The association between tobacco, alcohol, and drug use, stress, and depression among uninsured free clinic patients US born english speakers, non US born english speakers, and spanish speake

Journal of Ethnicity in Substance Abuse ISSN: 1533-2640 (Print) 1533-2659 (Online) Journal homepage: http://www.tandfonline.com/loi/wesa20 The association between tobacco, alcohol, and drug use, stress, and depression among uninsured free clinic patients: U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers Akiko Kamimura, Jeanie Ashby, Jennifer Tabler, Maziar M Nourian, Ha Ngoc Trinh, Jason Chen & Justine J Reel To cite this article: Akiko Kamimura, Jeanie Ashby, Jennifer Tabler, Maziar M Nourian, Ha Ngoc Trinh, Jason Chen & Justine J Reel (2016): The association between tobacco, alcohol, and drug use, stress, and depression among uninsured free clinic patients: U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers, Journal of Ethnicity in Substance Abuse To link to this article: http://dx.doi.org/10.1080/15332640.2015.1102114 Published online: 29 Jan 2016 Submit your article to this journal Article views: 25 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wesa20 Download by: [Laurentian University] Date: 25 March 2016, At: 23:03 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE http://dx.doi.org/10.1080/15332640.2015.1102114 The association between tobacco, alcohol, and drug use, stress, and depression among uninsured free clinic patients: U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers Akiko Kamimuraa, Jeanie Ashbyb, Jennifer Tablera, Maziar M Nouriana, Ha Ngoc Trinha,c, Jason Chena, and Justine J Reeld University of Utah, Salt Lake City, Utah; bMaliheh Free Clinic, Salt Lake City, Utah; cVietnam National University, Hanoi, Vietnam; dUniversity of North Carolina Wilmington, Wilmington, North Carolina Downloaded by [Laurentian University] at 23:03 25 March 2016 a ABSTRACT KEYWORDS The abuse of substances is a significant public health issue Perceived stress and depression have been found to be related to the abuse of substances The purpose of this study is to examine the prevalence of substance use (i.e., alcohol problems, smoking, and drug use) and the association between substance use, perceived stress, and depression among free clinic patients Patients completed a self-administered survey in 2015 (N ¼ 504) The overall prevalence of substance use among free clinic patients was not high compared to the U.S general population U.S.-born English speakers reported a higher prevalence rate of tobacco smoking and drug use than did non-U.S.-born English speakers and Spanish speakers Alcohol problems and smoking were significantly related to higher levels of perceived stress and depression Substance use prevention and education should be included in general health education programs U.S.-born English speakers would need additional attention Mental health intervention would be essential to prevention and intervention Alcohol problems; depression; drug use; free clinics; stress; tobacco smoking Introduction The abuse of substances, including alcohol, tobacco, and drugs, represents a significant public health issue in the United States For example, excessive alcohol consumption is the leading cause of premature deaths in the United States (Stahre, Roeber, Kanny, Brewer, & Zhang, 2014) Smokers are more likely to suffer from health problems such as lung cancer, cardiovascular diseases, long-term disabilities, and premature death (US Department of Health & Human Services, 2015) Secondhand smoke exposure is associated with adverse health outcomes and increased economic burdens, especially among minority groups (Max, Sung, & Shi, 2012) Similarly, drug use can contribute to a loss of work productivity and increased health-care and legal CONTACT Akiko Kamimura akiko.kamimura@utah.edu 1530 E, Salt Lake City, UT 84112 © 2016 Taylor & Francis Department of Sociology, University of Utah, 380 S Downloaded by [Laurentian University] at 23:03 25 March 2016 A KAMIMURA ET AL costs; drug use can also negatively affect brain function However, it is important to note that the effect of drug use on one’s physical and psychological health varies depending on the drug type (NCADD, 2015) While the importance of substance use prevention and interventions has been recognized in public health initiatives, research and practice on the subject of substance use prevention and intervention programs are scarce for some populations, particularly free clinic patients Free clinics provide free or reduced fee primary care services for un- or underinsured populations (Geller, Taylor, & Scott, 2004) Free clinics commonly rely on volunteers rather than paid employees for staffing needs and thereby tend to have unstable financial sources resulting in workforce and