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. Author manuscript; available in PMC: 2011 Feb 1.
Published in final edited form as: Alcohol Clin Exp Res. 2009 Nov 24;34(2):262–271. doi: 10.1111/j.1530-0277.2009.01089.x

The role of ethnic matching between patient and provider on the effectiveness of brief alcohol interventions with Hispanics

Craig Field *, Raul Caetano **
PMCID: PMC2827200  NIHMSID: NIHMS156552  PMID: 19951297

Abstract

Background

Evaluating the effectiveness of treatments such as brief alcohol interventions among Hispanics is essential to effectively addressing their treatment needs. Clinicians of the same ethnicity as the client may be more likely to understand the culture specific values, norms and attitudes and, therefore, the intervention may be more effective. Thus, in cases in which Hispanic patients were provided intervention by a Hispanic clinician improved drinking outcomes were expected.

Methods

Patients were recruited from an urban Level I Trauma following screening for an alcohol related injury or alcohol problems. Five hundred and thirty seven Hispanics were randomly assigned to brief intervention or treatment as usual. Hierarchical linear modeling was used to determine the effects of ethnic match on drinking outcomes including volume per week, maximum amount and frequency of five or more drinks per occasion. Analyses controlled for level of acculturation and immigration status.

Results

For Hispanics who received BMI, an ethnic match between patient and provider resulted in a significant reduction in drinking outcomes at 12 month follow up. In addition, there was a tendency for ethnic match to be most beneficial to foreign born Hispanics and less acculturated Hispanics.

Conclusion

As hypothesized, an ethnic match between patient and provider significantly enhanced the effectiveness of brief intervention among Hispanics. Ethnic concordance between patient and provider may have impacted the effectiveness of the intervention through several mechanisms including cultural scripts, ethnic specific perceptions pertaining to substance abuse and ethnic specific preferred channels of communication.

Keywords: Brief Intervention, Hispanics, Ethnic Matching, Acculturation, Immigration Status

INTRODUCTION

The empirical support for brief alcohol interventions in the medical care setting is fairly robust. Numerous clinical trials have demonstrated that brief interventions in the medical care setting are effective at decreasing alcohol consumption and its consequences (Bien et al., 1993; Burke et al., 2003; Burke et al., 2004; Moyer et al., 2002). These studies have predominately been conducted using non-minority samples or have neglected the effectiveness of such interventions among racial and ethnic minority populations. One criticism of empirically supported treatments including brief alcohol interventions is the inadequate representation of ethnic/racial minorities (Atkinson et al., 2001; Bernal & Scharron-del-Rio, 2001; Chambless et al., 1996; Hall, 2001; Hohmann & Parron, 1996; Miranda et al., 2005; Munoz & Mendelson, 2005; Vera et al., 2003). Moreover, interventions found to be effective in one population cannot be assumed to be equally effective among ethnic minorities (Marin et al., 1995).

One strategy for promoting the empirical foundation of existing interventions is to apply a standard intervention to a specific ethnic/racial group without significant modifications (Lopez et al., 2002). With this in mind, a randomized controlled trial of a brief intervention based on motivational interviewing was conducted to assess the effectiveness of this intervention across Whites, Blacks and Hispanics. The results of this trial indicated that brief intervention did not significantly reduce average volume consumed per week, maximum amount consumed in one day or percent days heavy drinking among Whites or Blacks (Field et al., In Press). In contrast, brief intervention significantly reduced drinking outcomes among Hispanics at six and 12 month follow-up (Field et al., In Press).

The findings from the parent study have important implications because Hispanics, report higher rates of heavy drinking and alcohol related problems (Caetano et al., 1998; Galvan & Caetano, 2003) than other minority groups. In comparison to non-Hispanics, Hispanics have higher rates of alcohol related consequences such as driving while intoxicated (Caetano & Clark, 1998a; Caetano & Clark, 1998b; Galvan & Caetano, 2003) and lifetime arrests for driving under the influence of alcohol (Caetano & Clark, 2000). Life course studies further suggest that alcohol problems are more stable over time among Hispanic men in comparison to Whites and that, once they experience problems, they are more susceptible to developing new problems (Caetano & Kaskutas, 1995; Caetano & Kaskutas, 1996). Given the growth of the Hispanic population and the their increased risk for developing alcohol related problems, evaluating the effectiveness of treatments such as brief alcohol interventions in this population is essential to effectively addressing this health disparity (Atkinson et al., 2001; Bernal & Scharron-del-Rio, 2001).

