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Factors leading African Americans and black Caribbeans to use social work services for treating mental and substance use disorders.

Compared with white Americans, African Americans with mental disorders or substance abuse problems are less likely to receive treatment (Wells, Klap, Koike, & Sherbourne, 2001). Studies have shown that only one-third of African Americans and black Caribbeans with mental disorders use mental health services (Fiscella, Franks, Doescher, & Saver, 2002;Jackson et al., 2007). African Americans and black Caribbeans with dual diagnosis (co-occurring substance use and mental disorder) are even less likely to use any professional services (Woodward et al., 2008).

Social workers provide a wide variety of mental health services to individuals, families, and groups and are the largest group of mental health practitioners in the country (Cohen, 2003; Hartman, 1994; Robiner, 2006). They tend, however, to be considered less effective providers of mental health services than psychologists and psychiatrists, bearing the burden of association with negatively stereotyped child protective workers and homeless-services workers (LeCroy & Stinson, 2004). Because social workers' role in mental health care is potentially vital, perhaps especially so for minority groups, we need to definitively identify factors promoting minority Americans' use of social work services in mental health contexts. Following the lead of Woodward et al. (2008) in their study, we examined dually diagnosed African Americans' and black Caribbeans' use of treatment services provided by social workers.

The conceptualization of our study is rooted in the behavioral model of health services use, a framework developed by Aday and Andersen (Aday, 1993; Aday & Andersen, 1974; Andersen, 1995) that proposes indicators and predictors of health services use. For several decades now, Aday and Andersen's model has been widely incorporated in studies of adults' use of mental health services (Dhingra, Zack, Strine, Pearson, & Balluz, 2010; Gamache, Rosenheck, & Tessler, 2000; Lipsky, Caetano, & Roy-Byrne, 2011; Maulik, Mendelson, & Tandon, 2010; Nejtek et al., 2011; L. A. Schmidt, Tam, & Larson, 2012; Stockdale, Tang, Zhang, Belin, & Wells, 2007; Theriot, Segal, & Cowsert, 2003) and social work services (Moore, 1993).

The literature on how members of ethnic groups use social workers for delivery of mental health services is scant. We deemed it important to investigate how choosing to use the services of social workers for treating mental health and substance use disorders might be related to an individual's perceived need for services, belief system, family resources, proximity to services, social--structural factors, and demographic characteristics.

Under Aday's behavioral model, need for services motivates service use and the selection of a service provider; moreover, need (or perceived need) may be self-identified or may be identified by a professional (Aday, 1993). Research with samples drawn from the general population found dual diagnosis to predict receipt of mental health care or substance abuse treatment (L. M. Schmidt, Hesse, & Lykke, 2011; Watkins, Burnam, Kung, & Paddock, 2001). However, one study linked dual diagnosis solely to perceived need to use information--not to obtain professional services or medication (Meadows et al., 2002). Many who might benefit from a comprehensive treatment plan (targeting mental health and substance abuse) either deny their substance abuse or do not know about services appropriate for them (Drake et al., 2001). It is not surprising, then, that although 35 percent to 54 percent of individuals with dual diagnosis receive treatment, only 7 percent to 16 percent are treated for both substance abuse and mental disorder (Harris & Edlund, 2005). Among African Americans and black Caribbeans specifically, the dually diagnosed are less likely than those diagnosed with mental disorder alone to use either professional services or informal support (for example, from family and friends; Woodward et al., 2008). In fact, almost 25 percent of black Americans (assumed to include African Americans and black Caribbeans) having a dual diagnosis do not attend treatment (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008).

In addition to need or perceived need, cultural belief systems figure in service usage, at times posing a barrier to treatment. Within African American culture, for instance, admitting one has mental illness is sometimes viewed as a personal weakness, and this perceived stigma could deter African Americans from discussing their mental health with family members and from approaching professionals concerning services (Alvidrez, Snowden, & Kaiser, 2008; Anglin, Link, & Phelan, 2006; Conner et al., 2010). The literature also shows, however, that African Americans who feel close to their families are less likely (than those without such reefing) to use professional mental health services (Woodward, Taylor, & Chatters, 2011). Moreover, many African Americans believe that mental disorders improve on their own, without treatment (Anglin, Alberti, Link, & Phelan, 2008). In addition, studies of adults have shown that older African Americans and African American women often use prayer as a way to cope with mental disorders (Conner et al., 2010; Snowden, 2001; Ward, Clark, & Heidrich, 2009; Ward & Heidrich, 2009).

