Brief Research Report published: 08 November 2019 doi: 10.3389/fpsyt.2019.00817 Predictors of Adherence to Treatment in Behavioral Health Therapy for Latino Immigrants: The Importance of Trust Irene Falgas-Bague 1,2*, Ye Wang 1, Souvik Banerjee 1, Naomi Ali 1, Karissa DiMarzio 1, Diego Palao Vidal 2,3,4 and Margarita Alegría 1,5 1Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States, 2Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain, 3 Department of Mental Health, University Hospital Parc Tauli-I3PT, Sabadell, Spain, 4 CIBERSAM, Barcelona, Spain, 5 Departments of Medicine and Psychiatry, Harvard Medical School, Boston, MA, United States A complex array of barriers to care influence patients' adherence to behavioral healthcare services. Understanding barriers to care is critical to ensure sufficient dosage of treatment. This study assessed the influence of perceived barriers on Latino migrants' prospective Edited by: adherence to treatment for co-occurring mental health and substance use disorders as Guilherme Borges, part of a clinical trial. Eligible participants (18–70 years-old) were recruited from community- National Institute of Psychiatry Ramon de la Fuente Muñiz (INPRFM), based settings and classified according to their intervention session attendance. Baseline Mexico assessments included socio-demographic factors, clinical characteristics (i.e., depression, Reviewed by: anxiety, post-traumatic stress disorder, substance use), psychosocial and cultural factors (i.e., Claudia Rafful, ethnic identity, health literacy, discrimination), and perceived attitudinal and structural barriers National Autonomous University of Mexico, Mexico to care. Treatment involved 10-sessions of cognitive-behavioral therapy, psychoeducation, Hongmei Wang, and mindfulness (Integrated Intervention for Dual problems and Early Action) and emphasized Zhejiang University, China participant's engagement in treatment. We used multinomial logistic regression models to *Correspondence: Irene Falgas-Bague examine the association between barriers to care reported at baseline, sociodemographic ifalgasbague@mgh.harvard.edu characteristics, psychosocial and cultural factors, clinical factors, and treatment adherence. Mistrust in previous behavioral health treatment(s) was the reported barrier significantly Specialty section: associated with completion of the program after adjusting for clinical, psychosocial, and This article was submitted to Public Mental Health, cultural factors, with those expressing mistrust in previous treatment(s) showing higher a section of the journal rates of completion compared to those who did not report this barrier. Evidence-based and Frontiers in Psychiatry culturally-tailored interventions provided by ethnically matched providers may overcome Received: 24 June 2019 Accepted: 16 October 2019 cultural mistrust and increase adherence to behavioral health care among Latino immigrants. Published: 08 November 2019 Keywords: Latinos, co-occurring disorders, barriers, adherence to treatment, ethnicity, immigrant Citation: Falgas-Bague I, Wang Y, Banerjee S, Ali N, DiMarzio K, Palao Vidal D and Alegría M (2019) Predictors of INTRODUCTION Adherence to Treatment in Behavioral Health Therapy for Latino Immigrants: Latinos represent the largest immigrant population in the United States (U.S.) and Spain (1). The The Importance of Trust. growth of first- and second-generation Latinos in both countries poses challenges for public health Front. Psychiatry 10:817. systems, from limited accessibility to behavioral health services (2, 3) to low quality and continuity of doi: 10.3389/fpsyt.2019.00817 care (4). Although disparities in behavioral health care among Latinos have been well-documented Frontiers in Psychiatry | www.frontiersin.org 1 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants in the U.S. (5), there is a paucity of research in both countries to better assess characteristics that encourage adherence in identifying factors that might shape adherence to behavioral immigrant populations. Third, we include a wide array of factors health treatments among Latino populations. A complex array of to determine if barriers remain important factors after adjusting psychological, cultural and sociodemographic factors influences for sociodemographic, clinical, and psychosocial characteristics an individual's entry and adherence to behavioral health care in a heterogeneous sample of Latino immigrants. To do this, we (6). Thus, identifying salient barriers to care is a critical task for evaluated predictors of adherence to treatment based on the clinicians and administrators. three groups that best represented the distribution of patient Existing literature suggests that individuals with co-occurring participation into the Integrated Intervention for Dual problems mental health and substance use disorders (COD) access and Early Action (IIDEA) intervention: 0–1 sessions (tercile 1 or behavioral health treatment at extremely low rates compared to reference category), 2–9 sessions (tercile 2), and 10–12 sessions individuals without co-morbidities (7). For example, only 9.1% (tercile 3) (see Figure 1s in Supplementary Material). of these individuals receive treatment for both disorders, while 52.5% receive no treatment at all (8). Yet, integrated treatments are among the most effective interventions for persons with COD (9, METHODS 10). Nevertheless, Latinos face unique barriers inhibiting access to specialized treatment (11). Research has shown that Latinos Study Design and Setting have lower rates of treatment adherence, attending fewer sessions Data were drawn from baseline interviews and clinical trial data and prematurely dropping out of cognitive behavioral therapy collected for the International Latino Research Partnership, a (CBT) compared to non-Latino Whites (12). These differences multisite study that sought to improve behavioral health care have been attributed to the double stigma associated with mental services for Latino migrants (22). Participants were enrolled illness and being an ethnic minority, logistical, motivational, and between September 2014 and February 2017 through direct attitudinal factors (13–15). For example, a previous study found contact in clinic waiting rooms, emergency departments, that approximately 50% of Latino immigrants reported self- community-based organizations, or through healthcare reliant attitudes regarding behavioral health care (e.g., wanting professionals and participant referrals. Participating clinics were to handle problems on one's own) and structural barriers (e.g., affiliated with large safety-net health care systems serving diverse difficulties with transportation and scheduling flexibility). The populations. All participants provided informed consent before study identified these barriers as significant obstacles to treatment participating in the trial. The study was approved by the review adherence (16). Even if Latino immigrants view their symptoms boards of all participating institutions. as warranting attention, they are unlikely to seek treatment if they do not believe they will benefit from professional services. Participants According to Andersen-Newman's healthcare utilization Eligible participants were those between 18–70 years old who model (17), predisposing (e.g., sociodemographic characteristics self-identified as Latino (from any Spanish-speaking country— and attitudes toward health care), enabling (e.g. employment), Caribbean, Central America and Mexico, or South America), and clinical factors (e.g. symptoms and severity) determine an and who had migrated to the U.S. or Spain. Participants had to individual's ability to cope and command resources to deal with screen positive for comorbid mental health and substance misuse problems, shaping his/her use of services (18). An extension of (COD) but report not currently receiving specialty behavioral this model includes psychosocial factors such as discrimination health services (i.e., therapy with a psychiatrist, psychologist, or and health literacy to better comprehend the complex role of social worker) in the past 3 months or upcoming month. Positive race/ethnicity in help-seeking (19, 20). Yet, the literature is COD screening included an affirmative response to two questions inconclusive with regards to how these factors predict adherence about mental health and two about substance use on the AC-OK to treatment. screener (23), a 15-item questionnaire validated in Spanish (24). One strategy that has been effective in improving adherence Sensitivity and specificity of the questionnaire was shown to be among Latino populations is culturally adapting interventions consistent with standardized screeners (24). Internal consistency (21). To this end, we conducted a multisite randomized trial of was comparable to the original English sample (α = 0.82 for the "Integrated Intervention for Dual Problems and Early Action" mental health and α = 0.90 for substance abuse). Participants (22), which was specifically designed to treat immigrant and U.S./ were excluded only if they lacked capacity to consent, assessed by Spain-born Latinos with COD (NIDA Grant R01DA034952). a validated screener (25), or reported suicidal ideation, assessed The trial was implemented at three sites (Boston, Madrid, and with the Paykel Suicide Scale (26). Barcelona) and incorporated a patient-centered, community- based approach. Treatment took place in-person or by phone and included extended outreach on Saturdays and Sundays. Procedures The current study aimed to assess predictors of treatment For the study, 2,284 prospective participants were approached adherence in a large sample of Latino immigrants with COD. directly by the research team in clinic waiting rooms or were There are several aspects that make our study novel. First, we referred by primary care providers or staff from community assess several barriers before immigrants enter treatment to agencies and then contacted by phone. Of these, 384 were determine if they predict individuals' adherence to care. Second, eligible to participate and 341 agreed to a baseline interview. we include immigrants from two countries, which allows us Trained interviewers conducted research assessments in Spanish Frontiers in Psychiatry | www.frontiersin.org 2 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants or English depending on participants' preferred language. race/ethnicity (White, Black, Indigenous/Native American, Interviews were audio-recorded and lasted approximately 1 Hispanic/Latino/Caribbean, and Mixed Race), highest