A number of studies have shown that level of acculturation and birthplace are associated with increased drinking, alcohol problems and other mental health problems among Hispanics (Balls-Organista et al., 2002; Caetano & Medina-Mora, 1988; Markides et al., 1990). Increased acculturation to US society often results in more liberal drinking norms and attitudes. (Black & Markides, 1993; Caetano, 1997; Caetano & Medina-Mora, 1988; Markides et al., 1990). As a result, highly acculturated Hispanics have lower rates of abstention and increased drinking and alcohol-related problems (Caetano, 1987a, c; Caetano & Medina-Mora, 1988; Neff et al., 1987; Markides et al., 1988; Markides et al., 1990). With regard to birthplace, U.S.-born Hispanics have a higher likelihood of reporting driving under the influence of alcohol than their foreign-born counterparts (Caetano & Clark, 2000; Caetano & McGrath, 2005). Grant et al. (2004) reported that Mexican Americans born in the U.S. had higher rates of abuse (16% versus 9.1%) and dependence (14.5% versus 6.2%) than those who were foreign born. Thus, when considering the potential influence of alcohol treatment and intervention among Hispanics it is important to take into account both the level of acculturation and immigration status.

Another factor that may explain the effectiveness of brief intervention with Hispanics reported above is the environment in which the intervention took place or the manner by which the intervention was administered. In particular, ethnic matching between client and therapist is one of the factors to be considered. Previous studies show that Hispanics are likely to be more comfortable when matched with therapists similar to them culturally (Casa et al., 2002; Vasquez, 2007). Clinicians of the same ethnicity of the client may be more likely to understand the culture specific values, norms and attitudes and, therefore, the intervention may be more effective (Comas-Diaz, 2006; Marin, 1989; Marin et al., 1995; Peterson & Marin, 1988; Vasquez, 2007). Further, ethnic matching between patient and provider may facilitate intervention among immigrants who may be distrustful and less likely to discuss their alcohol use with Non-Hispanics (Vasquez, 2007). Recruiting and engaging Hispanics necessitates some cultural adaptation of the intervention including providing care in settings that that they are more likely to use and feel safe, and providing care in the preferred language of the patient (Miranda et al., 2005; Whaley & Davis, 2007).

Unfortunately, the effect of patient - provider matching has not been addressed in a randomized controlled trial using an evidenced based treatment such as brief opportunistic interventions in a medical care setting. Thus based on findings from the main study, it is hypothesized that an ethnic match between patient and provider would facilitate treatment outcomes following brief intervention as a function, in part, of cultural scripts. That is, in cases in which Hispanic patients were provided intervention by a Hispanic clinician improved drinking outcomes were expected. Because acculturation to US society and birthplace are risk factors for heavier alcohol use and alcohol problems and these risk factors are also closely related to potential responses to ethnic matching between provider and patient, the analysis controls for the influence of these patient characteristics.

Methods

Study Recruitment

Patients were recruited from an urban Level I trauma center between May, 2003 and May, 2005. Written informed consent was obtained by study clinicians following medical stabilization and prior to discharge from the hospital. All subjects had to demonstrate orientation to person, place and time and adequate recall of recent and remote events prior to obtaining written informed consent. Subjects were compensated $25 for the baseline assessment and $50 for the six and twelve month follow up assessments. The study was approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center at Houston and the Institutional Review Board of the hospital where data were collected. A certificate of confidentiality from the National Institute on Alcohol Abuse and Alcoholism was also obtained to protect patient confidentiality.

Screening and Enrollment

Because the primary aim of the study was to evaluate potential ethnic differences in the effectiveness of a brief motivational intervention among injured patients, sampling was limited to patients who identified themselves as Black, White or Hispanic. The current study is limited to an examination of the Hispanics recruited for participation in this study (n=537).