Some African Americans view mental health providers with mistrust (Alvidrez, Snowden, & Kaiser, 2010; Snowden, 2001), stemming from experiences they have had with culturally incompetent therapists (Ward et al., 2009). The prospect of involuntary or coerced treatment of a mental or substance abuse disorder actually alarms very few African Americans (Alvidrez et al., 2010), but the bias (at times outright discrimination) against minority clients that some practitioners and agencies exhibit indeed affects African Americans' use of professional services as well as, clearly, the content and quality of services used (Snowden, 2003).

Family resources also influence mental health services use and choice of service provider. Studies of the general population show that individuals with insurance benefits extending to mental health care are likelier to receive services than individuals lacking such benefits (Wang, Berglund, & Kessler, 2000). Despite the usefulness of insurance covering mental health, however, one out of five severely mentally ill people are uninsured, and 80 percent of the uninsured obtain no mental health services (Garfield, Zuvekas, Lave, & Donohue, 2011; McAlpine & Mechanic, 2000). Furthermore, over a quarter (25.8 percent) of black Americans (including both African Americans and black Caribbeans) live in poverty, and 20.9 percent are uninsured (U.S. Census Bureau, 2010b). These figures suggest that a significant proportion of this group faces financial barriers to receiving mental health and substance abuse treatment services.

Analyses of the incomes and insurance status of African Americans and black Caribbeans, however, have shown neither factor to significantly affect use of the services of professionals (Maulik et al., 2010; Woodward et al., 2008, 2011). Probably because they find available health insurance unaffordable, African Americans and black Caribbeans tend to use emergency mental health services more often than they use outpatient services (Snowden, 2001). Of those eligible for Medicaid, however, most tend to use mental health outpatient services much more often than emergency services (Chow, Jaffee, & Snowden, 2003). Obviously, public medical insurance helps impoverished members of minority groups to use regular mental health services. Still, among black people living in poverty, being involuntarily referred for mental health services is more common than voluntarily using services (Chow et al., 2003).

Using services and choosing providers are decisions influenced by an individual's proximity to mental health service facilities as well. Residing in an urban area often helps promote an individual's access to mental health services (Alegria et al., 2002). Also concerning proximity to facilities, it has been observed that lack of transportation is a significant barrier to African Americans' use of mental health services (Davis, Ressler, Schwartz, Stephens, & Bradley, 2008), including, no doubt, the services offered by social workers. Assertive outreach efforts from mental health professionals (for example, phone calls, home visits) have been advocated to help mental health clients overcome transportation barriers (Drake et al., 2001; Kelly, Merrill, Shumway, Alvidrez, & Boccellari, 2012). Because home visits and transportation assistance alike are common functions of social work services (Beder, 1998; Bikson, McGuire, Blue-Howells, & Seldin-Sommer, 2009), social workers could very readily provide assertive outreach accommodating mental health clients, including those from ethnic minorities.

Finally, social-structural factors and demographic characteristics figure in patterns of service use among African Americans and black Caribbeans, minority groups whose rates of use of formal mental health services do not differ significantly 0ackson et al., 2007; Woodward et al., 2008). African Americans and black Caribbeans with a high school education or less are likelier than their more educated peers to use informal support to address a mental health disorder (Woodward et al., 2008). African Americans and black Caribbeans most likely to use professional mental health services are young men (Chow et al., 2003) who have a high school diploma (Woodward et al., 2011). Conversely, married African Americans and black Caribbeans are less likely to use professional services (Woodward et al., 2008).

The present study hypothesized that, within the African American and black Caribbean minority groups, the choice to use mental health services provided by a social worker (versus another professional or paraprofessional) would be shaped by perceived need, belief system, family resources, proximity to services, social--structural factors, and demographic characteristics.

METHOD

Sample

The present study constituted a secondary data analysis of participants in the National Survey of American Life (NSAL), a project evaluating relationships between race and mental health. From 2001 to 2003, NSAL collected information about mental health and mental health service use from 6,199 nationally representative adults, through interviews held in person and by phone; the response rate was 71.5 percent (Alegria, Jackson, Kessler, & Takeuchi, 2008). The sample for our study included 3,562 African American NSAL participants and 1,438 black Caribbean NSAL participants.

