Fixed and Random Effects Models for Fixed and Random Effects Models for Understanding Mental Health Treatment Understanding Mental Health Treatment

DisparitiesDisparities

Lonnie R. Lonnie R. SnowdenSnowdenHealth Policy and Management ProgramHealth Policy and Management Program

School of Public Health School of Public Health

University of California at BerkeleyUniversity of California at Berkeley

Research Supported by NIMH R01 MH070942Research Supported by NIMH R01 MH070942

Arriving at Limited English Proficiency as a Arriving at Limited English Proficiency as a Research InterestResearch Interest

Core interests, expertise, competenciesCore interests, expertise, competencies

Enlarging the scope of interests and projects: Enlarging the scope of interests and projects: Reaching out from the coreReaching out from the core

Cumulative learning from projectsCumulative learning from projects

Team membership and building: Complementary Team membership and building: Complementary roles among trusted collaborators roles among trusted collaborators

Snowden ConnectedSnowden Connected

Center for Drug Abuse Prevention in the Child Welfare System Center for Drug Abuse Prevention in the Child Welfare System (J. Landsverk, PI)(J. Landsverk, PI)

Child and Adolescent Services Research Center (J. Landsverk, Child and Adolescent Services Research Center (J. Landsverk, PI)PI)

George Warren Brown School of Social Work’s Center for George Warren Brown School of Social Work’s Center for Mental Health Services Research (E. Proctor, PI).Mental Health Services Research (E. Proctor, PI).

Genentech MOSAIC ProjectGenentech MOSAIC Project

Chapin Hall at the University of ChicagoChapin Hall at the University of Chicago

Some Distinguishing Characteristics of Policy Some Distinguishing Characteristics of Policy ResearchResearch

Social indicator measurement: Working to identify data and Social indicator measurement: Working to identify data and to assemble, clean, analyze data setsto assemble, clean, analyze data sets

Studies natural variation in policy optionsStudies natural variation in policy options

Time varying and level-of-political-authority varying Time varying and level-of-political-authority varying (different nations, states, counties, etc.): “Cross-sectional, (different nations, states, counties, etc.): “Cross-sectional, longitudinal”longitudinal”

Statistical and logical controlStatistical and logical control

Policy Research: Have Lower Tax Rates on Policy Research: Have Lower Tax Rates on Upper Income Earners Stimulated the US Upper Income Earners Stimulated the US

Economy?Economy?Sixty-five year post war economic observation periodSixty-five year post war economic observation period

What is the association between lower top marginal tax rates What is the association between lower top marginal tax rates and economic well-being?and economic well-being?

Correlating highest marginal tax rate with: savings, Correlating highest marginal tax rate with: savings, investment, productivityinvestment, productivity

Thomas L. Hungerford, TL (2012). Taxes and the Economy: An Thomas L. Hungerford, TL (2012). Taxes and the Economy: An Economic Analysis of the Top Tax Rates Since 1945. Congressional Economic Analysis of the Top Tax Rates Since 1945. Congressional Research ServiceResearch Service

Have Lower Tax Rates on Upper Income Have Lower Tax Rates on Upper Income Earners Stimulated the US Economy?Earners Stimulated the US Economy?

““There is not conclusive evidence, however, to substantiate a clear relationship between the 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 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, suggests the reduction in the top tax rates have had little association with saving, investment, or productivity growth”or productivity growth”

Hungerford (2012)Hungerford (2012)

Controlled Policy ResearchControlled Policy Research

““Correlation (alone) does not prove causation”: That Correlation (alone) does not prove causation”: That events co-occur, or that one follows the other, is events co-occur, or that one follows the other, is insufficient to establish a causal connection insufficient to establish a causal connection

Joint common causes and reverse causationJoint common causes and reverse causation

Reducing the possibility of coincidenceReducing the possibility of coincidence

Controlling in Research Tradition #1:Controlling in Research Tradition #1:Eliminating “Confounds”Eliminating “Confounds”

Followed by Psychologists, Psychiatrists, Nurses, Social Workers, Followed by Psychologists, Psychiatrists, Nurses, Social Workers, othersothers

Campbell D & Stanley J (1973). Experimental and Quasi-Campbell D & Stanley J (1973). Experimental and Quasi-Experimental Designs for ResearchExperimental Designs for Research

