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

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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.

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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 a , Jeanie Ashby b , Jennifer Tabler a , Maziar M Nourian a , Ha Ngoc Trinh a , c , Jason Chen a , and Justine J Reel d

a University of Utah, Salt Lake City, Utah; b Maliheh Free Clinic, Salt Lake City, Utah; c Vietnam National University, Hanoi, Vietnam; d University of North Carolina Wilmington, Wilmington, North Carolina

ABSTRACT

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 pro-blems, 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.

KEYWORDS

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

CONTACTAkiko Kamimura akiko.kamimura@utah.edu Department of Sociology, University of Utah, 380 S

1530 E, Salt Lake City, UT 84112.

costs; drug use can also negatively affect brain function However, it is impor-tant 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 impor-tance of subsimpor-tance 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 com-monly 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 do not receive any funding from the government (Darnell,2010) The majority of free clinic patients are unin-sured 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

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 relation-ship 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 recruit-ment strategies, and interpretation of study results The clinic provides free health-care services, including mostly routine health maintenance and pre-ventive care, for uninsured individuals who live below the 150th percentile federal poverty level and do not have access to employer-provided or govern-ment-funded health insurance The clinic has an on-site laboratory and phar-macy 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 orga-nizations and is funded by nongovernmental grants and donations The clinic

is open 5 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

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 3 months (from January 12, 2015 to April 22, 2015) using

a self-administered paper survey All survey materials, including the ques-tionnaire, consent cover letter, and flyer, were available in both English and Spanish Questions regarding alcohol, drug, and tobacco use were trans-lated 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 poten-tial participant expressed interest in participating in the study, he or she received a consent form, cover letter, and a self-administered paper-and-pen survey Hard-copy surveys were administered individually in a face-to-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

levels of risk of drug-related problems: 0 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 sta-tus (i.e., pick one from “current smoker,” “have not smoked for the past 6 months,” “quit more than 6 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 3 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 partici-pant 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 unexpect-edly?”) 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 cut-off 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 0 ¼ not at all to 3 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 2 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 mini-mal (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

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”)

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 chi-square 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 1 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

¼40.8, 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

than 60% of the participants (n ¼ 330, 65.5%) reported that they were Hispanic, Latino, or Latina Approximately 20% of the participants (n ¼ 103,

20.4%) self-identified as White The majority of Spanish speakers were

His-panic/Latino/Latina (n ¼ 249, 95.4%), while approximately 70% of U.S.-born English speakers (n ¼ 84, 68.9%) were White Forty-four percent of the part-icipants (n ¼ 222) had some college or higher levels of education U.S.-born English speakers (n ¼ 73, 59.8%) had higher levels of education than non-U.S.-born English speakers (n ¼ 56, 46.3%) and Spanish speakers (n ¼ 93, 35.6%; p < 01) Half of the participants (n ¼ 252, 50%) had full- or part-time employment Nearly half of the participants were married (n ¼ 231, 45.8%) Although more than half of non-U.S.-born English speakers (n ¼ 67, 55.4%) and Spanish speakers (n ¼ 137, 52.5%) were married, only 22.1%

Table 1. Sociodemographic characteristics, substance use experience, perceived stress, and depression of participants.

Total (N ¼ 504)

U.S.-born English speakers

(n ¼ 122)

Non-U.S.-born English speakers

(n ¼ 121)

Spanish speakers

(n ¼ 261)

p

value

Race/Ethnicity

Years in the United States

(non-U.S.-born only)

Interest in smoking

cessation education

Note Values represent number (%) or mean (SD); p value denotes significance from Pearson’s chi-square

tests between categorical variables (for cell size � 5 only) and ANOVA tests for continuous variables comparing U.S.-born English speakers, non-U.S.-born English speakers, and Spanish speakers.

a

The percentage is among participants who had drug use experience.

b

Higher scores indicate higher levels of perceived stress; F ¼ 13.7; score range 0–40.

c

Higher scores indicate higher levels of depression; F ¼ 12.8; score range 0–27.

N.S ¼ Not significant.