Measures

The outcome variable using professional services included three categories of mental health service utilization: using services that involved a social worker, using services that did not involve a social worker, and using no services at all. Using services that involved a social worker described those who, because of an adulthood emotional or substance use problem, had seen either a social worker only or had seen both a social worker and another professional or paraprofessional. This category reflects the common reality, in many mental health and substance abuse service settings, of collaborative care involving social workers and medical or other professionals and paraprofessionals (NASW, 2006a, 2006b; Newhill & Korr, 2004). Using services that did not involve social workers described those who, because of an adulthood emotional or substance use problem, had seen a professional or paraprofessional provider who was not a social worker. (Examples are medical professionals, psychiatrists, psychologists, clergy members, counselors, and faith healers.) Using no services at all served as the reference category in our study.

We used six groups of explanatory variables: perceived need, belief system, family resources, proximity to services, social--structural factors, and demographic characteristics. The three dichotomous (yes-no) variables we used to represent need for mental health services or substance abuse treatment were (1) dual diagnosis, (2) substance use disorder alone, and (3) mental disorder alone. The reference group comprised individuals never diagnosed with any substance use or mental disorder in adulthood. Dual diagnosis indicated a person diagnosed in adulthood with both substance dependence or abuse (the substance being nicotine, alcohol, or other drugs) and a mental disorder. Substance use disorder only described a person diagnosed (in adulthood) with substance dependence or abuse alone. Mental disorder only described a person diagnosed (in adulthood) with a mental disorder but not a substance use disorder. In surveying respondents about their mental health, NSAL researchers used the Diagnostic Interview Schedule to identify 33 DSM-IV-TR disorders (Alegria et al., 2008; Robins, Helzer, Croughan, & Ratcliff, 1981) on which the need-for-services variable was based. Like the NSAL researchers, we used the variable overall mental health to further represent perceived need for services; the variable was measured through individuals' self-ratings of their overall mental health, with responses ranging from I (poor) to 5 (excellent).

We used two variables to describe belief system: (1) stigma of treatment use and (2) racial discrimination. Stigma of treatment use was dichotomous and indicated whether a person reported not using mental health or substance abuse services for fear of others' reactions to his or her receiving services. The racial discrimination variable indicated whether a person reported having experienced discrimination in daily life that he or she attributed to race. This variable was measured with 10 items featuring offered responses that ranged from 1 (never) to 6 (almost every day). Examples are "You are treated with less respect than other people"; "People act as if they're better than you are"; and "You receive poorer service than other people at restaurants or stores." Higher scores suggested relatively frequent experience of racial discrimination, The Cronbach's alpha for the 10 items was .94.

Family resources were represented in the study by three dichotomous variables: (1) welfare receipt, (2) insured by medical insurance, and (3) coverage for mental health care. Welfare receipt indicated whether a person reported receiving public assistance; a "yes" response, then, signified low family income and sparse resources. Insured by medical insurance indicated whether a person was insured through an employer-sponsored medical insurance program or government medical insurance program (for example, Medicare, Medicaid, the Civilian Health and Medical Program of the Uniformed Services, or Veterans Affairs). Coverage for mental health care indicated whether the person's medical insurance extended to mental health care.

NSAL did not collect information on where respondents resided. We were able, however, to use the yes-no variable transportation problem to represent (by proxy) respondents' proximity to services. A "yes" response for this variable indicated that a respondent reported encountering a problem finding transportation to treatment.

Social--structural factors in our study described racial background (African American, black Caribbean) and educational level. During the data analysis, black served as the reference group for racial background. Educational level was represented by three dummy variables, college graduate, some college education, and high school graduate; the reference group was high school dropout. Demographic variables included in the present study were age (in years), male (yes-no), and married (yes-no). Married indicated a respondent who was married or cohabiting; the reference group comprised widowed, separated, divorced, and never-married individuals.

