Fixed%20and%20Random%20Effects%20Models%20for%20Understanding%20Mental%20Health%20Treatment%20Disparities

1
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 R01 MH070942

2
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

3
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 Works
  Center for Mental Health Services Research (E.
  Proctor, PI).
• Genentech MOSAIC Project
• Chapin Hall at the University of Chicago

4
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

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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

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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)

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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

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Controlling in Research Tradition 1Eliminating
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

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Controlling in Research Tradition 2 Avoiding
Bias

• Followed by Economists, Epidemiologists, some
  Sociologists
• Confounds inflate or deflate accurate estimation
  of population direct effects
• Endogeneityconfounded
• Policy research is a creature of Tradition 2

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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, 61,765773.
• 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.

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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, 230-237.
• 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
  proficiency. Medical Care, 50, 554-558.
•  

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Threshold Language Studies Publications

• McClellan S Snowden LR (Under review).
  Threshold language policys impact on access to
  minimally adequate mental healthcare among
  persons with limited English proficiency.
• Patel S, Firmender W Snowden LR (Under review).
  Threshold language policys language assistance
  programming Mental health consumers perspectives

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

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LEP and Treatment Access Results from the
California Health Interview Survey

• English Only29,991
• Bilingual9243 (Speaking a language other than
  English at home and speaking English well or
  very well)
• No English2,750 (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

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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 Received Needed Care
• English Only 18 51
• Bilingual 14 42
• No English 16 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, 289-293.
• .

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Californias 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

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Qualitative Methods

• Administering and interpreting the SEMI with
  Spanish-speaking 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

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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 lt30,000)
• 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

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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)

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The Quantitative Threshold Language Study

• Quasi-experimental time series with staggered
  onset of Independent Variable
• 1. Intervention counties serve as own controls
  pre- intervention
• 2. Counties with no threshold languages serve as
  control counties
• 3. Counties with other-than target threshold
  languages serve as control counties

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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. per- capita income

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Notifications 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.

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Notifications Impact on Asian-Language
Penetration Rates Over Three Years(Partial
Results)
Independent variable   B SE
Time   0.71 0.22
Threshold time   0.85 0.34
Threshold   14.6 3.90






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Language Assistance Programmings Impact

• Thirty-nine quarters over 10 years
• Russian, Vietnamese, Spanish
• Full implementation of threshold language
  assistance programming package directly assessed
• Measures programming packages implementation
  whenever it occurred, not in 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.
• ,

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Threshold Language Programmings Impact on
Penetration Rates Over 10 Years
  Russian (N390) Spanish (N1326) Vietnamese (N663)
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 0.018
Threshold 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
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Spanish-Language Treatment Programs, Policy-
Required Language assistance programming, and
mental health treatment access among
Spanish-speaking clients

• Spanish-speaking LEP and threshold language
  policys 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?

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Spanish-Language Treatment Programs, Policy-
Required Language assistance programming, and
mental health treatment access among
Spanish-speaking clients
Fixed county effects

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