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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)