Patients were excluded from participation for the following reasons: 1) they were less than 18 years of age 2) they spoke neither English nor Spanish 2) they had no identifiable residence 3) they were under arrest or in police custody at the time of admission or during their hospital stay 4) they were judged by the trauma care or research staff to be actively suicidal or psychotic 5) they were victims of sexual assault or 6) had a medical condition that precluded a face-to-face interview. Patients who were intoxicated at the time of their injury or presented with a Glasgow Coma Scale (GCS) ≤ 14 were monitored by research staff for inclusion in the study. Patients with a GCS ≤ 14 that did not resolve prior to discharge were not eligible for screening or enrollment.

Twenty four hour, seven day per week coverage was not feasible and, therefore, patient recruitment was limited to Thursday through Monday from 9 am to 6 pm. Recruitment during prior studies conducted at this trauma center as well as the implementation phase of this study suggested that these hours were the most efficient times to screen and enroll patients, and (Field, et al, 2001, Field, et al., 2004). To minimize the impact of screening procedures on medical care, a sequential screening process was employed. e.g., subsequent screening procedures were only implemented if the patient screened negative on prior screening criteria. Screening consisted of four sequential criteria: 1) Clinical indication of acute intoxication or alcohol use or positive BAC; 2) self reported drinking 6 hours prior to injury; 3) at risk drinking per NIAAA guidelines (e.g., 7 drinks/week women, 14 drinks/week men; more than 4 drinks/day in men; more than 3 drinks/day in women; NIAAA, 2005) or 4) positive on one or more items of the CAGE (Ewing, 1984; Kitchens, 1994). An assessment of the screening procedures including strengths and limitations has been discussed elsewhere (Field, Caetano, Pezzia, 2008).

Treatment as Usual with Assessment (TAU+) and Assessment with Brief Motivational Intervention (BMI)

Patients were randomized to either treatment as usual with assessment (TAU+) or an assessment with Brief Motivational Intervention (BMI) using a permuted block design (block size 6) to ensure approximately equal distribution of patients according to their race/ethnicity. Treatment assignment was generated off site and was provided to study clinicians in sealed opaque envelopes. To reduce interviewer bias, study clinicians were blinded to patient randomization prior to completion of the baseline assessment. All patients, regardless of treatment assignment received information regarding hospital and community services relevant to the injured patient. This information included, but was not limited to, substance abuse treatment and self help groups and the availability of drug and alcohol counselors. Information pertaining to hospital and community resources relevant to the care of injured patients was also provided. All patients were also provided handouts regarding the effects of alcohol, defition of at risk drinking and strategies to quite or cut down.

Treatment as Usual with Assessment (TAU+)

Following the initial assessment, all patients assigned to TAU+ were provided patient handouts. This was consistent with general practice for treating patients with alcohol problems at the Level 1 trauma center at the time the clinical trial was conducted.

Brief Motivational Intervention (BMI)

Brief Motivational Intervention (BMI) with injured patients has been described elsewhere (Dunn, Hungerford, Field, McCann, 2005; Field, Hungerford, Dunn, 2005). In short, brief intervention is based on motivational interviewing and the primary components consist of acknowledging the patients responsibility for changing drinking, encouraging the patient to explore pros and cons of drinking, assessing importance, confidence and readiness to change drinking behavior, reinforcing patient’s sense of self-efficacy, and providing support for any efforts or intention to quit drinking or reduce harm associated with drinking including injury. Following BMI, patients were provided the handouts described above. This information was either provided by request of the patient or was given to the patient with their permission (e.g., per the guidelines of motivational interviewing).