education hour. Participants were compensated with $40/€30 gift cards for level obtained, socioeconomic status (classified into two the assessment, but not for participating in treatment sessions. categories; total personal annual income >$15,000 or <$15,000), Upon completion of the baseline assessment, participants were immigration status (defined by citizen or non-citizen to host randomized to the IIDEA intervention or enhanced usual care country) and employment status (1 if employed, including part as part of the control group. Participants in the control group time; 0, otherwise). were contacted four times throughout the intervention period by a care manager, who administered the brief assessment used in Psychosocial and Cultural Factors clinical sessions and monitored each patient's mental health to We assessed individuals' perceived discrimination, intercultural assess increases in symptoms that might require specialized care. family conflict, health literacy, time in the host country, and A member of the research team contacted those randomized to number of visits to their country of origin as psychosocial and the intervention group (n = 172) to schedule the first appointment cultural factors that could predict adherence to the intervention. with a clinician. Clinicians were also randomized per patients' Participants completed the Everyday Discrimination Scale (EDS; available times for treatment. range = 9 to 54) (27, 28), previously used in the National Latino and Asian American Study (α = 0.82) (29). The EDS assessed how often participants experienced unfair treatment in their day-to- Intervention day life. Response categories ranged from 1 (never) to 6 (almost IIDEA was designed to maintain fidelity to evidence-based every day), with higher scores indicating greater perceived approaches while addressing a range of mental health discrimination. To assess intercultural family conflict, we used conditions (e.g., depression, anxiety, traumatic stress, mild to four items of the Family/Culture Stress subscale of the Hispanic moderate drug/alcohol abuse) in Latino adults. IIDEA is a brief, Stress Inventory (range = 0 to 10) (α = 0.67) (30), designed to transdiagnostic therapy model adapted to engage and retain measure family interference with personal goals, arguments with Latino participants in treatment. The program involves 10 weekly family members, and the breakdown of the family unit. Sense sessions delivered over 3–4 months by trained clinicians who of belonging was also assessed using one item (coded as yes = attend weekly supervision meetings. Depending on participant's 1, otherwise = 0) from the Family/Culture Stress subscale (30). needs, two extra sessions were offered at the end of the program. The 3-item Ethnic Identity Scale (α = 0.73), derived from the IIDEA integrates elements of CBT, motivational interviewing, 35-item Cultural Identity Scale for Latino Adolescents (range = relapse prevention, assertive communication, and HIV/STD 3–12) (31), was used to gauge cultural identity, with questions risk prevention. The program also includes basic elements of the pertaining to participants' self-identified culture or racial/ethnic cultural formulation model to improve participant engagement group. We also collected data on the amount of time participants in treatment. Clinicians included psychiatric residents, clinical had spent in their host country (US or Spain) and number of psychologists, and social workers. All clinicians were fluent visits to their country of origin in the past 12 months. We assessed Spanish speakers, with five of the 14 total clinicians self-identifying health literacy with three questions from the Health Literacy as Latinos; the remaining nine clinicians were Spanish natives. Screening Questionnaire (range = 3–15) (32), which assessed Depending on the participant's preferences, the intervention participant's ability to perform basic tasks and understand health was delivered in-person at a clinic or community setting or over care information ("How confident are you filling out medical the phone. The goals of the program were to: engage, elicit, and forms on your own?"). Another item from the Single Item improve coping skills to reduce symptoms of depression, anxiety, Literacy Screener (33) was added to the health literacy scale to and PTSD; improve assertive communication skills; reduce or identify patients from diverse populations with limited reading eliminate alcohol and substance use problems; and reduce HIV/ ability (α = 0.80). STD risk behaviors. Perceived Barriers to Care Measurements We asked participants about 11 barriers to behavioral health Adherence to IIDEA Intervention treatment at baseline (coded as 0 if not mentioned, and 1 if yes We measured adherence by the number of sessions attended. for each barrier) according to their previous experiences. If the We first explored the distribution of participants according to participant reported not having any previous experience with attendance to inform how to group the participants (see Figure 1s accessing behavioral health services, the research assistant asked in Supplementary Material). The first group (tercile 1) comprised her/him to think about what barriers she/he thinks they would participants who either never started the