Fixed and Random Effects Models for Understanding Mental

Fixed and Random Effects Models for Understanding Mental Health Treatment Disparities Lonnie R. Snowden Health Policy and Management Program School of Public Health University of California at Berkeley Research Supported by NIMH R 01 MH 070942

Arriving at Limited English Proficiency as a Research Interest Core interests, expertise, competencies Enlarging the scope of interests and projects: Reaching out from the core Cumulative learning from projects Team membership and building: Complementary roles among trusted collaborators

Snowden Connected Center for Drug Abuse Prevention in the Child Welfare System (J. Landsverk, PI) Child and Adolescent Services Research Center (J. Landsverk, PI) George Warren Brown School of Social Work’s Center for Mental Health Services Research (E. Proctor, PI). Genentech MOSAIC Project Chapin Hall at the University of Chicago

Some Distinguishing Characteristics of Policy Research Social indicator measurement: Working to identify data and to assemble, clean, analyze data sets Studies natural variation in policy options Time varying and level-of-political-authority varying (different nations, states, counties, etc. ): “Cross-sectional, longitudinal” Statistical and logical control

Policy Research: Have Lower Tax Rates on Upper Income Earners Stimulated the US Economy? Sixty-five year post war economic observation period What is the association between lower top marginal tax rates and economic well-being? Correlating highest marginal tax rate with: savings, investment, productivity Thomas L. Hungerford, TL (2012). Taxes and the Economy: An Economic Analysis of the Top Tax Rates Since 1945. Congressional Research Service

Have Lower Tax Rates on Upper Income Earners Stimulated the US Economy? “There is not conclusive evidence, however, to substantiate a clear relationship between the 65 -year steady reduction in the top tax rates and economic growth. Analysis of such data suggests the reduction in the top tax rates have had little association with saving, investment, or productivity growth” Hungerford (2012)

Controlled Policy Research “Correlation (alone) does not prove causation”: That events co-occur, or that one follows the other, is insufficient to establish a causal connection Joint common causes and reverse causation Reducing the possibility of coincidence

Controlling in Research Tradition #1: Eliminating “Confounds” Followed by Psychologists, Psychiatrists, Nurses, Social Workers, others Campbell D & Stanley J (1973). Experimental and Quasi-Experimental Designs for Research Catalogue of “confounds”: history, testing, maturation, etc. Notation: “X O X” De-confounding via randomized experimentation

Controlling in Research Tradition #2: Avoiding Bias Followed by Economists, Epidemiologists, some Sociologists Confounds inflate or deflate accurate estimation of population direct effects “Endogeneity”=confounded Policy research is a creature of Tradition #2

LEP and Mental Health: Reviews Bauer AM, Alegría M (2010). Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: A systematic review. Psychiatric Services, 61, 765– 773. Snowden LR, Masland M & Guerrero, R (2007). Federal civil rights policy and mental health treatment access for limited English proficiency persons. American Psychologist, 62, 109117.

Threshold Language Studies: Publications Snowden LR, Masland M & Guerrero, R (2007). Federal civil rights policy and mental health treatment access for limited English proficiency persons. American Psychologist, 62, 109 -117. Snowden LR, Masland M, Peng CJ, Lou C, Wallace N (2011). Limited English proficient Asian Americans: Threshold Language Policy and access to mental health treatment. Social Science and Medicine, 72, 230237. Mc. Clellan, S, Wu, F, Snowden, LR (2012). The Impact of Threshold language assistance programming on the accessibility of mental health services for persons with limited English proficiency. Medical Care, 50, 554 -558.

Threshold Language Studies: Publications Mc. Clellan S & Snowden LR (Under review). Threshold language policy’s impact on access to minimally adequate mental healthcare among persons with limited English proficiency. Patel S, Firmender W & Snowden LR (Under review). Threshold language policy’s language assistance programming: Mental health consumers’ perspectives

Threshold Language Studies: Publications Masland MM, Lou C, Snowden LR (2010). Use of communication technologies to cost effectively increase the availability of interpretation services in healthcare settings. Telemedicine & e-Health, 16, 1 -7. Snowden LR & Mc. Clellan S (Under review). Spanish language community-based mental health treatment programs , policy-required language assistance programming, and mental health treatment access in Spanish speaking Medicaidinsured population. American Journal of Public Health

LEP and Treatment Access: Results from the California Health Interview Survey English Only=29, 991 Bilingual=9243 (Speaking a language other than English at home and speaking English “well or very well”) No English=2, 750 (Speaking a language other than English at home and speaking English “not well or not at all”) Controls: Ethnicity, US born, years in US, Insured, poverty, age, married, good health, education, urban

LEP and Treatment Access: Results from the California Health Interview Survey Results from California Health Interview Survey bivariate analysis: (Confirmed in Multivariate Analysis) Need for MH Care English Only Bilingual No English 18% 14% 16% Received Needed Care 51% 42% 8% Sentell T, Shumway, M, Snowden, LR (2007). Access to mental health treatment by English language proficiency and race/ethnicity. Journal of General Internal Medicine, 22, 289293. .