Training and Supervision

Clinicians were master’s level or degreed and were certified in brief intervention following the successful completion of training. All clinicians received 3 days of training in Motivational Interviewing from a trainer in the Motivational Interviewing Network of Trainers. In addition, clinicians received two days of training regarding the application of Motivational Interviewing principles in the trauma care setting from a trainer in the Motivational Interviewing Network of Trainers. Successful completion of the certification process required submission of three audio taped interventions with clients which exceeded threshold proficiency as indicated by coding on the Motivational Interviewing Skill Code v1.0. Ten percent of interventions were randomly selected to be audio taped. Clinicians were required to submit an audio tape at least once per month. In all, 113 of the 736 intervention were taped and coded using the Motivational Interviewing Skill Code v1.0. The mean of the Global Therapist Rating (M=5.8, SE=.08), Reflection to Question Ratio (M=1.6, SE=.13), Percent Open Questions (M=.55, SE=..02), Percent Complex Reflections (M=.41, SE=..02) and Percent MI Consistent (M=.97, SE=1.3) behaviors counts were determined from the MISC ratings. With the exception of the percent of complex reflections in which some audio tapes were below threshold proficiency (>40%), the means and 95% CI indicated that therapist behaviors were at or above the threshold or expert proficiency levels.

Assessment

Patients who qualified for the study and agreed to participate were interviewed by research staff as soon after consent as possible. The interview took approximately 30–40 minutes. The assessment including items related to socioeconomic status, consumption, ethnicity and acculturation.

Ethnic identification

Respondents who identified themselves as “black of Hispanic origin (Latino, Mexican, Central or South American, or any other Hispanic origin)” and “white of Hispanic origin (Latino, Mexican, Central or South American, or any other Hispanic origin)” were classified as Hispanic. Respondents also identified their national origin. However, the small number of participants in Hispanic national groups other than Mexican Americans precludes an analysis by national origin. Ethnic identification of providers was also determined through self report using identical procedures. An ethnic match was considered present when patients and providers were both of Hispanic Origin.

Acculturation

The scale is built from 12 questions covering the following information: daily use of and ability to speak, read and write English and Spanish; preference for media (books, radio and T.V.) in English or Spanish; ethnicity of people with whom respondents interacted at church, at parties, and in the neighborhood respondents live in now and while growing up, and finally a series of questions about values thought to be characteristic of the Hispanic life style. With the exception of the items used to assess language use, all other items are coded in a 4-point Likert (strongly agree to strongly disagree) scale. The scale’s reliability was assessed with Cronbach’s Alpha (0.91) and the split-half method (.87, Guttman split-half coefficient). The scale correlates positively with being U.S. born (.58) and with number of years of life in the U.S. (.22), and correlates negatively with age (−.36). It also has positive correlations with drinking and alcohol problems. All these correlations are in the expected direction and empirically confirm the scale’s construct validity. Respondents’ scores on the scale were divided into three groups representing low, medium and high levels of acculturation. The cut off points for these groupings were based on results from previous national household surveys of Hispanics in which 33% of the respondents were categorized in each group. The level of acculturation of the providers who described themselves as Hispanic was not determined due to restrictions imposed by the Institutional Review Board.

Alcohol Use

Since intentional and unintentional injuries have been found to depend on patterns of drinking in addition to average volume of alcohol consumption (Rehm et al., 2003), several measures of alcohol consumption were assessed at intake and follow-up. Quantity and frequency of alcohol consumption was determined at baseline, six and twelve month follow up using a graduated frequency which assess frequency of intake of combined alcohol with seven quantity levels and eight frequency levels in descending order (Greenfield, 1998; Greenfield, 2000; Hilton, 1989; Midanik, 1994; Rehm et al., 1999). This is a preferred method that reduces underreporting of alcohol consumption and is used in standardized national alcohol surveys (Greenfield, 2000). One standard drink was defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard liquor (Dawson, 2003). Weekly alcohol volume was calculated using the basic quantity/frequency approach (Dawson, 2003) by multiplying usual quantity of drinks per occasion by frequency of drinking. In addition, the maximum number of standard drinks consumed in one day was determined by asking, “Now think of all kinds of alcoholic beverages combined, that is, any combination of beer, wine, or liquor. During the past 12 months, what was the largest number of drinks that you had in a single day?” For maximum amount consumed in one day response categories were not provided. Finally, the frequency of drinking five or more per at baseline, six and 12 month follow up was determined by asking, “During the past 12 months, how often did you have five or more drinks of any kind of alcoholic beverage at one time (that is, any combination of cans of beer, glasses of wine, or drinks containing liquor of any kind)? Respondents were provided nine response categories indicating various frequencies of this drinking behavior in descending order including never, one to five times per year, six to 11 times per year, one time per month, two or three times per month, one or two times per week, three or four times per week, nearly everyday and everyday.

