Health Policy & Management Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/7127
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Item DISPARITIES IN ADOLESCENT MENTAL HEALTH SERVICES UTILIZATION AND HELP-SEEKING(2024) Truong, Michelle L; Sehgal, Neil J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Inequities in access to and utilization of mental and behavioral health care for adolescents have persisted for numerous decades. Adolescents from racial and ethnic minority backgrounds, as well as those in underserved geographic regions, are disproportionately impacted. As the youth mental health crisis escalates, it is critical to study the mechanisms driving these disparities to inform effective and targeted interventions and policies. Divided into three studies, this dissertation explored the influence of individual, cultural, and contextual factors on adolescent help-seeking behaviors using data from the 2009 and 2011 to 2019 California Health Interview Survey (CHIS).The first study employed mediation analyses to assess the extent to which having a subjective or perceived need for mental health care, conditional on objective need, contributes to racial and ethnic disparities in mental health services utilization. I found significant racial and ethnic differences in subjective needs for mental health services and that these differences partially explain the racial and ethnic disparities in service utilization. The second study explored differences in mental health service utilization among subgroups of non-Hispanic (NH) Asian and Latino/Hispanic adolescents compared to NH white adolescents. I found that Vietnamese and Mexican adolescents were significantly less likely to utilize mental health services relative to their NH white counterparts. The third study merged the adolescent data with provider data from the National Plan and Provider Enumeration System (NPPES), facility data from the National Substance Use and Mental Health Services Survey (N-SUMHSS), and population data from the US Decennial Census Redistricting Data Summary Files to assess the moderating effects of distance to the nearest pediatric mental health facility and provider-to-population densities on the relationship between subjective mental health care needs and service utilization. I discovered that provider density and subjective needs interact, resulting in a diminished effect of subjective needs on service utilization among adolescents residing in areas with lower primary care provider density. I did not find that distance to the nearest pediatric mental health facility had a significant impact on service utilization. This dissertation examined racial, ethnic, and geographic mental health care disparities among a diverse adolescent population in California. Findings from this work contribute to the understanding of adolescent help-seeking behaviors and provide insights for targeted interventions and policies to advance mental health care equity.Item Distress and Deaths of Despair in the U.S. Healthcare Delivery System: Understanding Patterns in Healthcare among Distressed Americans(2024) Spencer, Merianne Rose Tiglao; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The United States has experienced rising mortality rates for the past several decades. Drug poisonings have increased nearly five-fold, suicide rates by nearly 40%, and by nearly 30% percent for alcohol-induced deaths between 1999 and 2021. This collection of drug-, alcohol- and suicide deaths are oftentimes referred to as “deaths of despair”, first coined by economists Anne Case and Angus Deaton who cited health and socioeconomic disparities driving Americans into mental distress, depression, and anxiety. The impact on the mental health of Americans was further exacerbated by the COVID-19 pandemic; this exposed vulnerabilities in the mental healthcare system as well as the various stressors that negatively impacted individuals across the globe. Using nationally representative data, this dissertation delves into the deaths of despair phenomenon using a multidisciplinary health services research lens. Access, utilization, and risk from deaths of despair are examined by using psychological distress (which is treated as a proxy for despair in the first two aims). Using the Kessler-6 scale, a well-accepted and clinically valid tool for non-specific mental distress, this dissertation explores patterns of healthcare spending among those with varying severity levels of psychological distress over a two-decade period; delves into patterns of healthcare utilization among young adults aged 18-30 (a population disproportionately impacted by stressors during the COVID-19 pandemic) by psychological distress; and quantifies the risk of death among those with varying severity levels of psychological distress.Item Mental health and mental health services during the COVID-19 pandemic(2021) Benjenk, Ivy; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The COVID-19 pandemic significantly impacted mental health and mental health services in the United States. During February 2021, 42% of Americans experienced symptoms of depression or anxiety. During the pandemic, the largest and most sustained growth in telemedicine occurred in mental health services. The goal of this dissertation is to explore strategies for maintaining mental health services and promoting mental health during the COVID-19 pandemic. In this work, I review the literature on what is currently known about the impact of the COVID-19 pandemic on mental health and mental health services. I provide conceptual frameworks that posit how vulnerable populations are at highest risk for losing access to healthcare during the pandemic and how population-level strategies are needed to promote mental health recovery. In my first research paper, I use qualitative data collected from semi-structured interviews with twenty adults with serious mental illness (SMI) during the pandemic. I found that most study participants did not experience increases in unmet mental health or social service needs. However, several participants who lacked identification documents, housing, and/or a personal device reported significant increases in unmet needs, including inability to access mental health care and public benefits. As many participants in the qualitative study reported receiving audio-only telemental health services versus video telemedicine during the pandemic, I used data from the Medicare Current Beneficiary Survey COVID-19 Supplements to explore the use of audio-only telemedicine during the pandemic. Findings suggest that the high rate of audio-only telemedicine is not exclusively related to the digital divide or patient preferences, but also to provider behavior. Lastly, as the COVID-19 pandemic impacted the mental health of the entire population, I used data from the Census Bureau’s Household Pulse Survey to explore whether availability and receipt of an effective COVID-19 vaccine could promote mental health. Results suggest a reduction in the predicted probability of mental health symptoms after approval of the vaccine and a lower predicted probability of mental health symptoms among those who have been vaccinated, however these rates remain higher than what was seen prior to the pandemic. Overall findings suggest that the mental health care system has adapted fairly well to meet the needs of persons with SMI during the pandemic and mental health has improved since the approval of the vaccine, but additional work will be needed to reengage those who were disconnected from mental health services during the pandemic and to achieve pre-pandemic levels of mental health.Item Perceived Neighborhood Cohesion, Homeownership, and Race/Ethnicity: Implications for Adult Mental Health(2021) Brown, Melanie; Boudreaux , Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This study utilized 2013-2017 data from the National Health Interview Survey to evaluate the association between perceived neighborhood cohesion and mental health outcomes (serious psychological distress, anxiety, and depression) and how this association varies by race/ethnicity. This study also evaluated perceived neighborhood cohesion as a mediator of the relationship between homeownership and mental health. Results indicated that residing in a cohesive neighborhood is associated with reductions in risk (p<.01) for adverse mental health outcomes. Individuals living in cohesive neighborhoods had a reduced risk of 1.30 percentage points of serious psychological distress, a 4.10 percentage point reduced risk of anxiety symptoms, and a 3.80 percentage point reduced risk of depression symptoms. This study found a statistically significant reduction in risk of adverse mental health outcomes for those that own vs. rent their home and this relationship is partially mediated by neighborhood cohesion. These findings suggest that neighborhood cohesion provides a protective benefit against adverse mental health outcomes.