intervention or attended have encountered. The list of reported barriers was a combination only one session. The second group (tercile 2) included those who of attitudinal and structural factors that may influence health had completed two to nine sessions, and the third group (tercile 3) care utilization according to the model. Attitudinal barriers included those who completed 10 or more sessions. (related to the individual's beliefs and values) included "wanting to handle a problem on one's own," "thinking treatment would Sociodemographic and Predisposing Factors not work," "concerns about stigmatization," and "concerns about Demographic factors included age, gender, and site of recruitment poor treatment because of one's ethnic/racial background." (Barcelona, Madrid, or Boston). We also collected self-reported Structural barriers (related to individual's perception of Frontiers in Psychiatry | www.frontiersin.org 3 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants the health care system) included "fear of not knowing how care and treatment adherence while controlling for demographic to communicate problems because of language barriers," (age, gender, site, employment status), psychosocial "previous negative experiences with treatment," "treatment (discrimination), and clinical (HSCL, benzodiazepine use scale, cost," and "problems with transportation and scheduling times." ASI alcohol scores at baseline) factors. To mitigate the issue of Participants indicated whether they had experienced each barrier multi-collinearity among the baseline characteristics, our final and had the opportunity to add additional barriers not described model included those with significant subgroup differences at in the assessment. the 95% confidence level—site, benzodiazepine dependence, ASI alcohol, HSCL, and two measures of treatment barriers—as well Illness Level/Clinical Factors as basic demographics (age, gender), employment status, and a Depression was measured with the Patient Health Questionnaire measure of everyday discrimination, as we hypothesized that (PHQ-9) (α = 0.85) (34, 35), as assessed by DSM-IV diagnostic these would be significant predictors of immigrants' adherence criteria of major depressive disorder. We also administered the to care (50). To address missing data in the HSCL instrument brief General Anxiety Disorder scale (GAD-7) (α = 0.86) (36, 37), (19% of observations were missing because the instrument was a seven-item clinical screener for generalized anxiety. To assess administrated later in the study), we implemented multiple trauma, we included the Brief Trauma Questionnaire (BTQ) imputation methods using the "mi" procedure in Stata (51). (38), a 10-item self-reported measure that examines experiences This technique creates twenty complete datasets, imputes of potentially traumatic events, and the Post-Traumatic Stress missing values using a chained equations approach, analyses Disorder Checklist (PCL-5) (α = 0.94) (39, 40), a self-reported each dataset, and uses standard rules (52) to combine estimates measure of the DSM-V symptoms of PTSD. We also used the and adjust standard errors for uncertainty due to imputation. Hopkins Symptoms Checklist (HSCL-20) (α = 0.92) (41), a We also conducted a sensitivity analysis excluding the HSCL 20-item measure assessing symptoms of anxiety and depression. instrument from the multinomial regression. For missing values The resulting score is the average rating across all items (range: other than HSCL measure, we used list-wise deletion for (N = 0–4) with higher scores indicating more severe symptoms. 3; 1.7%); so, the analytic sample for the multivariate analysis Substance use was measured using: the Alcohol Use Disorders comprised 169 observations. Identification Test (AUDIT) (α = 0.78) (42, 43), a World Health Organization screener for excessive drinking; the Drug Abuse Screening Test (DAST) (α = 0.87) (44, 45), a 10-item, yes/no self- RESULTS reported instrument designed to screen for substance use; drug (α = 0.84, range: 0–1, cut-off: 0.1+) and alcohol sections (α = 0.70, Adherence to Intervention range: 0–1, cut-off: 0.1+) of the Addiction Severity Index (ASI)- Table 1 summarizes the baseline sociodemographic characteristics Lite (46) which evaluates lifetime and past 30-day behaviors; and of the sample and the three categories of treatment adherence. a selection of eight items from the Benzodiazepine Dependence Across the three sites, 27.9% (N = 48) of participants attended Questionnaire (BDEPQ) (α = 0.90) (47) that measure dependence 0–1 sessions, 34.9% attended (N = 60) 2–9 sessions, and 37.2% to benzodiazepine tranquilizers, sedatives, and hypnotics. We (N = 64) of participants completed the whole program, attending measured smoking using the Fagerström Test for Nicotine 10 or more sessions. Adherence across the recruitment sites was Dependence (48, 49) (α = 0.75), a standard six-item instrument significantly different (p = 0.012), with Barcelona exhibiting the assessing the intensity of physical addiction to nicotine. lowest rates. No significant differences in treatment adherence were found by age, gender, race/ethnicity, region of origin, socioeconomic status, employment, or education. Statistical Analysis Participants randomized to receive the IIDEA intervention Our