A qualitative investigation to inform yoga intervention recruitment practices for racial/ethnic minority adolescents in outpatient mental health treatment

ObjectiveYoga is recognized as an effective approach to improving overall physical and mental health; however, there may be perceived barriers to yoga participation, particularly among populations most at risk for mental health issues. We conducted qualitative formative research to help inform recruitment practices for a future study and to specifically understand the barriers and facilitators to engagement in yoga practice among racial/ethnic minority adolescents, as well as adolescents in outpatient mental health treatment.MethodsQualitative data were collected at a community health clinic that serves low income families in southeastern Florida. Using semi structured interviews with racial and ethnic minority adolescents between 12 and 17 years old, participants were asked about beliefs and perceptions about yoga, as well as recommendations on recruiting peers. A thematic analysis approach was used to identify and examine common themes.ResultsTwenty interviews were conducted and eight major themes emerged from the data. Themes were grouped as (1) Facilitators to recruitment and (2) Barriers to recruitment.InterpretationAdvertising free yoga that emphasizes the social, physical, and mental benefits can help assuage negative perceptions of yoga and promote the advantages of yoga among teenagers. Having recruitment materials and modalities that highlight inclusivity of all genders and physical abilities in the yoga classes are also important in facilitating participation. Understanding perceptions of yoga, as well as perceived barriers and facilitators, among racially/ethnically diverse adolescents in outpatient mental health treatment, can assist recruitment efforts, increase yoga intervention participation, and ultimately, improve mental health outcomes for underserved populations.     

Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients

OBJECTIVE: Although discriminatory health care experiences and health care provider distrust have been shown to be associated with health care disparities, little is known about their contribution to racial/ethnic disparities in antiretroviral therapy adherence. We therefore sought to assess the extent to which discriminatory health care experiences and health care provider distrust influence treatment-related attitudes, beliefs, and self-reported adherence in a national sample of HIV-infected patients. STUDY DESIGN: This secondary analysis used data from the HIV Cost and Services Utilization Study. We used structural equation modeling to identify pathways from minority status to adherence through discrimination, distrust, and treatment-related attitudes and beliefs. PARTICIPANTS: The sample was the 1886 participants who completed the baseline and 2 follow-up interviews and were prescribed antiretroviral therapy at the second follow-up interview (54% white, 28% black, 14% Hispanic, and 3% others). RESULTS: Minorities were less likely to report perfect adherence than whites (40% vs. 50%, P < or = 0.001). Over one third (40%) of all participants reporting ever having discriminatory health care experiences since having HIV, and 24% did not completely or almost completely trust their health care providers. The effect of minority status on adherence persisted in the full model. More discrimination predicted greater distrust, weaker treatment benefit beliefs, and, in turn, poorer adherence. Distrust affected adherence by increasing treatment-related psychological distress and weakening treatment benefit beliefs. CONCLUSIONS: The relationship between minority status and adherence was not fully explained by patient-level factors. Future studies should consider conceptualizing minority status as a contextual factor rather than predictor.     

Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

ObjectivesDrawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.MethodsWe interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.ResultsParticipants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.ConclusionOur findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.Practice ImplicationsWe discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers’ burnout.     

Between and within race differences in patient-centeredness and activation in mental health care

ObjectivesThe aim of this study was to compare Black and White mental health care patients’ perceptions of their providers’ and their own participation in patient-centered mental health care. Perceptions of patient-centered care (PCC) in relation to the Multidimensional Model of Racial Identity were explored.MethodsBlack and White veterans receiving mental health care (n = 82) completed surveys assessing patient activation, involvement in care, perceptions of PCC, and therapeutic alliance. Black participants (n = 40) also completed the Multidimensional Inventory of Black Identity.ResultsThere were no differences by race in perceived PCC, though Black participants had lower levels of therapeutic alliance with their mental health care provider and were less activated. Black identity centrality, private regard, and public regard were positively related to PCC and elements of PCC such as patient information seeking/sharing.ConclusionsIntragroup identity variables such as racial centrality, regard, and ideology influenced perceived PCC among Black participants. Race identity variables should be explored in future research on racial disparities and PCC.Practice implicationsMental health care providers serving Black patients should create opportunities to discuss racial identity and race-related experiences as part of their efforts to improve therapeutic alliance and increase the patient-centeredness of care.     