Follow Up Assessment

Research staff blind to treatment assignment conducted follow up assessments by telephone at six and 12 months. Of patients eligible, 324 or 60% of Hispanics completed six month follow up and 262 or 49% completed 12 month follow up. Hispanics (OR=.59, 95% CI=.43–.83) were significantly less likely to complete 6 month follow up. There were no significant predictors of loss to follow up at 12 months. Among Hispanics, participants who were U.S. born were significantly less likely to be lost to follow up at 6 and 12 months (OR=.44, 95% CI=.27–.71; OR=.44 95% CI=.28–.72, respectively). Neither treatment assignment nor level of acculturation were significant predictors of loss to follow up among Hispanics.

Statistical Analysis

Longitudinal analyses were conducted using hierarchical linear modeling (HLM) of drinking outcomes with random effects for subject and time within subject using HLM version 6.06 (Raudenbush & Bryk, 2002; Raudenbush et al., 2004). Volume per week and maximum amount were log transformed. Frequency of five or more per occasion was treated as a continuous variable from zero to eight. Analyses controlled for age, gender, employment status, marital status, education, baseline alcohol use, prior alcohol treatment, type of injury and injury severity. HLM was used to model the effects of treatment, ethnicity and covariates of interest on change in drinking outcomes from baseline to the six and twelve month follow-up. Because preliminary analysis indicated clearly nonlinear time paths, time was categorical, with dummy variables indicating the contrasts between baseline and 6 month follow-up and between baseline and 12 month follow-up. These time effects for changes in drinking outcomes were dependent on intervention, immigration status and level of acculturation of the patient, ethnic match between patient and provider, an interaction between patient – provider ethnic match and brief intervention other covariates described above.

The analyses were conducted in stages by first 1) examining the effect of intervention, immigration status and level of acculturation, 2) then the main effect of ethnic match was included and 3) finally the interaction between patient – provider match on ethnicity and intervention. The effect size and magnitude of change are reported when intervention is significant. The observed effect sizes were calculated by dividing the difference between the observed mean changes for TAU+ and BMI by the pooled standard deviation (Rosnow & Rosenthal, 1996). Effect sizes ranged from small (approximately d=.20) to medium (d=.50) (Cohen, 1988).

RESULTS

Hispanics make up 36% of the total sample recruited for participation in this study. The final sample of Hispanic patients randomized to TAU+ or BMI consisted of 537 Hispanics. Forty seven percent (n=253) of the Hispanic population identified Spanish as their preferred language and were interviewed by a bilingual clinician who also conducted the brief alcohol intervention in Spanish following randomization. Table 1 presents the demographic characteristics of the Hispanic patient population. Throughout the study period there were nine providers conducting assessment and intervention. Six of the providers identified themselves as Hispanic and conducted 70% of the assessments or assessment and interventions (depending upon random assignment to treatment as usual plus assessment or brief motivational intervention) with Hispanic patients. There was an ethnic match between patient and provider for 71% of the 259 brief motivational interventions.

Table 1.

Demographic Characteristics

N %
Total Enrolled 537
Age 29 (9)*
Male 475 88.5
Marital Status
 Single, Never Married 254 47.3
 Married or Cohabitating 179 33.3
 Separated, Divorced or Widowed 104 19.4
Education
 More than High School 68 12.7
 High School or GED 120 22.3
 Less than High School 349 65.0
Employed for Wages 414 77.1
Language Preference
 English 286 53.3
 Spanish 251 46.7
US Born 246 45.8
Years in US* 18 (13)
Acculturation
 Low 184 34.3
 Medium 172 32.0
 High 181 33.7
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*

mean (standard deviation)

Volume per Week

Table 2a shows changes in volume per week across time by treatment group and presence or absence of an ethnic match between patient and provider. As observed in Table 2b, Brief Motivation Intervention (BMI) was significant at 12 month follow up (Step 1). Hispanics who received BMI drank significantly less on average in comparison to Hispanics who did not receive BMI (d12=.13). Foreign born Hispanics were significantly less likely to drink more on average at 12 months than their US born counterparts (p=.01). In addition, Hispanics who were less acculturated drank significantly less on average at six and 12 month follow up than highly acculturated Hispanics (p6=.02 and p12=.004, respectively). A priori planned contrast also indicated that less acculturated Hispanics drank less on average at 6 and 12 month follow up than Hispanics with a medium level of acculturation (p6=.04 and p12=.006; Results not shown).