Catalogue of “confounds”: history, testing, maturation, etc. Notation: Catalogue of “confounds”: history, testing, maturation, etc. Notation: “X O X”“X O X”

De-confounding via randomized experimentation De-confounding via randomized experimentation

Controlling in Research Tradition #2: Controlling in Research Tradition #2: Avoiding Bias Avoiding Bias

Followed by Economists, Epidemiologists, some Followed by Economists, Epidemiologists, some SociologistsSociologists

Confounds inflate or deflate accurate estimation of Confounds inflate or deflate accurate estimation of population direct effectspopulation direct effects

““Endogeneity”=confoundedEndogeneity”=confounded

Policy research is a creature of Tradition #2Policy research is a creature of Tradition #2

LEP and Mental Health: ReviewsLEP and Mental Health: Reviews

Bauer AM, Alegría M (2010). Impact of patient language Bauer AM, Alegría M (2010). Impact of patient language proficiency and interpreter service use on the quality of proficiency and interpreter service use on the quality of psychiatric care: A systematic review. psychiatric care: A systematic review. Psychiatric ServicesPsychiatric Services, , 6161,765–773.,765–773.

Snowden LR, Masland M & Guerrero, R (2007). Federal civil Snowden LR, Masland M & Guerrero, R (2007). Federal civil rights policy and mental health treatment access for limited rights policy and mental health treatment access for limited English proficiency persons. English proficiency persons. American PsychologistAmerican Psychologist, , 6262, 109-, 109-117.117.

Threshold Language Studies: PublicationsThreshold Language Studies: Publications

Snowden LR, Masland M & Guerrero, R (2007). Federal civil rights policy and mental health Snowden LR, Masland M & Guerrero, R (2007). Federal civil rights policy and mental health treatment access for limited English proficiency persons. treatment access for limited English proficiency persons. American PsychologistAmerican Psychologist, , 6262, 109-117., 109-117.

Snowden LR, Masland M, Peng CJ, Lou C, Wallace N (2011). Limited English proficient Asian 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. Americans: Threshold Language Policy and access to mental health treatment. Social Science and Social Science and MedicineMedicine, , 72, 72, 230-237.230-237.

McClellan, S, Wu, F, Snowden, LR (2012). The Impact of Threshold language assistance McClellan, 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 programming on the accessibility of mental health services for persons with limited English proficiency. proficiency. Medical CareMedical Care, 50, 554-558. , 50, 554-558.

  

Threshold Language Studies: PublicationsThreshold Language Studies: Publications

McClellan S & Snowden LR (Under review). Threshold McClellan S & Snowden LR (Under review). Threshold language policy’s impact on access to minimally adequate language policy’s impact on access to minimally adequate mental healthcare among persons with limited English mental healthcare among persons with limited English proficiency.proficiency.

Patel S, Firmender W & Snowden LR (Under review). Patel S, Firmender W & Snowden LR (Under review). Threshold language policy’s language assistance Threshold language policy’s language assistance programming: Mental health consumers’ perspectivesprogramming: Mental health consumers’ perspectives

Threshold Language Studies: PublicationsThreshold Language Studies: Publications

Masland MM, Lou C, Snowden LR (2010). Use of Masland MM, Lou C, Snowden LR (2010). Use of communication technologies to cost effectively increase the communication technologies to cost effectively increase the availability of interpretation services in healthcare settings. availability of interpretation services in healthcare settings. Telemedicine & e-HealthTelemedicine & e-Health, , 1616, 1-7. , 1-7.

Snowden LR & McClellan S (Under review). Spanish Snowden LR & McClellan S (Under review). Spanish language community-based mental health treatment programs language community-based mental health treatment programs , policy-required language assistance programming, and , policy-required language assistance programming, and mental health treatment access in Spanish speaking mental health treatment access in Spanish speaking Medicaid-insured population. Medicaid-insured population. American Journal of Public American Journal of Public Health Health

LEP and Treatment Access: Results from the LEP and Treatment Access: Results from the California Health Interview Survey California Health Interview Survey

English Only=29,991 English Only=29,991

Bilingual=9243 (Speaking a language other than English at home Bilingual=9243 (Speaking a language other than English at home and speaking English and speaking English ““well or very wellwell or very well””))