Racial (vs. self) affirmation as a protective mechanism against the effects of racial exclusion on negative affect and substance use vulnerability among black young adults

Affirming one’s racial identity may help protect against the harmful effects of racial exclusion on substance use cognitions. This study examined whether racial versus self-affirmation (vs. no affirmation) buffers against the effects of racial exclusion on substance use willingness and substance use word associations in Black young adults. It also examined anger as a potential mediator of these effects. After being included, or racially excluded by White peers, participants were assigned to a writing task: self-affirmation, racial-affirmation, or describing their sleep routine (neutral). Racial exclusion predicted greater perceived discrimination and anger. Excluded participants who engaged in racial-affirmation reported reduced perceived discrimination, anger, and fewer substance use cognitions compared to the neutral writing group. This relation between racial-affirmation and lower substance use willingness was mediated by reduced perceived discrimination and anger. Findings suggest racial-affirmation is protective against racial exclusion and, more generally, that ethnic based approaches to minority substance use prevention may have particular potential.     

Examining racial and ethnic disparities in site of usual source of care

Little is known about why minorities have a lower propensity to use private doctors' offices for their usual source of care than non-Hispanic whites. This study used the 2001 Commonwealth Fund's Health Care Quality Survey of adults to determine if this disparity is due to racial and ethnic differences in attitudes about health and healthcare, and perceptions of racial and ethnic discrimination in healthcare. We found that race and ethnic disparities at the site of the usual source of care persisted even after controlling for individuals' attitudes about health and healthcare, and their perceptions about racial and ethnic discrimination in healthcare. We found that the impact of attitudes and perceptions did vary by subgroups. These factors were important for Asians' site of usual source of care but had little impact on African Americans' site of usual of care. However, despite their differential impact by race and ethnicity, attitudes and perceptions were not the source of observed disparities in site of care. Therefore, in addition to focusing on provider-patient relationships, perhaps future research and policymakers should focus on system-level factors to explain and increase minority use of care in private physicians' offices.     

Effects of gender-matching and racial self-labeling on paranoia in African-American men with severe mental illness

OBJECTIVE: The present study examined the effects of gender-matching and racial self-labeling on the paranoid symptoms of African-American men with severe mental illness. It was hypothesized that gender matching would: 1) reduce self-reports of both interpersonal and cultural paranoia in these male participants with severe mental illness, and 2) the gender effect would be strongest among those patients who racially self-label as African-American. METHOD: One-hundred-twenty-four African-American male psychiatric patients were interviewed by a male or female black psychologist. A multivariate analysis of variance (MANOVA) was conducted with the Fenigstein Paranoia Scale (FPS) and Cultural Mistrust Inventory (CMI) as dependent variables, and the male gender-matched group (0=no, 1=yes) and racial self-labeling as the independent variables controlling for age; education; never married (0=no, 1=yes); diagnosis of schizophrenia (0=no, 1=yes); need for approval; self-esteem; and the scales of Distrust, Perceived Hostility of Others, and False Beliefs and Perceptions from the Psychiatric Epidemiology Research Interview. RESULTS: There was a significant main effect for male gender-matching on the FPS. Participants in the male gender-matched group scored lower than the other group on the FPS. For the CMI, there was a significant interaction of male gender match by racial self-labeling effect. Participants who were male gender-matched and self-labeled as African-American reported the highest scores on the CMI. CONCLUSION: The findings provide partial support for the hypotheses. Both gender-matching and racial identity together may be important considerations for black males needing mental health services.     