financial instability (Gertz, Frank, & Blixen, 2011; Nadkarni & Philbrick, 2005) Approximately 60% of free clinics not receive any funding from the government (Darnell, 2010) The majority of free clinic patients are uninsured adults aged 19 to 64 with low income who tend to suffer from chronic conditions such as diseases of the circulatory or respiratory system (Nadkarni & Philbrick, 2003; Notaro et al., 2012) The emergency department frequently represents the sole health-care resource for free clinic patients other than free clinics (Gertz et al., 2011) Only 8.5% of primary care free clinics provide on-site services for substance abuse (Darnell, 2010) Since less than 10% of free clinics provide services to address substance abuse, little is known about substance use among free clinic patients To our knowledge, smoking of tobacco is the only form of substance use that has been examined in relation to the free clinic patient population Tobacco cessation programs have been implemented at some free clinics (Foley et al., 2012; Pockey et al., 2012) Uninsured free clinic patients reported significantly higher smoking rates (36.8%) than the U.S general population (17.9%) (Notaro et al., 2012) and people below the poverty level (29.2%) (Centers for Disease Control and Prevention, 2015) A large portion of the patients served by free clinics are racial or ethnic minorities (Kamimura, Christensen, Tabler, Ashby, & Olson, 2013), and while ethnic minorities reported lower prevalence of smoking than Whites (Asian 9.6%, Hispanic 12.1%, African American 18.3%, White 19.4%) (CDC, 2015), their risk of smoking increases if their income is low (McCabe, Woodruff, & Zuniga, 2011) Besides smoking, the prevalence of substance use among free clinic patients has not been examined Given that the prevalence of smoking among free clinic patients is higher than it is among low-income populations who are not free clinic patients, there is a possibility that free clinic patients may also exhibit a higher incidence of use of other substances and have a different pattern of substance use Examining substance use among free clinic patients may provide increased knowledge that may facilitate better mental health interventions Increased access to and quality of mental health services for free clinic patients is Downloaded by [Laurentian University] at 23:03 25 March 2016 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE important because free clinic patients have been reported to have moderate depression and lower levels of mental health functioning compared to the U.S general population (Kamimura et al., 2013) Substance use is often related to depression and anxiety (Davis et al., 2006; 2005; Kessler, 2004; Lechner et al., 2014) Smoking is in particular associated with increased levels of stress (Stein et al., 2008) Perceived stress may serve as an indicator of the risks for illicit drug use (Moitra, Anderson, & Stein, 2013) Due to the cyclical relationship between perceived stress and illicit drug use, it is important to study the effects of substance abuse in all populations However, since free clinic patients may show different levels of stress and substance abuse, it is especially important to study intervention and prevention services for free clinic patients suffering from depression and anxiety The purpose of this study is to examine the prevalence of substance use (i.e., alcohol problems, smoking, and drug use) as well as the association between substance use, perceived stress, and depression among free clinic patients There is a paucity of research regarding alcohol and drug use among the population There is also a lack of knowledge available on how perceived stress and depression among free clinic patients are linked to substance use Therefore, this study will increase an understanding about free clinic patients and underserved populations by providing information that may be used to improve the mental health of the population as related to substance use Method Overview The current community-based research project was conducted at a free clinic in the Intermountain West The clinic staff collaborated with the research team to develop the survey instrument, study protocol, participant recruitment strategies, and interpretation of study results The clinic provides free health-care services, including mostly routine health maintenance and preventive care, for uninsured individuals who live below the 150th percentile federal poverty level and not have access to employer-provided or government-funded health insurance The clinic has an on-site laboratory and pharmacy The clinic has six full-time paid personnel and over 300 active volunteers, including approximately 60 volunteer interpreters The clinic, which has been in operation since 2005, has no affiliation