Limitations

One limitation was our study's reliance on the variable transportation problem as a proxy measure for proximity to services (provided by social workers or others). A second limitation we faced was the makeup of the sample: The majority of the African Americans and black Caribbeans participating in NSAL reported not receiving welfare and having both medical insurance and workable transportation options. This suggests that their financial resources were relatively ample, compared with the black population in general (U.S. Census Bureau, 2010b). That is, although the sample we used was indeed nationally representative, it nevertheless tended toward relative affluence (as well as adequate education). Therefore, generalizing of results beyond this sample should be undertaken cautiously.

Data Analysis

In light of the outcome variable's three categories, we performed multinomial logistic regression using STATA (Aldrich & Nelson, 1984; Hosmer & Lemeshow, 1989; Menard, 1995). Furthermore, our data analysis included use of a sampling weight provided with the NSAL data set. Preliminary analyses of tolerance statistics and correlations suggested there was no obvious multicollinearity problem, Our model's statistical significance was determined by the likelihood-ratio test statistic (G) between the null and hypothesized models, with subsequent analytical focus placed on each explanatory variable's statistical significance in relation to each outcome category. The odds ratio, [e.sub.b] (greater or less than 1), indicated whether the probability of a particular outcome increased or decreased with each unit increase in the explanatory variable.

RESULTS

Of the 5,000 respondents, 2.7 percent had used services from social workers, 21.4 percent had used services from other professionals or paraprofessionals; 76 percent had not used services at all (see Table 1). Dual diagnosis was reported by 5.5 percent; a further 2.9 percent reported having a diagnosis of substance use disorder only, while 28.9 percent reported having a diagnosis of mental disorder only. The large majority, 62.7 percent, reported no diagnosis during adulthood. The participants on average viewed their overall mental health as very good (measuring 3.9 on our five-point scale). Only 0.5 percent of participants reported believing a stigma attached to using mental health service providers. The average measure of experienced racial discrimination was 17.4 out of a possible 60. Slightly over 6 percent of the participants reported receiving welfare benefits. The majority of the sample, 76.3 percent, had medical insurance; for 56 percent, that insurance covered mental health care. As for racial background, over 71 percent of participants were African American, with about 29 percent being black Caribbeans. Concerning education, 16.7 percent of respondents were college graduates, 23.9 percent had some college education, 35.7 percent were high school graduates, and 23.7 percent had not graduated from high school. The average age of a member of the sample was 42.5 years; 36.6 percent of the sample were male, and 36.7 percent were married.

Multivariate analysis results confirmed that the hypothesized model (G = -2,476.89, p < .01) differed from the null model to a statistically significant degree (see Table 2). Likelihood of using services involving a social worker increased significantly in the presence of a dual diagnosis ([e.sup.b] = 35.12, p < .01), a substance use disorder diagnosis only ([e.sup.b] = 9.10, p < .01), or a mental disorder diagnosis only ([e.sup.b]= 13.78, p < .01). Moreover, such likelihood was negatively associated with a person's overall mental health ([e.sup.b] = 0.61, p < .01). Although a belief in stigma attaching to treatment increased the chance of using services from a social worker significantly ([e.sup.b] = 4.14, p < .01), racial discrimination made no significant impact. Welfare receipt ([e.sup.b] = 2.02, p < .05) and having insurance coveting mental health services ([e.sup.b] = 2.48, p < .01) were associated positively with likelihood of using the services of a social worker; conversely, medical health insurance status was not associated significantly with such use. Transportation problem and racial background were like insurance status in showing no significant impact on likelihood of using services involving a social worker. Having a college degree made one likelier ([e.sup.b] = 2.46, p < .01), in this study, to use services involving a social worker; no significant impact was observed for any other educational level. Whereas older people ([e.sup.b] = 1.01, p < .05) were likelier than younger ones to use services involving a social worker, neither gender nor marital status significantly affected using services involving a social worker.