Patient perceptions of access to care and referrals to specialists: a comparison of African-American and white older patients with knee and hip osteoarthritis

BACKGROUND: There is a marked racial difference in the use of knee and hip replacement for osteoarthritis (OA). The reasons for this disparity remain unclear. We examined how African-American and white patients with symptomatic OA of the knee and/or hip compare with respect to their perceptions of care for knee and hip OA. METHODS: Survey of 596 male patients with OA of the knee and/or hip in primary care clinics at Cleveland VAMC. RESULTS: African-American (44%) and white (56%) study participants were comparable with respect to age and clinical factors. African Americans were more likely to have VA insurance only [OR=1.93 (1.13-3.28)]. African Americans were less likely to report difficulty getting medical care when needed [OR=0.54 (0.34-0.88)]. Differences in the two groups regarding satisfaction with and confidence in the primary physician were not significant. The proportions of participants who received specialty care referrals were similar. CONCLUSION: African-American patients reported having only VA insurance more often than white patients. Other aspects of perceived system and provider-based factors were similar between groups.     

Racial/Ethnic differences in self-reported health problems and herbal use among older women

The purpose of this study was to examine the racial/ethnic differences in self- reported health problems and herbal use as a self-care practice between white American and African-American older women, and between herbal users and nonusers. Two data sets collected in 1998 and 2002 were combined to perform this study. The total sample (143 participants) consisted of 85 white Americans and 58 African-American women > or = 65 years, living independently in the community. While there were statistically significant differences in education (chi-squared = 19.085, p=0.0001) and annual income (chi-squared = 21.905, p=0.0001) between white American and African-American women, no differences were found in the use of herbals between the two groups. There was a significant relationship between the number of herbals used and the number of nonprescribed medications used (gamma = 0.320, p<0.01). No relationship was detected between the number of herbals used and self-reported health problems (gamma = 0.075, p<0.01), and between the number of nonprescribed medications used and self-reported health problems (gamma = 0.047, p<0.01). White American herbal users utilized the highest number of combination products (prescribed, nonprescribed and herbals) of all. African-American herbal users indicated a higher number of combination products than African-American nonusers. Results suggested that herbals were used as a complementary rather than an alternative therapy to manage perceived health concerns in both groups.     

Examining differential treatment effects for depression in racial and ethnic minority women: a qualitative systematic review

OBJECTIVE: To examine effectiveness of depression treatment in racial and ethnic minority women. REVIEW METHODS: Inclusion criteria: 1) the study examined treatment of depression among racial and ethnic minority women age > 17, 2) data analysis was separated by race and ethnicity, and 3) the study was conducted in the United States. Interventions considered were: psychotropic medications, psychotherapy (including cognitive-behavioral, interpersonal therapy and any type of psychotherapy adapted for minority populations) and any type of psychotherapy combined with case management or a religious focus. Individual and group psychotherapy were eligible. Each study was critically reviewed to identify treatment effectiveness specific to racial and ethnic minority women. RESULTS: Ten published studies met the inclusion criteria (racial and ethnic minority participants n = 2,136). Seven of these were randomized clinical trials, one was a retrospective cohort study, one was a case series, and the remaining one had an indeterminate study design. Participants' age ranged from 18-74 years, with a higher proportion > 40 years. Most were low income. Differences in treatment responses between African-American, Latino and white women were found. Adapted models of care, including quality improvement and collaborative care, were found to be more effective than usual care and community referral in treating depression. Although medication and psychotherapy were both effective in treating depression, low-income women generally needed case management to address other social issues. CONCLUSION: Adapted models that allow patients to select the treatment of their choice (medication or psychotherapy or a combination) while providing outreach and other supportive services (case management, childcare and transportation) appear to result in optimal clinical benefits.     