California’s Threshold Language Policy Response to Limited English Proficiency A widely implemented response to Title VI: Threshold language policy Trigger: “Surpassing threshold”: 3, 000 persons or 5% of Medical enrollees, whichever is lower, speakers of non. English language Threshold Language Policy-required programming in California: Notification translators, translated written materials, 24 -hour hotline

Qualitative Methods Administering and interpreting the SEMI with Spanishspeaking and Vietnamese-speaking consumers Ten speakers of each language Personal experience of requirements in context of personal distress and assistance seeking Purposes: Flesh-out interpretation of findings, generate hypotheses

The Quantitative Threshold Language Study Public mental health services consolidated, decentralized to county level Wide variation among plans and county environments (e. g. LA vs. many counties with population <30, 000) Quasi-experimental research via cross sectional-longitudinal econometrics Unit of Analysis: County x quarter- County penetration rate as observed during a quarter (57 x 36 = 2052): No individual people

The Quantitative Threshold Language Study Dependent Variables: Medicaid (Medi-Cal) Penetration Rates and Quality Indicators County Administrators Survey: 66% response rate Key independent variable #1: notification Key independent variable #2: threshold language required programming at minimally adequate levels (24 hour crisis line, translation of materials, use of translators, notification)

The Quantitative Threshold Language Study Quasi-experimental time series with staggered onset of Independent Variable: 1. Intervention counties serve as “own controls” preintervention 2. Counties with no threshold languages serve as counties control 3. Counties with other-than target threshold languages serve as control counties

The Quantitative Threshold Language Study Other controls: 1. Fixed effects (preferred) rule out static inter-county differences, whether observed or unobserved 2. Linear time trend 3. English penetration rate 4. Selected variables (time varying covariates): e. g. percapita income

Notification’s Impact on Access to Care for Speakers of Threshold Asian Languages Short term: Thirteen quarters (July 1998 to June, 2001) Aggregated Asian Languages: Vietnamese, Cantonese, Hmong, Cambodian Competing or Complementary Services Controlled: Cultural Competence Training, Bilingual Staff, Asian Language. Specific clinics and service program. Snowden LR, Masland M, Peng CJ, Lou C, Wallace N (2011). Limited English proficient Asian Americans: Threshold Language Policy and access to mental health treatment. Social Science and Medicine, 72, 230 -237.

Notification’s Impact on Asian-Language Penetration Rates Over Three Years (Partial Results) B SE Time 0. 71 0. 22 Threshold × time 0. 85* 0. 34 Threshold 14. 6* 3. 90 Independent variable

Language Assistance Programming’s Impact Thirty-nine quarters over 10 years Russian, Vietnamese, Spanish Full implementation of threshold language assistance programming package directly assessed Measures programming package’s implementation whenever it occurred, not in relation to trigger Mc. Clelland S, Wu F& Snowden LR (2012). The Impact of threshold assistance programming on the accessibility of mental health services for persons with Limited English Proficiency in the Medi-Cal Setting. Medical Care, 50, 554 -558.

Threshold Language Programming’s Impact on Penetration Rates Over 10 Years Predictor Russian (N=390) Coefficient Time (Quarters) -0. 025 Programing 8. 173** Programing * Time 0. 296 ** Threshold notification 0. 787 English Penetration Rate 0. 535** Eligible Benes (1, 000) -3. 439** Per Capita Income (1, 000) 0. 260 ** Republican Party -0. 397 Spanish (N=1326) Coefficient Vietnamese (N=663) Coefficient 0. 006 0. 110 -0. 001 -0. 105 -0. 009 3. 266** 0. 018 -0. 117 0. 096** 0. 444** 0. 000 -0. 196 -0. 018* -0. 005 0. 117* 0. 343

Spanish-Language Treatment Programs, Policy- Required Language assistance programming, and mental health treatment access among Spanish-speaking clients Spanish-speaking LEP and threshold language policy’s language assistance programming: No global increase in penetration rates Specialized, Spanish language clinics: County operated vs. Community-Based Organization-operated under contract Closing English-speakers vs. Spanish speaking LEP access disparities state wide?

Spanish-Language Treatment Programs, Policy- Required Language assistance programming, and mental health treatment access among Spanish-speaking clients Fixed county effects Quarterly time tend LEP programming Programming*Qtr No Use of Contractor Programming* Contractor English Pen Rate Eligible (1, 000) Per capita income Votes republican Programming*Cont ractor*English Pen Rate 0. 007 (0. 004)* 0. 053 (0. 075) -0. 002 (0. 003) -0. 137 (0. 246) 0. 280 (0. 115)** 0. 090 (0. 008)** 0. 000 (0. 001) -0. 034 (0. 009)** 0. 033 (0. 080) 0. 034 (0. 021)