Table 2.

Table 2a Volume per week at Baseline and Follow up as a function of treatment assignment and ethnic match
BMI TAU+
Baseline 6 Months 12 Months Baseline 6 Months 12 Months
Ethnic Match 16.5 (20.4) 6.5 (14.2) 6.6 (16.9) 14.3 (21.0) 6.9 (12.9) 10.5 (22.9)
No Ethnic Match 16.0 (26.6) 7.6 (13.6) 8.9 (15.3) 18.7 (42.3) 8.8 (17.2) 8.9 (14.3)
Table 2b Effect of Ethnic Match between patient and provider on Volume Per Week
Step 1
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.38 .22 .08§ −.57 .23 .02†
Immigrant Status* −.30 .28 .28 −.75 .30 .01‡
Low Acculturation** −.75 .32 .02† −.97 .33 .004‡
Medium Acculturation** −.13 .27 .64 −.05 .29 .86
Step 2
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.38 .21 .08§ −.58 .23 .01‡
Immigrant Status* −.22 .29 .44 −.54 .31 .09§
Low Acculturation** −.70 .32 .03† −.82 .34 .02†
Medium Acculturation** −.10 .27 .71 .03 .30 .91
Ethnic Match −.23 .27 .38 −.63 .29 .03†
Step 3
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.02 .38 .97 .16 .40 .69
Immigrant Status* −.23 .29 .42 −.55 .32 .08§
Low Acculturation** −.70 .32 .03† −.82 .34 .02†
Medium Acculturation** −.15 .28 .60 −.07 .30 .80
Ethnic Match .03 .35 .94 −.07 .37 .85
Ethnic Match X Intervention −.52 .47 .27 −1.15 .50 .02†
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*

Reference: US Born

**

Reference: High Acculturation

§

p≤.10

†

p≤.05

‡

p≤.01

In step 2, an ethnic match between patient and provider was significantly associated with volume per week at 12 months (p=.03). BMI, immigration status and low acculturation remained significant after controlling for an ethnic match between patient and provider. No main effect was observed for an ethnic match between patient and provider at 6 month follow up.

Even after controlling for an interaction between intervention and ethnic match between patient and provider (Step 3), the effect of low acculturation remained significant at six and 12 month follow up (p6=.03 and p12=.02, respectively). For Hispanics who received BMI, an ethnic match between patient and provider resulted in a significant reduction in average amount consumed per week at 12 months (p=.02).

Frequency of Five or More Drinks Per Occasion

Table 3a shows changes in frequency of five or more per occasion across time by treatment group and presence or absence of an ethnic match between patient and provider. As observed in Table 3b, BMI was significantly associated with less frequent heavy drinking (i.e., five or more per occasion) among Hispanics at 12 months (Step 1). Hispanics who received BMI drank five or more per occasion significantly less often than Hispanics who did not receive brief intervention (d12=.23). Hispanics who were less acculturated also drank five or more drinks per occasion less frequently at 12 months than highly acculturated Hispanics (p=.04). A priori contrast also indicated that less acculturated Hispanics drank less on the heaviest drinking day at 12 month follow up than Hispanics with a medium level of acculturation (p12=.02; Results not shown).

Table 3.

