felt I was part of them since the first moment. They are an example of an intercultural and interdisciplinary team. And this you can prove in their results. As the first foreign post doctoral fellow in this Center I had the opportunity to be involved in national and international grant proposals, participate in high level research meetings, being co-author in high impact factor papers and being personally and professionally supported by high qualified professionals and human beings. In CMMHR each of them has his or her unique specialty and amazing best capacities which make them an example team and a belief for a better world.
In terms of concrete outcomes of my six months stay at CMMHR I lead a joint grant proposal between Lisbon and Porto Medical Schools and CMMHR which is still being reviewed by the partnership Harvard Medical School-Portugal and I co-authored four papers, one of them being first author: 1) Alegria, M., Goncalves, M. & Carson, N. Disparities in youth behavioral services and Barriers to adequate services. 2) Lapatin, S., Goncalves, M., Nillni, A., Chavez, L. & Alegria, M. Standardizing Disparities Stories: Lessons from the Use of Vignettes in a Study of Mental Health Service Disparities. 3) Mulvaney-Day, N., Goncalves, M., Valdes, J. Li, X. & Alegria, M. Change in patterns of behavioral health care following health reform. 4) Goncalves, M., Cook, B., Mulvaney-Day, N., Alegria, M. Retention in mental health care of Portuguese speaking patients.
During my stay at CMMHR I could confirm my passion for project/program management, international liaison roles and intersystem communication (academia and communities/professionals). If I think about a future I would like to be someone who supervises an international global network related to the mental health care of Portuguese speakers around the globe. This might sound an utopia but I know everything is possible if you work for it and with the right team!
To finalize I would like to emphasize the challenge I have been throwing to this exceptional and strong team: Portuguese is one of the few languages spoken in such widely distributed parts of the world, and is the fifth or sixth most-spoken first language in the world. Portuguese speakers are found in Europe, Africa, South America, Asia and North America. Studying the Portuguese speakers’ mental health (care) is a global opportunity for us!
My name is Benjamin Cook, and I am a Research Associate at the Center and Instructor in the Department of Psychiatry. I am the Principal Investigator of a small project funded by the National Institute of Mental Health entitled, “Innovations in the Measurement of Racial/Ethnic Disparities in Mental Health Care.” I’ve been fortunate to work with a number of collaborators on this project, including Thomas McGuire, Professor of Health Economics and Alan Zaslavsky, Professor of Health Care Policy (Statistics) at Harvard Medical School’s Department of Health Care Policy, Willard Manning, Professor in the Department of Health Studies, Division of the Biological Sciences, and the Harris School of Public Policy at the University of Chicago, Sam Zuvekas, Senior Economist at the Agency for Healthcare Research and Quality, and Kari Lock, Ph.D. candidate in the Harvard University Department of Statistics.
The primary aim of this project are to advance the methodology of measuring racial and ethnic disparities in health care, applying tools used by health policy researchers, economists, and statisticians to better identify, track, and understand disparities in mental health and health care access, utilization and expenditures. We have produced three manuscripts so far, two published and one in press.
"Measuring Trends in Racial/Ethnic Healthcare Disparities," was published in the January 2009 edition of Medical Care Research and Review, in collaboration with Thomas McGuire and Samuel Zuvekas. In this paper, we measured trends in medical expenditure and access to care for non-Latino Whites, Blacks, and Hispanics between 1996 and 2005, finding that Black-White disparities in having an office-based or outpatient visit and medical expenditure were roughly constant and Hispanic-White disparities increased for office-based or outpatient visits and for medical expenditure between 1996 and 2005. Figure 1 shows the Black-White and Hispanic-White disparity trends in healthcare expenditures.
Unadjusted Black-White (BW) and Hispanic-White (HW) Differences in total Medical Expenditures (US$2005)
In a paper with Willard Manning of the University of Chicago entitled, “Measuring Racial/Ethnic Disparities across the Distribution of Health Care Expenditures,” we assessed whether Black-white and Hispanic-white disparities increase or abate in the upper quantiles of total health care expenditure, conditional on covariates. Using 2001-2005 MEPS data, we applied two-part models and quantile regression techniques to identify disparities among those most in need of health care. We found that even among those that are most in need of care, large racial/ethnic disparities exist. Figure 2 below shows that Blacks and Hispanics do not “catch up” with White expenditures even far to the right of the graph where individuals are in need of the most expensive health care. Additional analyses found that these disparities remain significant in upper quantiles even after adjusting for education and income. This manuscript was published in the October 2009 edition of Health Services Research
We are currently working on a follow-up paper, “Measuring Disparities across the Distribution of Mental Health Care Expenditures,” that applies these same methodologies to mental health care expenditures. The analysis of mental health expenditure raises different conceptual and methodological issues from total medical expenditures because of the large proportion of the population with zero mental health care expenditure (86% of the non-Latino whites, 8% of African-Americans, and 7% of Latinos). We focus more in this paper on understanding the correlates of disparities in any mental health service use and in understanding disparities in the 95th, 97th, and 99th quantiles.