sample includes only participants from the intervention differed in terms of sociodemographic and clinical characteristics arm of the study (N = 172), divided into subgroups according between the participants across the three sites (Boston, Madrid, to the number of treatment sessions they received: 0–1 sessions and Barcelona) as well as between the participants in Spain (tercile 1) (N = 48), 2–9 sessions (tercile 2) (N = 60), and 10–12 (Madrid+Barcelona) and the US (Boston). Table 1s in the sessions (tercile 3) (N = 64). We assessed differences between Supplementary Material reflects these differences. Overall, the three subgroups, comparing proportions and means (with participants recruited in Spain were younger, with higher standard deviations) of sociodemographic, clinical measures, education level, mostly coming from South America (89.1%), and sociocultural factors, by using bivariate regression and being first generation immigrants without citizenship and lower Pearson Chi-square tests for inter-group differences for sense of belonging while participants recruited in U.S. were older continuous and categorical baseline characteristics. We also and reported being of Caribbean or Central American origin summarized individual barriers to care reported by participants (including Mexico) in a much higher proportion (40.9% and and assessed subgroup differences using Chi-square tests with 36.4%, respectively). Participants in the U.S. reported longer pairwise comparison of 2–9 treatment sessions (tercile 2) and time from migration compared to those recruited in Spain 10–12 treatment sessions (tercile 3) versus those who attended and reported higher scores in the measures of discrimination, 0–1 session (tercile 1 as reference category). Using multinomial acculturation stress, depression, anxiety, trauma, and smoking logit models, we evaluated the associations between barriers to but lower scores in the alcohol abuse (AUDIT) measure. Frontiers in Psychiatry | www.frontiersin.org 4 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants TABLE 1 | Sociodemographic individual characteristics and adherence to intervention (N = 172). Total intervention sample (n = 172) Treatment Treatment Treatment Difference-test adherence adherence adherence tercile 1 tercile 2 tercile 3 (0–1 sessions) (2–9 sessions) (10–12 sessions) (n = 48) (n = 60) (n = 64) N % % % % P-value Site Boston 44 25.6 18.8 28.3 28.1 0.012 Madrid 41 23.8 10.4 25.0 32.8 Barcelona 87 50.6 10.8 46.7 39.1 Age category 18–34 100 58.1 64.6 60.0 51.6 0.064 35–49 48 27.9 31.3 28.3 25.0 50+ 24 14.0 4.2 11.7 23.4 Gender Male 78 45.3 52.1 43.3 42.2 0.539 Female 94 54.7 47.9 56.7 57.8 Race† White 29 17.0 18.8 11.7 20.6 0.641 Black 9 5.3 4.2 8.3 3.2 Indigenous/Native American 9 5.3 4.2 3.3 7.9 Hispanic/Latino/Caribbean 21 12.3 8.3 15.0 12.7 Mixed 103 60.2 64.6 61.7 55.6 Region of origin United States/Spain 9 5.2 8.3 5.0 3.1 0.222 Central America and Mexico 27 15.7 8.3 21.7 15.6 South America 115 66.9 77.1 61.7 64.1 Caribbean 21 12.2 6.3 11.7 17.2 Education level Less than high school 68 39.5 45.8 46.7 28.1 0.062  HS diploma, GED, vocational school, 104 60.5 54.2 53.3 71.9 or more Total personal income before tax in past year†† < US$15,000 142 83.5 91.3 83.3 78.1 0.184 ≥US$15,000 28 16.5 8.7 16.7 21.9 Employment status Unemployed 80 46.5 45.8 51.7 42.2 0.568 Employed 92 53.5 54.2 48.3 57.8 Column percentage summed across racial groups exceeds 100% due to rounding up to first decimal point. † Reported total personal income before tax is not adjusted for cost of living in the two countries. †† Table 2 presents bivariate relationships between psychosocial, Reported Barriers and Adherence to the cultural and clinical factors, reported barriers to care, and treatment IIDEA Intervention adherence. Adherence to the intervention was not related to The association of perceived barriers to care and adherence to psychosocial or cultural factors. Those who reported at least one treatment is depicted in Table 3. Reported barriers of mistrust barrier (89.0% of the sample) had significantly higher treatment in previous treatment(s) (p = 0.007) and transportation adherence compared to those who reported no barriers (p = 0.007). or scheduling problems (p = 0.003) were both significant Moreover, those who reported three or more barriers (59.3% of the predictors of greater treatment adherence (10+ sessions vs. sample) showed higher treatment adherence compared to those who 0–1 sessions). reported zero, one, or two barriers (p = 0.004). Bivariate analyses Results of the association between barriers to care and of baseline clinical profile with treatment adherence groups (Table treatment adherence after adjusting for psychosocial, 2) showed that participants with higher scores on the HSCL-25 demographic, and clinical factors are presented in Table 4. exhibited higher adherence to the program than those with lower Participants who reported mistrust in previous treatment(s) scores (p = 0.027). The same pattern was observed for participants had significantly higher odds of completing 10–12 treatment with higher scores on the BDEPQ (p = 0.009) and ASI Alcohol (p = sessions (tercile 3) vs. 0–1 sessions (tercile 1) (OR = 3.79, 0.042). No significant associations were found regarding the other CI = [1.49,9.66]). Transportation