Table 3a Frequency of Five or More per Occasion at Baseline and Follow up as a function of treatment assignment and ethnic match*
BMI TAU+
Frequency of Five or More Baseline 6 Months 12 Months Baseline 6 Months 12 Months
Ethnic Match Never 2 (1.1) 53 (53.0) 41 (54.7) 1 (.5) 38 (35.8) 29 (34.9)
1–11x/yr 24 (13.0) 16 (16.0) 16 (21.3) 34 (17.9) 32 (30.2) 19 (22.9)
1x/month 35 (18.9) 12 (12.0) 7 (9.3) 28 (14.7) 11 (10.4) 6 (7.2)
2–3x/month 29 (15.7) 12 (12.0) 7 (9.3) 49 (25.8) 18 (17.0) 22 (26.5)
1 or 2x/wk 64 (34.6) 1 (1.0) 1 (1.3) 54 (28.4) 4 (3.8) 5 (6.0)
3–4x/wk 18 (9.7) 3 (3.0) 1 (1.3) 15 (7.9) 1 (0.9) 0 (0)
Nearly Everyday/Everyday 13 (7.0) 3 (3.0) 2 (2.7) 9 (4.7) 2 (1.9) 2 (2.4)
No Ethnic Match Never 0 (0) 24 (44.4) 16 (33.3) 0 (0) 24 (46.2) 18 (36.7)
1–11x/yr 25 (32.9) 9 (16.7) 12 (25.0) 22 (28.2) 11 (21.1) 11 (22.4)
1x/month 8 (10.5) 6 (11.1) 6 (12.5) 11 (14.1) 4 (7.7) 9 (18.4)
2–3x/month 11 (14.5) 9 (16.7) 9 (18.8) 18 (23.1) 7 (13.5) 6 (12.2)
1 or 2x/wk 15 (19.7) 4 (7.4) 2 (4.2) 13 (16.7) 4 (7.7) 3 (6.1)
3–4x/wk 12 (15.8) 1 (1.9) 1 (2.1) 5 (6.4) 2 (3.8) 2 (4.1)
Nearly Everyday/Everyday 5 (6.6) 1 (1.9) 2 (4.2) 9 (11.5) 0 (0) 0 (0)
Table 3b Effect of Ethnic Match between patient and provider on Frequency of Five or More per Occasion
Step 1
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.33 .21 .12 −.52 .23 .02†
Immigrant Status* −.31 .27 .25 −.44 .29 .14
Low Acculturation** −.47 .31 .13 −.67 .33 .04†
Medium Acculturation** .21 .27 .43 .21 .28 .47
Step 2
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.33 .21 .12 −.53 .23 .02†
Immigrant Status* −.22 .28 .43 −.33 .31 .29
Low Acculturation** −.41 .31 .19 −.59 .33 .08§
Medium Acculturation** .23 .27 .38 .24 .29 .40
Ethnic Match −.26 .26 .32 −.33 .28 .24
Step 3
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment .10 .38 .79 .12 .39 .75
Immigrant Status* −.23 .28 .41 −.33 .31 .28
Low Acculturation** −.41 .31 .19 −.59 .33 .08§
Medium Acculturation** .18 .27 .51 .15 .29 .61
Ethnic Match .05 .35 .87 .16 .37 .66
Ethnic Match X Intervention −.63 .46 .17 −1.0 .49 .04†
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*

Frequency (Percent)

*

Reference: US Born

**

Reference: High Acculturation

§

p≤.10

†

p≤.05

‡

p≤.01

In step 2, no main effect was observed for ethnic match at either 6 or 12 month follow up. After controlling for an interaction between brief intervention and an ethnic match between patient and provider (Step 3), an ethnic match between the patient and provider resulted in less frequent heavy drinking at 12 months (p=.04) among Hispanics receiving BMI.

Maximum Amount Consumed in One Day

Table 3a shows changes in maximum amount consumed in one day across time by treatment group and presence or absence of an ethnic match between patient and provider. As observed in Table 3b, BMI significantly reduced the maximum amount consumed in one day at six and 12 month follow up (p6=.006 and p12=.003, respectively). Hispanics who received BMI drank significantly less on their heaviest drinking day than Hispanics who did not receive BMI at six and 12 months (d6=.27 and d12=.28, respectively). Foreign born Hispanics consumed significantly less on the heaviest drinking day than their US born counterparts at 12 month follow up (p=.001). In addition, Hispanics who were less acculturated drank significantly less on the heaviest drinking day at 6 and 12 month follow up than highly acculturated Hispanics (p6=.02 and p12=.001, respectively). A priori contrast also indicated that less acculturated Hispanics drank less on the heaviest drinking day at 12 month follow up than Hispanics with a medium level of acculturation (p12=.03; Results not shown).