Using services involving another professional or paraprofessional was significantly more likely in the presence of dual diagnosis ([e.sup.b] = 22.81, p < .01), of a substance use disorder diagnosis only ([e.sup.b] = 8.42, p < .01), of a mental disorder diagnosis only ([e.sup.b] = 10.91, p < .01), and of deteriorating mental health ([e.sup.b] = 0.70, p < .01). Although belief in a stigma had no significant impact on likelihood of using services from another professional, experienced racial discrimination ([e.sup.b] = 1.01, p < .05) increased that likelihood. Although receiving welfare and medical insurance status showed no significant impact on likelihood of using services from another professional, having coverage for mental health services ([e.sup.b] = 1.86, p < .01) did promote such service use. Neither transportation barriers nor race was significantly associated with likelihood of using services from another professional. College graduates ([e.sup.b] = 1.64, p < .01) and respondents with some college education ([e.sup.b] = 1.55, p < .01) were more likely than high school dropouts to use services from another professional. Women ([e.sup.b] = 0.52, p < .01) were likelier than men to use services from a professional other than a social worker, but neither age nor marital status affected such likelihood significantly.

DISCUSSION

Our study successfully identified some factors associated with whether African Americans and black Caribbeans experiencing mental health or substance use disorders choose to use services provided by social workers. It showed that very few within these groups use such services. The observed low rate of use of social work services echoes an apparent public perception that social work intervention's effectiveness is low compared with that of other services (LeCroy & Stinson, 2004). The African Americans and black Caribbeans in our sample probably perceived social work unfavorably. However, one limitation of our study stemmed from the original survey's lack of items concerning respondent choice of a social worker rather than another professional (or vice versa) to provide services. That is, we could not know which type of professional services a respondent would have chosen had all types been available. Therefore, we must be cautious in making inferences about unfavorable perceptions of social workers.

Of our sample, 37.2 percent had been diagnosed with a mental or substance use disorder, and 24 percent had sought services for a disorder at some point in their adult lives; that is, over one-third (35.5 percent) of those diagnosed as ill did not get services. Yet even this rate of underutilization of mental health services is merely half that reported by two previous studies (Fiscella et al., 2002; Jackson et al., 2007). A plausible explanation for such a discrepancy is that the earlier studies focused on mental health service use in the preceding 12 months only, whereas we measured service use throughout adulthood.

Results from our multivariate analysis were sufficient to explain relationships between using services that involved a social worker and the six variable groups (perceived need, belief system, family resources, proximity to services, social-structural factors, and demographic characteristics). We also measured these variable groups' relationships to using services that did not involve a social worker. The findings confirmed that perceived need (that is, diagnosis of mental or substance use disorder) and perceived deterioration of mental health were associated with greater likelihood of using a professional service of some kind. Analysis of our data also showed that 75.5 percent of respondents having a disorder or disorders nevertheless reported being in good, very good, or excellent mental health (results not included in tables). This is a contradictory finding, one suggesting respondents either were "in denial" concerning their diagnoses or had underestimated the seriousness of their disorders; denying and minimizing both are potential responses to the stigmatization of mental disorder (Alvidrez et al., 2008; Conner et al., 2010). In addition, all three types of diagnosis we measured appeared to have a greater effect on the choice to use social work services than on the choice to use services from other professionals. Our study found that an individual with a dual diagnosis was 2.5 times likelier than one with a mental disorder alone to use services provided by a social worker. Social workers, then, according to our study, are important to multidisciplinary efforts providing comprehensive services to the mentally ill, especially where the dually diagnosed are concerned. Prior studies' results have implied the same (NASW, 2006a, 2006b; Newhill & Korr, 2004).

Our study also found that belief in a stigma attaching to treatment significantly increased the likelihood of using social work services for treatment. At the same time, such a belief failed to significantly affect service use outside social work. This finding contradicts the widely accepted idea that stigma hinders African Americans from using mental health services (Alvidrez et al., 2010; Anglin et al., 2006). In our study, only an extremely small percentage (0.5 percent) of the surveyed African Americans and black Caribbeans reported that stigma was a barrier to choosing to access mental health or substance use services. It is plausible that minority individuals who view the use of professional services to be stigmatized are more comfortable consulting social workers than other professionals or that they consult social workers because of court mandates to do so.

Our study found that experiencing racial discrimination was not significantly related to using social work services but did significantly raise the likelihood of consulting other professionals. This result may be attributable to social work education programs' emphasis on diversity training and cultural competence training, intending to diminish racial discrimination's role as a barrier to service use (Council on Social Work Education, 2008).