Racial Differences in Physical and Mental Health: Socio-economic Status, Stress and Discrimination

This article examines the extent to which racial differences in socio-economic status (SES), social class and acute and chronic indicators of perceived discrimination, as well as general measures of stress can account for black-white differences in self-reported measures of physical and mental health. The observed racial differences in health were markedly reduced when adjusted for education and especially income. However, both perceived discrimination and more traditional measures of stress are related to health and play an incremental role in accounting for differences between the races in health status. These findings underscore the need for research efforts to identify the complex ways in which economic and non-economic forms of discrimination relate to each other and combine with socio-economic position and other risk factors and resources to affect health.     

Impact of victimization,community climate,and community size on the mental health of sexual and gender minority youth

Sexual and gender minority (SGM) youth are at risk of stigma and victimization, which may lead to increased mental health symptoms, including depression, anxiety, and stress. The role of the community in exacerbating or mitigating the frequency of victimization and mental health symptoms among SGM youth has been understudied. Using a minority stress framework, this study examined the association between physical and nonphysical anti‐SGM victimization, perceived community climate, and community size and their effects on depression, anxiety, and stress among SGM youth. An online survey was completed by 296 SGM‐identified youth (aged 14–18 years). Results revealed that nonphysical forms of victimization were associated with depression, anxiety, and stress above and beyond physical victimization and community variables. Both types of victimization were more common in communities that participants perceived to be hostile and small towns. Practice implications include ways to reduce victimization and improve mental health via community climate and community interventions.     

Perceived racial discrimination as an independent predictor of sleep disturbance and daytime fatigue

Perceived discrimination is a potential cause of racial and ethnic disparities in health. Disturbed sleep may serve as a mechanism linking perceived racism with health consequences. This study investigates data from 7,148 adults from Michigan and Wisconsin who participated in the 2006 Behavioral Risk Factor Surveillance System. Hierarchical logistic regression analyses explored associations between perceived racial discrimination and self-reported sleep disturbance and daytime fatigue. Sleep disturbance and daytime fatigue were reported in 19% and 21% of the sample, respectively. Black/African American respondents (21%) report perceiving worse experiences, compared to people of other races, when seeking health care at higher rates than non-Hispanic White respondents (3%). Results from logistic regression models show that perceived racial discrimination is associated with increased risks of sleep disturbance (odds ratio [OR] = 2.62, p < .0001) and daytime fatigue (OR = 2.07, p < .0001). After adjustment for all covariates, perceived discrimination remains a significant predictor of sleep disturbance (OR = 1.60, p = .04). The interaction between perceived racism and race (Black/African American vs. non-Hispanic White) was nonsignificant. This population-based research adds to the growing body of data, suggesting that perceived racism may impact health via its influence on sleep-wake behaviors.     

Pathways linking racial/ethnic discrimination and sleep among U.S.-born and foreign-born Latinxs

This study examined the association between racial/ethnic discrimination and sleep through psychological distress and body mass index (BMI), and determined whether the aforementioned associations vary between U.S. and foreign-born Latinxs. Participants were 1332 Latinx adults enrolled in the Texas City Stress and Health Study. Multistage sampling methods were used to select participants. A model linking racial/ethnic discrimination with sleep disturbances through direct and indirect (i.e., psychological distress and BMI) paths demonstrated good fit. Greater racial/ethnic discrimination was associated with greater psychological distress and higher BMI. Psychological distress and BMI were also significant predictors of sleep disturbances. The indirect path from racial/ethnic discrimination to sleep disturbances via psychological distress was significant. A model with parameters constrained to be equal between U.S.-born and foreign-born Latinxs suggested associations were comparable between these groups. Our study demonstrated the relevance of racial/ethnic discrimination to sleep disturbances, particularly its association via psychological distress among Latinxs.     

Strangers still? The experience of discrimination among Chinese Americans

This study investigates the perceptions of discrimination within an Asian American community. Over 1,500 Chinese Americans were interviewed regarding experiences with unfair treatment due to their race or ethnicity and their language and or accent. Demographic variables, acculturation level, and amount of contact opportunity were used to predict perceived discrimination using multiple hierarchical logistic analyses. Approximately 21% of Chinese Americans reported being unfairly treated in their lifetime. The specific predictors varied depending on whether the discrimination was due to race and ethnicity, or language and accent. Retention of cultural practices, age of immigration, and contact opportunity were associated with racial discrimination. Only contact opportunity was associated with language and accent discrimination. Implications are discussed with respect to perceptions of similarity, the contact hypothesis, and bicultural adjustment. © 2002 John Wiley & Sons, Inc.     