with religious organizations and is funded by nongovernmental grants and donations The clinic is open days a week The number of patient visits was 18,967 in 2013 The clinic does not require patients to show documentation of legal residency or citizenship and therefore provides services to undocumented immigrants, U.S citizens, and documented immigrants Approximately half of the clinic patients self-identified as Hispanic 4 A KAMIMURA ET AL Downloaded by [Laurentian University] at 23:03 25 March 2016 Study participants and data collection Before we initiated data collection at the free clinic, the institutional review board (IRB) approved this study The adult participants spoke and read English or Spanish and were patients of the identified free clinic The data were collected for months (from January 12, 2015 to April 22, 2015) using a self-administered paper survey All survey materials, including the questionnaire, consent cover letter, and flyer, were available in both English and Spanish Questions regarding alcohol, drug, and tobacco use were translated Other questions had an existing Spanish version A bilingual translator translated the English materials (when Spanish versions were not available) into Spanish Another bilingual translator conducted back-translation from Spanish to English The third bilingual translator checked accuracy of the translation The translation process followed the Brislin model (Brislin, 1970, 1986) Recruitment of participants occurred at the free clinic during clinic hours by distributing flyers to patients in the waiting room If a potential participant expressed interest in participating in the study, he or she received a consent form, cover letter, and a self-administered paper-andpen survey Hard-copy surveys were administered individually in a faceto-face setting Members of the study team (i.e., trained student research assistants) recruited participants and were available to answer questions throughout survey completion Measures Alcohol problems Alcohol problems were assessed using the CAGE questionnaire which is an acronym of four questions about alcohol problems (e.g., “Have you ever felt you should cut down on your drinking?”) (Ewing, 1984) If a participant experienced alcohol problems, as described by answering yes to two or more of the four questions, he or she is considered to have clinically significant alcohol problems The CAGE has been shown to be an effective assessment tool internationally using diverse samples Drug use Drug use of participants was assessed using the Drug Abuse Screening Test (DAST-10) developed by Harvey A Skinner (Skinner, 1982, 2001; Skinner & Goldberg, 1986) The DAST-10 queries whether a participant has experienced 10 types of drug-related problems, excluding alcohol and tobacco, in the past 12 months Examples of these problems include having used drugs other than those required for medical reasons, having ever felt bad or guilty about drug use, and having had medical problems as a result of drug use Scores, which are based on the number of problems experienced, are interpreted as the following JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE Downloaded by [Laurentian University] at 23:03 25 March 2016 levels of risk of drug-related problems: ¼ none; 1–2 ¼ low; 3–5 ¼ moderate; 6–8 ¼ substantial; 9–10 ¼ severe The DAST-10 has been widely used as a screening tool for practice and research (Maisto, Carey, Carey, Gordon, & Gleason, 2000; Yudko, Lozhkina, & Fouts, 2007) Smoking Three original questions regarding smoking were developed for the purpose of this study to determine behavior around and exposure to smoking The first question asked the participant to classify his or her current smoking status (i.e., pick one from “current smoker,” “have not smoked for the past months,” “quit more than months ago,” or “have never smoked”) The second question probes whether a participant is exposed to secondhand tobacco smoke in the home and/or workplace more than days a week using a yes or no response format The third question is only for participants who indicated they were smokers in the first question and asks whether the participant is interested in tobacco cessation programs (yes or no) Stress Levels of perceived stress were measured by the Perceived Stress Scale (PSS)-10 (Cohen, Kamarck, & Mermelstein, 1983) The PSS-10 consists of 10 items (e.g., “How often have you been upset because of something that happened unexpectedly?”) using a 5-point Likert scale (Never ¼ 0; Almost never ¼ 1; Sometimes ¼ 2; Fairly often ¼ 3; Very often ¼ 4) Four of the items are reverse scored The sum of the scores from the 10 items represents the respondent’s total perceived stress (range 0–40) Higher scores correspond to higher levels of stress There is no cutoff point to determine specific