Although our results showed that welfare recipients were relatively likely to use services from social workers, receipt of welfare was not significantly associated with using services from other professionals. An important implication is that low-income African Americans and black Caribbeans tend to use social work services. In addition to their financial difficulties, many welfare recipients face problems involving psychological distress, mental health, substance use, domestic violence, housing, or court proceedings (Cheng, 2007; Eamon & Wu, 2011; Morgenstem et al., 2003). Moreover, according to the literature, individuals receiving welfare or Medicaid tend to obtain only short-term treatment when they have a mental health problem (Pavetti, Derr, Kauff, & Barrett, 2010).

Like several earlier studies (Maulik et al., 2010; Woodward et al., 2008, 2011), our study found no association between medical insurance coverage and the use of professional services of either type; consistent with one earlier finding (Wang et al., 2000), we also found that having coverage extending to mental health care did promote use of both types of professional services, although the association was strongest for social work services. Generally speaking, mentally ill persons who lack mental health insurance benefits are unlikely to use professional services. Where those enrolled in welfare programs are concerned, these results are no surprise: Medicaid covers the typical welfare recipient and provides mental health benefits. However, just 56 percent of our sample had Medicaid-type mental health benefits. For some individuals, then, lack of medical insurance extending to mental health care clearly poses a barrier to service use.

Our study also demonstrated that college education promoted service use within and outside social work; just as with mental health insurance benefits, though, a stronger association was observed for use of social work services. Over 60 percent of our sample had some college education; in another sample of black Americans (including both African Americans and black Caribbeans), 48 percent had some college education (U.S. Census Bureau, 2010a). This suggests that our sample comprised relatively well-educated individuals. Nevertheless, the unexpected relationship we observed between education and using the services of social workers calls for further research.

Our study also observed age and gender to be significantly associated with service use outside social work, although similar significant associations were not seen concerning the use of social work services. These results, too, may be attributable to the emphasis social work education has placed on diversity training and cultural competence training in recent decades (Council on Social Work Education, 2008).

CONCLUSION AND IMPLICATIONS

Our study indicated clear, strong associations between using the services of social workers and the variables dual diagnosis, mental disorder alone, substance use disorder alone, stigma of treatment use, welfare receipt, and coverage of mental health care. Moreover, it indicated that a low rate of use of professional services may lead to further deterioration of mental health, as does the underestimation of a disorder's seriousness. A distinct implication of such findings is that social work educators must sufficiently prepare social work students to serve dually diagnosed clients as well as those with single diagnoses. Moreover, social work students need preparation in how to collaborate efficiently with other kinds of professionals to care for clients.

Because clients who use the services of social workers may well perceive the services to be stigmatized, social workers should be skilled at ensuring that clients "work through" initial resistance (for example, denial, rationalization) or negative self-image. Collaborative engagement and empowerment are tools suited to the purpose, but the task also requires understanding the impact of race--ethnicity, gender, and age. This means that social work education programs must continue to emphasize diversity and cultural competence, along with services for poor and underserved populations.

To help overcome negative stereotypes of the child protective worker and homeless-services worker specifically, a national multimedia campaign might present accurate images of professionals in social work competently helping clients in various settings (NASW, 2012). Social work agencies might disseminate such images at the local level by publicizing available services and sharing success stories with the media. Special effort will be required among African Americans and black Caribbeans to foster use of professional services offered by social workers and others. One step should be to involve both African American and black Caribbean clients, as well as stakeholders in their communities, in the development of psychoeducational materials. Such involvement will help ensure that the materials are culturally relevant to patients and their families (Alvidrez et al., 2010). With the support of, for instance, African American religious institutions, effective psychoeducation could usefully inform communities about mental health, substance abuse, available services, and local resources. Furthermore, acknowledging the importance to clients of supportive relationships with their families and friends, professional providers of mental health interventions should join forces, where possible, with these sources of informal support to the ill and addicted. Enhanced social networks should be one of the goals of intervention (Woodward et al., 2008).

Our study showed that the lack of mental health insurance coverage is, for African Americans and black Caribbeans, a serious barrier to using needed professional services. Such coverage remains limited compared with other medical coverage, even after two decades of improvement (Barry et al., 2003; Gitterman, Sturm, Pacula, & Scheffler, 2001). Therefore, the advocacy of a patients' bill of rights, of generous coverage options, and of expanded eligibility for full Medicaid benefits remains a responsibility of the social work profession (and social workers) (Garfield, Lave, & Donohue, 2010; Garfield et al., 2011; Gitterman et al., 2001); the cause will be furthered by similar advocacy within African American and black Caribbean communities.