Racial and ethnic differences in students' attitudes and behavior toward organ donation.

Donor authorizations tend to be especially low among African Americans and other minority and ethnic groups. This study assessed and compared the beliefs, attitudes, and rates of participation regarding organ donation among a sample of racially and ethnically mixed university students. A 64-item survey questionnaire regarding organ/tissue donation issues was administered to 683 undergraduate students from different racial and ethnic backgrounds at a state-assisted university in the Midwest. The findings from the study indicated that African-American students differ significantly from white students in their attitudes and beliefs toward organ donation, while Asian-American, Hispanic, and international students were similar to white students in their attitudes and beliefs regarding organ donation. However, a greater percentage of African-American students have granted permission for organ donation compared to African Americans in the general population.     

Racial Differences in Adolescents' Perceived Vulnerability to Disease and Injury

This study examined gender and racial differences in adolescents' risk perceptions of major diseases and motor vehicle injury and whether these perceptions agree with national mortality rates and parental health history. Adolescent (N = 135; 55% African-American) boys and girls reported on their chances compared to other adolescents of developing specific diseases or experiencing a motor vehicle injury and their knowledge of parental health history. Logistic regression models revealed that girls' risk perceptions were similar to boys' ratings even though females are at less risk than males per national figures. Caucasian adolescents inaccurately perceived that they were at significantly greater risk than African-American peers for motor vehicle injury, stroke, cancer, and heart attack. Adolescents' knowledge of a father's diabetes was predictive of greater perceived vulnerability to diabetes.     

Future Directions in Research on Racism-Related Stress and Racial-Ethnic Protective Factors for Black Youth

Research on racism-related stress and racial-ethnic protective factors represents an important enterprise for optimizing the mental health of African American and other racial and ethnic minority youth. However, there has been a relative dearth of work on these factors in the clinical psychology research literature, and more work is needed in outlets such as these. To this end, the current article adopts a developmental psychopathology framework and uses recent empirical findings to outline our current understanding of racism-related stress and racial-ethnic protective factors (i.e., racial identity, racial socialization, Africentric worldview) for African American youth. We then provide nine recommendations—across basic, applied, and broader/cross-cutting research lines—that we prioritize as essential to advancing the future scientific investigation of this crucial research agenda. Within and across these recommendations, we issue a charge to researchers and clinicians alike, with the ultimate goal of alleviating the negative mental health impact that racism-related stress can have on the well-being and mental health of African American and other racial and ethnic minority youth.     

Cultural perceptions in cancer care among African-American and Caucasian patients

PURPOSE: This exploratory study examined perceptions and beliefs of African Americans and Caucasians related to cancer care. Understanding belief systems and cultures optimizes cancer treatment and care delivery to ethnic minority individuals. PATIENTS AND METHODS: Focus groups were conducted with 39 African-American and Caucasian cancer patients. Data analysis included whole group analysis with a team of five researchers. RESULTS: Regardless of ethnicity, cancer patients share many of the same emotions and experiences, and want complete information and quality care. Differences were also apparent. African-American participants were more likely to report increased religious behaviors, believe that healthcare providers demonstrate care with simple actions and provision of practical assistance, and use church and community information sources. Caucasian participants were more likely to report spiritual but not overtly religious changes, and depend on healthcare providers for information. CONCLUSION: Understanding how culture colors perceptions, communication and information requirements is critical to providing effective care to ethnically diverse cancer patients. Findings have implications for professionals understanding ways patients seek information, the role of spirituality and religion in care, and ways healthcare providers demonstrate care.