or scheduling problems, clinical factors (e.g., PHQ-9, PCL-5, Fagerström Test). benzodiazepine dependence, discrimination, HSCL-25, and Frontiers in Psychiatry | www.frontiersin.org 5 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants TABLE 2 | Baseline barriers, social, cultural, and clinical factors and adherence to IIDEA (N = 172). Total IIDEA IIDEA IIDEA IIDEA Difference-test Sample adherence adherence adherence (n = 172) tercile 1 tercile 2 tercile 3 (0–1 sessions) (2–9 sessions) (10–12 sessions) (n = 48) (n = 60) (n = 64) n Mean/% Mean/% Mean/% Mean/% P-value Generations 1st Generation 154 90.6% 87.2% 93.2% 90.6% 0.577 2nd Generation 16 9.4% 12.8% 6.8% 9.4% Citizenship† Noncitizen 78 46.2% 45.8% 49.2% 43.6% 0.825 Citizen 91 53.9% 54.2% 50.9% 56.5% Sense of belonging† No 70 40.9% 37.5% 40.7% 43.8% 0.800 Yes 101 59.1% 62.5% 59.3% 56.3% Speak language in the host Country† No 43 25.0% 18.8% 30.0% 25.0% 0.407 Yes 129 75.0% 81.3% 70.0% 75.0% Health Literacy Scale 170 12.51 12.54 12.36 12.63 0.863 Median 13.50 13.00 13.00 14.00 Interquartile range 4.00 3.00 4.00 4.00 Discrimination Scale 171 18.02 16.67 17.87 19.17 0.284 Median 16.00 14.00 16.00 17.50 Interquartile range 9.00 9.50 8.00 11.88 Ethnic Identity Scale 171 9.44 9.42 9.47 9.44 0.987 Median 10.00 10.00 10.00 9.00 Interquartile range 3.00 2.00 3.00 3.00 Family Conflict Scale 171 2.25 1.77 2.49 2.38 0.149 Median 2.00 1.00 2.00 2.00 Interquartile range 3.00 3.00 3.00 3.00 Acculturative Stress Scale 171 3.30 2.96 2.95 3.89 0.093 Median 3.00 2.00 2.00 4.00 Interquartile range 4.00 3.50 3.00 3.50 Years in US/Spain 154 10.03 9.40 10.65 9.90 0.776 Reported barriers Number of reported barriers <3 70 40.7% 60.4% 35.0% 31.3% 0.004 ≥3 barriers reported 102 59.3% 39.6% 65.0% 68.8% Any reported barriers No 19 11.0% 22.9% 5.0% 7.8% 0.007 Yes 153 89.0% 77.1% 95.0% 92.2% Clinical factors Depression (PHQ-9) 172 10.88 9.98 10.85 11.58 0.318 Generalized anxiety (GAD-7) 172 8.53 7.19 8.97 9.13 0.081 PTSD (PCL) 172 27.19 22.88 28.87 28.86 0.113 Drug abuse (DAST) 170 1.27 1.61 1.33 0.97 0.294 Alcohol abuse (AUDIT) 172 5.20 5.52 5.33 4.84 0.577 Benzodiazepines (BDEPQ) 171 2.13 1.63 1.17 3.41 0.009 ASI Alcohol 172 0.22 0.16 0.22 0.26 0.042 ASI Drug 172 0.04 0.04 0.05 0.03 0.404 Hopkins Symptom Checklist (HSCL)‡ 140 1.55 1.37 1.46 1.78 0.027 Smoking (Fagerström) 172 0.69 0.65 1.02 0.41 0.132 Reported trauma exposure No 8 4.7% 8.3% 0.0% 6.3% 0.092 Yes 164 95.3% 91.7% 100.0% 93.8% Column percentage sum exceeds 100% due to rounding up to first decimal point. † The Hopkins Symptom Checklist was missing for 32 cases since the instrument was administrated later in the study. ‡ ASI Alcohol measures were not significantly related to treatment DISCUSSION adherence in the multinomial logistic models after adjusting for other factors. A sensitivity analysis excluding the imputed To our knowledge, this is one of the few studies to prospectively HSCL-25 instrument yielded no substantial differences in examine perceived barriers to care associated with adherence the associations between the measures of barriers to care and to culturally-adapted cognitive behavioral interventions aimed treatment adherence. at treating co-occurring mental health and substance use Frontiers in Psychiatry | www.frontiersin.org 6 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants TABLE 3 | Reported barriers to care and adherence to treatment (N = 172). Reported barrier to care: Total Treatment Treatment Treatment Chi2 test Chi2 test intervention adherence adherence adherence (tercile 2 vs. (tercile 3 vs. sample tercile 1 tercile 2 tercile 3 tercile 1) tercile 1) (n = 172) (0–1 sessions) (2–9 sessions) (10–12 sessions) (n = 48) (n = 60) (n = 64) n % % % % P-value P-value Want to handle the problem on your own No 56 32.6 39.6 23.3 35.9 0.077 0.693 Yes 115 66.9 60.4 75.0 64.1 Think the previous treatment would not work No 90 52.3 66.7 51.7 42.2 0.105 0.007 Yes 80 46.5 31.3 46.7 57.8 Received treatment before and it didn't work No 136 79.1 81.3 78.3 78.1 0.837 0.685 Yes 35 20.3 18.8 20.0 21.9 Concerned about how much money it would cost No 104 60.5 68.8 56.7 57.8 0.237 0.279 Yes 66 38.4 31.3 41.7 40.6 Concerned about what people would think if they found out you were in treatment No 98 57.0 64.6 53.3 54.7 0.279 0.292 Yes 73 42.4 35.4 45.0 45.3 Have problems with things like transportation or scheduling that made it hard to get to treatment No 126 73.3 87.5 73.3 62.5 0.094 0.003 Yes 45 26.2 12.5 25.0 37.5 Were you unsure about where to go or who to see No 93 54.1 64.6 53.3 46.9 0.279 0.063 Yes 78 45.3 35.4 45.0 53.1 Were you scared of being put in a hospital against your will No 122 70.9 79.2 68.3 67.2 0.257 0.161 Yes 49 28.5 20.8 30.0 32.8 Were you concerned that you would be treated unfairly because of your race/ethnicity No 139 80.8 79.2 81.7 81.3 0.608 0.784 Yes 32 18.6 20.8 16.7 18.8 Did you think you might not be able to communicate because of linguistic barrier No 151 87.8 85.4 91.7 85.9 0.186 0.938 Yes 20 11.6 14.6 6.7 14.1 Is there any other obstacle you encountered† No 166 96.5 97.9 95.0 96.9 0.684 0.735 Yes 5 2.9 2.1 3.3 3.1 All barrier indicators are binary variables. Row frequencies and percent for positive outcome are reported. †Other obstacles included severity of symptoms, undocumented status, and