Another manuscript in progress, "Comparing Methods of Racial and Ethnic Disparities Measurement across Different Settings of Mental Health Care," compares different methods of measuring racial/ethnic healthcare disparities (a rank and replace method, a propensity score-based method, and other methods more typically used in the previous literature). The 2002-2006 Medical Expenditure Panel Survey is used with linkage to the 2000-2005 National Health Interview Survey in order to pull in additional, important covariates. Preliminary findings are that racial/ethnic disparities were significant for total, prescription drug, and outpatient mental health care expenditures, and that disparity in access to care is more of a significant driver of overall disparities than disparity in expenditures given access to care.
The above mentioned papers provide different, nuanced views of health care and mental health care disparities, finding persistent healthcare disparities over time and among those in most need, and finding that mental health care expenditure disparities are largely driven by disparities in access to care. We hope that the analyses will begin to provide policymakers with a more targeted picture of the areas in which disparities exist and inform future interventions at disparities reduction. Other papers are under development in this project to more specifically identify mechanisms by which these disparities arise and could be reduced. For example, Dr. Cook and Dr. McGuire are working on another manuscript entitled, “Medical Comorbidities and Mental Health Care Disparities,” in which we assess physical comorbidities as a mediator of mental health care utilization. Approximately 40 percent of individuals using mental health services report having diabetes, high blood pressure or having fair or poor physical health. African-Americans and Latinos are more likely than whites to endorse these indicators of comorbidity. Using the 2002-2006 MEPS, we assess whether treatment for these physical health conditions improve or decrease the chances of receiving mental health treatment. The study will have implications for improving provider recognition of mental health problems and potentially present another leverage point for decreasing mental health care disparities.
Center Profiles - Innovation in the measurement of Racial/Ethnic Disparities in Mental Health Care
Dr. Benjamin Cook is currently working as the Principal Investigator on an R03 grant from the National Institutes of Health, aimed at advancing the methodology of measuring racial and ethnic disparities in health care. It applies tools used by health policy researchers, economists, and statisticians to better identify, track, and understand disparities in mental health and health care access, utilization and expenditures. He and his team of investigators have produced three manuscripts so far, two published and one in press. Read more about the innovative approaches in methodology his research is developing in our Center Profiles feature.
Summer Internships 2009
This summer we welcomed three new interns to the Center: Kristine Molina, M.S., Michael Flores, MPH, and Kristen Keefe, BA (expected 2010). Each brought their educational background and experience in the field to make a significant contribution to Center research projects and activities. We are happy to share thoughts from the interns, in their own words, about their experience at the Center this summer, and going forward.
Kristine M. Molina, M.S.: I am currently a doctoral candidate in the joint PhD program in Personality & Social Contexts Psychology and Women’s Studies, and working towards a Graduate Certificate in Latina/o Studies at the University of Michigan. I was fortunate to receive an Institute for Social Research Young Investigator in Ethnic Minority Mental Health Research Grant to obtain training and conduct research as a pre-doctoral intern at CMMHR this summer. However, I am grateful to Dr. Debra Pérez for making this internship opportunity possible. Currently, I am using the NLAAS for my dissertation work, which seeks to examine the culturally and gender-specific process by which discrimination comes to affect the mental health of Latina/os at various social locations. This research was chosen as an oral presentation at the June 2009 Critical Research Issues in Latino Mental Health Conference, and also received 2nd Place at the Society of Multivariate Experimental Psychology’s Quantitative Training for Underrepresented Students Conference Poster Presentations in August 2009. I became interested in CMMHR after reading the discrimination article based on the NLAAS that was published in 2008. I realized there were many important projects going on at the Center that I could learn from through being an intern. In particular, I was interested in the research being conducted with populations of color to better understand why health disparities exist and how they can be eliminated. Given my research interests in social determinants of health among racial and ethnic minorities, the Center seemed a perfect fit for me to obtain further research experience in this area. The main project on which I’ve been collaborating focuses on estimating likelihood of psychiatric illness from neighborhood structural characteristics of deprivation using census tract-level data, among the four major ethnic and racial groups represented in the CPES data set. The second project on which I’ve been working relates to examining correlates and prevalence rates of neurasthenia, also using the CPES data set. What I have enjoyed most from working at the Center this summer has been the mentorship I’ve received from Dr. Alegría, as well as the amazing support from the rest of the staff. Receiving feedback on my work using the NLAAS has proven to be quite helpful in making my dissertation more theoretically and methodologically strong. I’ve also learned about the advantages of collaborating on research across disciplinary boundaries. Most importantly however, my internship this summer has taught me much about both the inherent challenges and personal and professional rewards of conducting rigorous research aimed at improving the lives of underserved populations.