(n ¼ 27) of U.S.-born English speakers were married One fourth of the part-icipants (n ¼ 126) were born in the United States Non-U.S.-born partpart-icipants

represented 46 countries from Latin America, Pacific Islands, the Middle East, Africa, Western and Eastern Europe, and Asia Of the non-U.S countries

represented, Mexico had the largest number of participants (n ¼ 200, 52.9%

of the non-U.S.-born participants), followed by Tonga (n ¼ 28, 7.4% of the non-U.S.-born participants), and Peru (n ¼ 18, 4.8% of the non-U.S.-born

participants) (Data on the country of origin is not shown in the table) On average, non-U.S.-born participants lived in the United States for 15.1 years

(SD ¼ 9.1) Approximately 40% of the participants (n ¼ 206, 40.9%) had been

a patient of the clinic for 2 years or longer

Prevalence of alcohol problems, drug use, tobacco smoking

Approximately 10% of the participants (n ¼ 49, 9.7%) reported a total score

of 2 or greater on the CAGE questionnaire, which indicates having had alcohol problems There was no significant difference among the three

groups Approximately half of the participants (n ¼ 254, 50.4%) reported at

least one drug use experience The percentage was higher among U.S.-born

English speakers (n ¼ 94, 77%) than among the non-U.S.-born English speak-ers (n ¼ 53, 43.8%) and Spanish speakspeak-ers (n ¼ 107, 41%; p < 01) Among

those participants who reported a total score of 1 or greater, more than

80% (n ¼ 209) had a total score of only one or two; that is, a low level of drug

use Thirty-three participants (13%) reported moderate drug use Eleven part-icipants (4.3%) reported substantial levels of drug use Nearly 70% of the

participants had never smoked (n ¼ 340, 67.5%) The percentage of

indivi-duals who had never smoked was higher among non-U.S.-born English

speak-ers (n ¼ 91, 75.2%) and Spanish speakspeak-ers (n ¼ 194, 74.3%) than among U.S.-born English speakers (n ¼ 55, 45.1%; p < 01) The prevalence rate of current smoking was 11.7% (n ¼ 59) U.S.-born English speakers (n ¼ 38, 31.1%)

showed a higher incidence of current smoking than did non-U.S.-born

Eng-lish speakers (n ¼ 8, 6.6%) and Spanish speakers (n ¼ 13, 5%; p < 01) Approximately 6% of all participants (n ¼ 32, 6.3%) indicated that they were

interested in smoking cessation education More than 10% of the participants

(n ¼ 65, 12.9%) were exposed to secondhand smoke more than three times a

week The percentage of secondhand smoke exposure was higher among

U.S.-born English speakers (n ¼ 31, 25.4%) than among non-U.S.-U.S.-born English speakers (n ¼ 14, 11.6%) and Spanish speakers (n ¼ 20, 7.7%; p < 01).

Stress and depression

U.S.-born English speakers reported the highest level of perceived stress (mean ¼ 20.1, SD ¼ 7.3), followed by non-U.S.-born English speakers

(mean ¼ 18.0, SD ¼ 5.5), and Spanish speakers (mean ¼ 16.3, SD ¼ 6.3;

p < 01) U.S.-born English speakers reported the highest level of depression

(mean ¼ 10.8, SD ¼ 7.4, moderate depression), followed by non-U.S.-born English speakers (mean ¼ 8.2, SD ¼ 6.1, mild depression), and Spanish

speakers (mean ¼ 7.0, SD ¼ 6.2, mild depression; p < 01).

Predictors of perceived stress and depression

Table 2presents predictors of perceived stress and depression Alcohol prob-lems were significantly associated with higher levels of perceived stress

(p < 01) and depression (p < 01) Participants who had never smoked reported lower levels of perceived stress (p < 05) and depression (p < 01) U.S.-born (p < 01) and non-U.S.-born (p < 05) English speakers reported

higher levels of perceived stress compared to Spanish speakers

Discussion

This study examined 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 The study illustrates three main findings First, the overall prevalence of substance use among free clinic patients was not high compared to the U.S general population Second, U.S.-born English speakers reported a higher prevalence rate of tobacco smoking (both current and lifetime) and experiences with drug use than

Table 2. Predictors of perceived stress and depression (N ¼ 504).

U.S.-born English speakersc

Note The p value denotes significance from multivariate regression analysis.

aHigher scores indicate higher levels of perceived stress.

bHigher scores indicate higher levels of depression.

c

Reference category is Spanish speakers.

N.S ¼ Not significant.