fear of discrimination due to sexual orientation. disorders among Latino immigrant populations. We did not positive association between greater severity of alcohol find differences in treatment adherence related to employment, misuse and mood symptoms and treatment completion in the gender, or educational status across groups. bivariate analysis, once we adjusted for the reported barriers Symptom severity alone did not predict adherence after and sociodemographic characteristics, the association was no accounting for barriers to care. Although we found a significant longer statistically significant. So contrary to our hypothesis, Frontiers in Psychiatry | www.frontiersin.org 7 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants TABLE 4 | Odds ratios and 95% confidence intervals from a multinomial logistic care. Fear of disclosing severe mental health symptoms is a regression model for the association between barriers to care and adherence to common phenomenon among immigrant populations because treatment (reference: treatment adherence tercile 1, or 0–1 sessions) (N = 169). of perceived risks, such as deportation and loss of employment Characteristic Treatment Treatment (53, 54). adherence tercile adherence 2 tercile 3 (2–9 sessions) (10–12 sessions) Mistrust in Prior Treatment Uniquely Think the previous treatment 2.23 3.79** Predicted Adherence wouldn't work Contrary to our expectations, individuals who reported more [0.92,5.40] [1.49,9.66] barriers had higher rates of adherence to treatment than those Have problems with things like 1.78 2.51 who reported fewer barriers. Of all the barriers assessed, mistrust transportation or scheduling that in prior treatment most strongly predicted adherence. Individuals made it hard to get to treatment [0.56,5.65] [0.79,7.93] who reported "thinking that the previous treatment would not Age group (ref: 18–34) 1 1 work" showed higher rates of completion than those not reporting [.,.] [.,.] this barrier, after adjusting for clinical factors (including severity), 35–49 0.86 0.47 discrimination, and demographic characteristics. This surprising [0.32,2.31] [0.16,1.44] finding may be due the intervention's accessibility and culturally 50+ 2.26 4.16 [0.36,14.07] [0.68,25.35] specific design. Female 1.29 1.02 The IIDEA program used several strategies to address access [0.52,3.21] [0.39,2.67] and cultural needs of Latino immigrants, including providing care Site (re: Boston) 1 1 in community-based organizations, allowing greater flexibility in [.,.] [.,.] Madrid 2.75 3.09 scheduling sessions (including nights and weekends, providing [0.64,11.72] [0.70,13.67] sessions by phone or in community settings), administering Barcelona 0.63 0.57 treatment in patients' preferred language, and using extensive [0.20,2.03] [0.17,1.92] follow-up procedures (e.g., calling before sessions). These Employment status (ref: 1 1 features, uncommon in standard treatment options, might have unemployed) [.,.] [.,.] appealed to individuals who do recognize a need for care, but Employed 0.7 0.98 previously found traditional services to be inaccessible, inflexible, [0.30,1.65] [0.40,2.42] and culturally incompetent. Benzodiazepine 0.91 1.01 Cultural matching between patients and providers is key [0.79,1.04] [0.89,1.15] in addressing the barrier of cultural mistrust in treatment, Discrimination 1 0.99 [0.94,1.06] [0.94,1.05] and the integration of these culturally competent approaches ASI Alcohol 1.46 1.72 in the IIDEA intervention may explain why participants [0.83,2.57] [0.98,3.00] with this barrier continued treatment compared to those Hopkins Symptom Checklist 1.23 1.58 without mistrust. Previous research has shown that linguistic (HSCL) matching impacts therapeutic alliance and improves quality [0.64,2.37] [0.79,3.13] Sample size for treatment 58 64 of care (55). Culturally tailored interventions have shown to adherence group improve treatment engagement and adherence among Latino Sample size for model 169 169 populations (56, 57), particularly when the adaptation utilizes **P < 0.01 (two-tailed tests). There are three cases that have at least one missing metaphors and symbols matching the patient's worldview, value and therefore are listwise deleted. The variable "ASI Alcohol" is standardized considers symptom attributions, and implicitly addresses to mean = 0 and standard deviation = 1. Multiple imputation technique with chained cultural factors (58). A meta-analysis of cultural matching equations was used to impute missing values for Hopkins Symptom Checklist (HSCL)—32 missing values were imputed. between therapists and patients (59) found that patients showed a strong preference for therapists of their own ethnicity clinical symptom severity did not significantly predict treatment and a tendency to perceive them more positively. There is also adherence after accounting for barriers to care, as reported in the possibility that participants who did not report mistrust other studies (6, 8). This finding may be due to differences in in prior services might be dropping the intervention at early our sample composition. The previous studies finding severity stages for other reasons, such as lack of time and competing of symptoms as a predictor of adherence included people with demands of childcare (60). no or low levels