stress levels The PSS has been tested for reliability and validity Cronbach’s alpha of this study population was 0.84 Depression The Patient Health Questionnaire (PHQ-9), which is a nine-item survey using a 4-point Likert scale (from ¼ not at all to ¼ nearly every day), measured levels of depression for this study The PHQ-9 asks how often a participant has been afflicted by known symptoms of depression during the past weeks such as “little interest or pleasure in doing things,” “feeling tired, or having little energy,” and “poor appetite or overeating.” PHQ-9 scores as a measure of the level of depression severity are defined as minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), or severe (20–27; Kroenke, Spitzer, & Williams, 2001) The PHQ-9 score was used for determining the overall level of self-reported depression The PHQ-9 is a valid and reliable tool and has been widely used (Martin, Rief, Klaiberg, & Braehler, 2006) Cronbach’s alpha of this study population was 0.91 6 A KAMIMURA ET AL Sociodemographic characteristics Demographic questions included age, race/ethnicity, country of origin, length of years living in the United States (non-U.S.-born participants only), education level, employment status, marital status, and length of being a patient of the clinic (i.e., “2 years or fewer” or “2 years or longer”) Downloaded by [Laurentian University] at 23:03 25 March 2016 Data analysis Data were analyzed using SPSS (version 22) The participants were divided into three groups for comparison (U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers) because previous studies on free clinic patients suggest that these three groups differ from each other in sociodemographic status, health status, and health-related quality of life; in addition, dividing the sample according to language in which individuals completed the survey best represents race/ethnicity and immigration status (Kamimura et al., 2013, 2014) Descriptive statistics were used to capture the distribution of the outcome and independent variables The three groups of participants were compared using Pearson’s chisquare tests for categorical variables (if each cell had more than five respondents) and analysis of variance (ANOVA) for continuous variables Prior to running ANOVA tests, equality of variance was tested for unbalanced sample sizes among the three groups Post hoc analyses were conducted to assess the robustness of the ANOVA analyses and to confirm their findings Multivariate multiple regression analysis was conducted to test the association between substance use, perceived stress, depression, and individual factors Regression coefficients (standard errors) were used to obtain 95% confidence intervals (CIs) Results Demographic characteristics Table summarizes the sociodemographic characteristics, substance use experience, perceived stress, and depression of 504 participants recruited from convenience sampling (122 U.S.-born English speakers, 121 non-U.S.-born English speakers, and 261 Spanish speakers) Participants who completed the survey in English were considered English speakers while participants who took the survey in Spanish were considered Spanish speakers The mean age of the participants was 43.8 (SD ¼ 12.7) Spanish speakers were the oldest (mean ¼ 45.3, SD ¼ 12.7), followed by non-U.S.-born English speakers (mean ¼ 43.9, SD ¼ 13.8), and U.S.-born English speakers (mean ¼ 40.8, SD ¼ 14.5) More than 60% of participants were women (n ¼ 322, 63.9%) Almost 70% of Spanish speakers were women (n ¼ 181, 69.3%) Moreover, approximately 60% of non-U.S.-born English speakers (n ¼ 71, 58.7%) and U.S.-born English speakers (n ¼ 70, 57.4%) were women More JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE Table Sociodemographic characteristics, substance use experience, perceived stress, and depression of participants Total (N ¼ 504) Downloaded by [Laurentian University] at 23:03 25 March 2016 Mean age, years Female White Hispanic/Latino/Latina Asian or Pacific Islander African/African American/Black Native American Some college or higher Currently employed Currently married U.S born Years in the United States (non-U.S.-born only) Clinic patient 2þ years Alcohol problems Drug use experience Lowa Intermediatea Substantiala Never smoked Current smoker Interest in smoking cessation education Secondhand smoking Perceived stressb Depressionc U.S.-born English speakers (n ¼ 122) 43.8 (12.7) 40.8 (14.5) 322 (63.9) 70 (57.4) Race/Ethnicity 103 (20.4) 84 (68.9) 330 (65.5) 30 (24.6) 50 (9.9) (3.3) 10 (2.0) (2.5) (0.6) (2.5) 222 (44.0) 73 (59.8) 252 (50.0) 56 (45.9) 231 (45.8) 27 (22.1) 126 (25.0) 122 (100) 15.1 (9.1) NA 206 49 254 209 33 11 340 59 32 Non-U.S.-born English speakers (n ¼ 121) Spanish speakers (n ¼ 261) p value 43.9 (13.8) 71 (58.7) 45.3 (12.7) 181 (69.3)