No English=2,750 (Speaking a language other than English at home No English=2,750 (Speaking a language other than English at home and speaking English and speaking English ““not well or not at allnot well or not at all””))

Controls: Ethnicity, US born, years in US, Insured, poverty, age, Controls: Ethnicity, US born, years in US, Insured, poverty, age, married, good health, education, urbanmarried, good health, education, urban

LEP and Treatment Access: Results from the LEP and Treatment Access: Results from the California Health Interview SurveyCalifornia Health Interview Survey

Results from California Health Interview Survey bivariate Results from California Health Interview Survey bivariate analysis: (Confirmed in Multivariate Analysis)analysis: (Confirmed in Multivariate Analysis)

Need for MH CareNeed for MH Care Received Needed CareReceived Needed Care

English OnlyEnglish Only 18%18% 51%51%

BilingualBilingual 14%14% 42%42%

No EnglishNo English 16%16% 8% 8%

Sentell T, Shumway, M, Snowden, LR (2007). Access to mental health treatment by English Sentell T, Shumway, M, Snowden, LR (2007). Access to mental health treatment by English language proficiency and race/ethnicity. language proficiency and race/ethnicity. Journal of General Internal MedicineJournal of General Internal Medicine, , 2222, 289-293., 289-293.

. .

CaliforniaCalifornia’’s Threshold Language Policy Response to s Threshold Language Policy Response to Limited English ProficiencyLimited English Proficiency

A widely implemented response to Title VI: Threshold A widely implemented response to Title VI: Threshold language policylanguage policy

Trigger: Trigger: ““Surpassing thresholdSurpassing threshold””: 3,000 persons or 5% of : 3,000 persons or 5% of Medical enrollees, whichever is lower, speakers of non-Medical enrollees, whichever is lower, speakers of non-English languageEnglish language

Threshold Language Policy-required programming in Threshold Language Policy-required programming in California: Notification translators, translated written California: Notification translators, translated written materials, 24-hour hotlinematerials, 24-hour hotline

Qualitative MethodsQualitative Methods

Administering and interpreting the SEMI with Spanish-Administering and interpreting the SEMI with Spanish-speaking and Vietnamese-speaking consumersspeaking and Vietnamese-speaking consumers

Ten speakers of each languageTen speakers of each language

Personal experience of requirements in context of personal Personal experience of requirements in context of personal distress and assistance seekingdistress and assistance seeking

Purposes: Flesh-out interpretation of findings, generate Purposes: Flesh-out interpretation of findings, generate hypotheseshypotheses

The Quantitative Threshold Language StudyThe Quantitative Threshold Language Study

Public mental health services consolidated, decentralized to Public mental health services consolidated, decentralized to county levelcounty level

Wide variation among plans and county environments (e.g. Wide variation among plans and county environments (e.g. LA vs. many counties with population <30,000)LA vs. many counties with population <30,000)

Quasi-experimental research via cross sectional-longitudinal Quasi-experimental research via cross sectional-longitudinal econometrics econometrics

Unit of Analysis: County x quarter- Unit of Analysis: County x quarter- County penetration rate County penetration rate as observed during a quarter as observed during a quarter (57 x 36 = 2052): No individual (57 x 36 = 2052): No individual peoplepeople

The Quantitative Threshold Language StudyThe Quantitative Threshold Language Study

Dependent Variables: Medicaid (Medi-Cal) Penetration Rates Dependent Variables: Medicaid (Medi-Cal) Penetration Rates and Quality Indicatorsand Quality Indicators

County Administrators Survey: 66% response rateCounty Administrators Survey: 66% response rate

Key independent variable #1: notification Key independent variable #1: notification

Key independent variable #2: threshold language required Key independent variable #2: threshold language required programming at programming at minimally adequate minimally adequate levelslevels (24 hour crisis (24 hour crisis line, translation of materials, use of translators, notification)line, translation of materials, use of translators, notification)

The Quantitative Threshold Language StudyThe Quantitative Threshold Language Study

Quasi-experimental time series with staggered onset of Quasi-experimental time series with staggered onset of Independent Variable:Independent Variable:

1. Intervention counties serve as “own controls” pre- 1. Intervention counties serve as “own controls” pre- interventionintervention

2. Counties with no threshold languages serve as 2. Counties with no threshold languages serve as control control countiescounties