Future research might delve more directly into links between the location of respondents' residences and their use of social work services. It might also examine the consequences, for mental health, of low rates of service use and even delayed service use; public awareness of these consequences could potentially increase usage rates. Finally, future research might examine how well current strategies to reduce the stigmatization of mental illness are working within the African American and black Caribbean communities and how those strategies might be strengthened.

doi 10.1093/hsw/hlt005

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Tyrone C. Cheng, PhD, LCSW, PIP, is associate professor, School of Social Work, University of Alabama, 118 Little Hall, Box 870314, Tuscaloosa, AL 35487; e-mail: ccheng@ sw.ua.edu. Michael A. Robinson, PhD, LGSW, is assistant professor, School of Social Work, East Carolina University, Greenville, NC.

Original manuscript received February 8, 2012

Final revision received July 11, 2012

Accepted July 20, 2012

Advance Access Publication May 9, 2013
Table 1: Descriptive Statistics for Outcome and Explanatory Variables

Variable Percent Average

Outcome
Using services that involved a social worker 2.7
Using services that did not involve a social worker 21.4
Using no services at all 76.0
Explanatory
Dual diagnosis 5.5
Substance use disorder alone 2.9
Mental disorder alone 28.9
No diagnosis 62.7
Overall mental health 3.9
Stigma of treatment use
 Yes 0.5
 No 99.5
Racial discrimination 17.4
Welfare receipt
 Yes 6.1
 No 93.9
Insured by medical insurance
 Yes 76.3
 No 23.7
Coverage for mental health care
 Yes 55.7
 No 44.3
Transportation problem
 Yes 0.5
 No 99.5
African American 71.2
Caribbean Black 28.8
College graduate 16.7
Some college education 23.9
High school graduate 35.7
High school dropout 23.7
Age (years) 42.5
Male 36.6
Female 63.4
Married
 Yes 36.7
 No 63.3

Variable Minimum Maximum

Outcome
Using services that involved a social worker
Using services that did not involve a social worker
Using no services at all
Explanatory
Dual diagnosis
Substance use disorder alone
Mental disorder alone
No diagnosis
Overall mental health 1 5
Stigma of treatment use
 Yes
 No
Racial discrimination 10 60
Welfare receipt
 Yes
 No
Insured by medical insurance
 Yes
 No
Coverage for mental health care
 Yes
 No
Transportation problem
 Yes
 No
African American
Caribbean Black
College graduate
Some college education
High school graduate
High school dropout
Age (years) 18 94
Male
Female
Married
 Yes
 No

Table 2: Multinomial Logistic Regression
Results for Using Services That Did and Did
Not Involve a Social Worker (N = 5,000)

 Using Services Using Services
 That Involved That Did Not
 Social Worker Involve Social
Variable (e (b)) Worker (e (b))

Dual diagnosis
 (no diagnosis) 35.12 ** 22.81 **
Substance use
disorder alone
 (no diagnosis) 9.10 ** 8.42 **
Mental disorder
 alone (no
 diagnosis) 13.78 ** 10.91 **
Overall mental health 0.61 ** 0.70 **
Stigma of treatment
 use (no) 4.14 * 0.75
Racial discrimination 1.01 1.01 *
Welfare receipt (no) 2.02 * 1.03
Insured by medical
 insurance (no) 1.65 1.02
Coverage for mental
 health care (no) 2.48 ** 1.86 **
Transportation
 problem (no) 1.09 0.85
African American
 (black Caribbean) 1.27 1.13
College graduate
 (high school
 dropout) 2.46 * 1.64 **
Some college
 education (high
 school dropout) 1.63 1.55 **
High school graduate
 (high school
 dropout) 1.05 1.10
Age 1.01 1.02 **
Male (female) 0.94 0.52 **
Married (no) 0.79 0.93

Note: Reference categories are in parentheses. G=-2476.89 **.
* p .05. ** p < .01.
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Author:Cheng, Tyrone C.; Robinson, Michael A.
Publication:Health and Social Work
Article Type:Report
Geographic Code:1USA
Date:May 1, 2013
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