of symptomatology while this trial required participants in the sample to have elevated levels of psychiatric Strengths and Weaknesses of the Study symptomatology. For this group with already elevated The present study has several strengths. It highlights the symptomatology and involving co-morbidity, greater severity as importance of exploring barriers to care before initiating reported by the respondent might not independently correlate therapeutic interventions with Latino immigrants. Findings with adherence to treatment. Another potential explanation is contribute to the evidence on addressing cultural mistrust that fears of disclosing severe symptoms might lead to inaccurate and improving treatment adherence using intensive but reporting, thus making severity a noisy indicator of need for flexible community-based approaches with culturally-tailored Frontiers in Psychiatry | www.frontiersin.org 8 November 2019 | Volume 10 | Article 817 Falgas-Bague et al. Predictors of Treatment Adherence for Latino Immigrants interventions. An additional strength of the study was the wide ETHICS STATEMENT heterogeneity of Latinos (i.e., 17 different countries of origin) across the recruitment sites. The studies involving human participants were reviewed and Our study has several limitations. First, we did not assess approved by Institutional Review Board, Massachusetts General problem recognition. Some individuals with a high number of Hospital, Boston, Massachusetts, USA Institutional Review barriers to care who did not initiate treatment may be unaware of Board, University Hospital Parc Tauli-I3PT, Sabadell, Spain having a mental health or substance use problem and we would Institutional Review Board, Universitat Autonoma de Barcelona, be unable to capture them in our study. These individuals could Barcelona, Spain Institutional Review Board, CIBERSAM, drop out of treatment early, unaware of the potential benefits of Barcelona, Spain. The patients/participants provided their treatment. We acknowledge that the sample used in the analysis written informed consent to participate in this study. is relatively small and future studies should attempt to replicate the analysis with larger samples. We also recognize that cultural matching between provider and participant is often not possible AUTHOR CONTRIBUTIONS in community-based settings. We recommend that future studies MA, DV, and IF-B contributed to the conception and design of the evaluate whether ethnic and linguistic mismatch by providers and study. YW and SB organized the database and performed the statistical participants impact adherence to the intervention. Despite these analysis. IF-B and MA wrote the first draft of the manuscript. NA limitations, the study offers important insight on the importance and KD wrote sections of the manuscript. All authors contributed to of exploring barriers to treatment and tailoring interventions to manuscript revision and approved the submitted version. specific ethnic groups. FUNDING CONCLUSIONS International Latino Research Partnership. Research reported in This study provides valuable information on how mistrust in this publication was supported by the National Institute on Drug behavioral health services might influence treatment adherence Abuse (NIDA) of the National Institutes of Health under Award in an evidence-based, culturally-centered intervention for Latino Number R01DA034952. The content is solely the responsibility immigrants with co-occurring disorders. The present findings of the authors and does not necessarily represent the official support ethnic and linguistic matching between patients and views of the National Institutes of Health. providers as effective methods for tackling attitudinal barriers to behavioral health treatment. Specifically, these methods could assist Latino immigrants in overcoming cultural mistrust ACKNOWLEDGMENTS toward services and increase their adherence to treatment. Our findings also suggest that exploring barriers to treatment prior We acknowledge the contribution of the patients and clinicians to initiating treatment may allow clinicians to better address that participated in this study. Without their cooperation, the individual perceptions that treatment might not work, and study would not have been possible. Furthermore, we gratefully consequently could impact improved adherence. thank Sheri Lapatin and Lizbeth Herrera for their assistance during the study, and Isabel O'Malley for her contributions to the revisions and preparation of the manuscript. DATA AVAILABILITY STATEMENT The datasets for this manuscript are not publicly available because SUPPLEMENTARY MATERIAL it involves an ethnic minority sample including participants with substance use. 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Sweeney A, Gillard S, Wykes T, Rose D. The role of fear in mental health are credited and that the original publication in this journal is cited, in accordance service users' experiences: a qualitative exploration. Soc Psychiatry Psychiatr with accepted academic practice. No use, distribution or reproduction is permitted Epidemiol (2015) 50(7):1079–87. doi: 10.1007/s00127-015-1028-z which does not comply with these terms. Frontiers in Psychiatry | www.frontiersin.org 11 November 2019 | Volume 10 | Article 817