Kristine at the Society of Multivariate Experimental Psychology's Quantitative Training for Underrepresented Groups (QTUG) Conference held in Toronto, Canada in August 2009 where she was awarded 2nd place for her presentation titled Examining the Relationship between Everyday Discrimination and Psychological Distress among Latina/o Subgroups: Considering the Role of Gender
Kristen Keefe: I’m currently a student at Boston College and will be entering my senior year this fall. I worked previously in the Psychiatry department at Cambridge Health Alliance, which introduced me to Dr. Alegria and her extensive work on health care disparities. While I am majoring in Psychology and minoring in Hispanic studies at BC, I was unsure of how to best merge my interests in these two fields until I was awarded this internship opportunity. This summer I have not only furthered my knowledge in Psychology, but have also strengthened my Spanish speaking skills and enhanced my understanding of the culture. Taking part in a wide range of research projects, together with working in a virtually bilingual environment, have allowed me to accomplish this. I have spent my time here working on a variety of projects that have introduced me to all aspects of the research process. My first week, I saw firsthand the endless hard work that goes into submitting a grant proposal, something I could not have ever learned in a classroom. The passion and dedication I saw in everyone involved sparked an interest in research that I may not have experienced otherwise. From there, I became involved with the Right Question Project, dissemination for the NLAAS and Advanced Center studies, and website development. My tasks spanned a wide range, from listening to RQP intervention tapes and providing feedback for improvement, to reviewing articles and determining important policy implications. Most recently, I have been working closely with Dr. Alegria and Kristine Molina to put together a paper on neurasthenia. I was surprised at just how little I knew about the process, and am so thankful to have received an opportunity to get involved. How to best conduct a literature review or present results in a way that is informative, yet innovative and interesting, are among the invaluable bits of knowledge that only come with experience. Finally, due to the guidance and advice I fortunately received from everyone here, I am leaving the Center with a much better understanding of what I hope will be my future career. I look forward to bringing the knowledge I have acquired this summer to my classes this upcoming year, and hope to continue my involvement in research.
Michael Flores, M.P.H.: The opportunity to be a summer-intern at the Center for Multicultural Mental Health Research (CMMHR) materialized from my involvement in the Sally Casanova Pre-Doctoral Fellowship. Through this award I was afforded the financial means to conduct research at an academic institution. I was instantly drawn to CMMHR due to its focus on mental health services research. I wanted to contribute to a body of knowledge that would ultimately impact policy, practice, and service delivery for multicultural populations. During my eight week tenure I took part in the submission of a NIH R01 grant proposal as well as contributed to the foundation of an international pilot project. My experience as an intern was further enhanced by working closely with distinguished researchers such as Dr. Margarita Alegria, Dr. Benjamin Cook, Dr. Norah Mulvaney-Day, and Dr. Nicholas Carson who inspired as well as fostered a greater affinity for disparities research. My experience as an intern at CMMHR bridged the academic and real worlds. I observed how skills acquired in my graduate program were intrinsic attributes in the Center’s research setting. It overwhelmingly justified the years of hard work. At the conclusion of my internship, I was unexpectedly offered a full time position at CMMHR. This was an amazing opportunity I would not refuse. Consequently, I am the research coordinator for a multi-site intervention entitled the Right Question Project- Mental Health. Overall, my summer internship experience was unforgettable and a great opportunity for a burgeoning researcher.