3. Counties with other-than target threshold 3. Counties with other-than target threshold languages languages serve as control countiesserve as control counties

The Quantitative Threshold Language StudyThe Quantitative Threshold Language Study

Other controls: Other controls:

1. Fixed effects (preferred) rule out static inter-county 1. Fixed effects (preferred) rule out static inter-county differences, whether differences, whether observed or unobserved observed or unobserved

2. Linear time trend 2. Linear time trend

3.English penetration rate3.English penetration rate

4. Selected variables (time varying covariates): e.g. per-4. Selected variables (time varying covariates): e.g. per-capita incomecapita income

Notification’s Impact on Access to Care for Speakers Notification’s Impact on Access to Care for Speakers of Threshold Asian Languagesof Threshold Asian Languages

Short term: Thirteen quarters (July 1998 to June, 2001)Short term: Thirteen quarters (July 1998 to June, 2001)

Aggregated Asian Languages: Vietnamese, Cantonese, Aggregated Asian Languages: Vietnamese, Cantonese, Hmong, CambodianHmong, Cambodian

Competing or Complementary Services Controlled: Cultural Competing or Complementary Services Controlled: Cultural Competence Training, Bilingual Staff, Asian Language-Competence Training, Bilingual Staff, Asian Language-Specific clinics and service program.Specific clinics and service program.

Snowden LR, Masland M, Peng CJ, Lou C, Wallace N (2011). Limited English proficient 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. Asian Americans: Threshold Language Policy and access to mental health treatment. Social Social Science and Medicine Science and Medicine, , 7272, 230-237., 230-237.

Notification’s Impact on Asian-Language Penetration Rates Over Three Years

(Partial Results)

Language Assistance ProgrammingLanguage Assistance Programming’’s Impacts Impact

Thirty-nine quarters over 10 yearsThirty-nine quarters over 10 years

Russian, Vietnamese, SpanishRussian, Vietnamese, Spanish

Full implementation of threshold language assistance programming package Full implementation of threshold language assistance programming package directly assesseddirectly assessed

Measures programming packageMeasures programming package’’s implementation whenever it occurred, not s implementation whenever it occurred, not in relation to triggerin relation to trigger

McClelland 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

 Russian (N=390)

Spanish (N=1326)

Vietnamese (N=663)

Predictor Coefficient Coefficient Coefficient

Time (Quarters) -0.025 0.006 -0.009 Programing 8.173** 0.110 3.266**Programing * Time 0.296 ** -0.001 0.018Threshold notification 0.787 -0.105 -0.117 English Penetration Rate 0.535** 0.096** 0.444**Eligible Benes (1,000) -3.439** 0.000 -0.196 Per Capita Income (1,000) 0.260 ** -0.018* 0.117*Republican Party -0.397 -0.005 0.343

Spanish-Language Treatment Programs, Policy- Required Spanish-Language Treatment Programs, Policy- Required Language assistance programming, and mental health Language assistance programming, and mental health

treatment access among Spanish-speaking clientstreatment access among Spanish-speaking clients

Spanish-speaking LEP and threshold language policy’s Spanish-speaking LEP and threshold language policy’s language assistance programming: No global increase in language assistance programming: No global increase in penetration ratespenetration rates

Specialized, Spanish language clinics: County operated vs. Specialized, Spanish language clinics: County operated vs. Community-Based Organization-operated under contractCommunity-Based Organization-operated under contract

Closing English-speakers vs. Spanish speaking LEP access Closing English-speakers vs. Spanish speaking LEP access disparities state wide?disparities state wide?

Spanish-Language Treatment Programs, Policy- Required Spanish-Language Treatment Programs, Policy- Required Language assistance programming, and mental health Language assistance programming, and mental health

treatment access among Spanish-speaking clientstreatment access among Spanish-speaking clients

Fixed county effects

Quarterly time tend 0.007 (0.004)*LEP programming 0.053 (0.075)Programming*Qtr -0.002 (0.003)No Use of Contractor -0.137 (0.246)Programming* Contractor 0.280 (0.115)**English Pen Rate 0.090 (0.008)**Eligible (1,000) 0.000 (0.001)Per capita income -0.034 (0.009)**Votes republican 0.033 (0.080)Programming*Contractor*English Pen Rate 0.034 (0.021)