In step 2, no significant main effect was observed for ethnic match at either 6 or 12 month follow up. After controlling for an ethnic match between patient and provider, the effect of low acculturation remained significant at 6 and 12 month follow up (p6=.02 and p12=.03, respectively).

After controlling for an interaction between brief intervention and an ethnic match between patient and provider (Step 3), the effect of low acculturation remained significant at 6 and 12 month follow up (p6=.02 and p12=.03, respectively). For Hispanics who received BMI, an ethnic match between the patient and provider had a marginally significant effect on frequent heavy drinking at 12 months (p=.08).

DISCUSSION

Between 1990 and 2003, the Hispanic population rose from about 9.1% (22 million) to 13.4% (39 million) making Hispanics the largest ethnic minority group in the United States (US Census Bureau, 2003a). By 2050, current census projections predict that the number of Hispanics in the United States will double to more than 25% of the total US population (US Census Bureau, 2003b). Mexican Americans constitute about 60% of the US Hispanic population and are currently the largest Hispanic subgroup. This underscores the importance of the studies findings indicating that brief opportunistic interventions in the trauma care setting are effective among Hispanics, leading to significant reductions in alcohol use patterns that have been associated with intentional and unintentional injuries (Rehm et al., 2003). Findings further suggest that lower levels of acculturation and foreign birth are associated with greater reductions in alcohol use among Hispanics. Most importantly, brief intervention was significantly more effective when the intervention was conducted by a Hispanic provider independent of acculturation and immigrant status. Providing culturally adapted interventions by matching the ethnicity of the patient and provider and providing intervention in the preferred language of the patient appears to enhance the effectiveness of brief motivational interventions in the medical setting among Hispanics. Further adaptation and tailoring of brief interventions in this underserved population may further enhance drinking outcomes.

Ethnic concordance between patient and provider may have impacted the effectiveness of the intervention through several mechanisms including cultural scripts, ethnic specific perceptions pertaining to substance abuse and ethnic specific preferred channels of communication. Inattention to these differences may lead to misunderstandings between Hispanics and Non-Hispanics and thereby, influence treatment outcomes (Trandis et al., 1984). Comas-Diaz (2006) discussed how these interactions may be more likely to lead to “missed empathic opportunities.” Cultural scripts are patterns of social interaction that are a core characteristic of a particular cultural group (Trandis et al., 1984). More than being indicative of personal values, cultural scripts are values and beliefs that characterize a particular culture or ethnic group (Marin & Gamba, 2003). As a result, the potential impact of attending to these cultural scripts and cultural norms likely extends beyond empathy, which is a core component of interventions based on Motivational Interviewing(Miller & Rollnick, 2002). In contrast to interventions based on motivational interviewing, in the treatment as usual condition there was no opportunity to convey appreciation and understanding of cultural scripts through the use of reflections, communication of empathy or examination of personal values.

Among Hispanics two important cultural scripts are “simpatia” and “familism” (Sabogal et al., 1987; Trandis et al., 1984). Through “simpatia” individuals show their ability to share in other’s feelings, to behave with dignity and respect toward others, and to strive for harmony in interpersonal relations(Trandis et al., 1984). This latter characteristic implies a general acquiescence and a tendency to anticipate positive social interactions. Similarly, and perhaps more important to the context in which this study was carried out, Hispanic patients have shown greater willingness to adhere to the advice of medical professionals who are overwhelmingly perceived as one the most credible sources of information (Marin et al., 1989; Marin G & Marin BV, 1990). These tendencies may have influenced the overall responsiveness of the patient to the intervention and lead to improved drinking outcomes.

“Familism” is another core value in the Hispanic culture and family-related consequences associated with substance abuse have been found to be of central concern to Hispanics. Hispanics more often indicate willingness to talk with family members regarding alcohol problems (Marin BV et al., 1990; Marin BV, Marin G & Juarez, 1990; Sabogal et al., 1987). Hispanics also believe they would be less embarrassed to talk about these issues and more strongly believe the relative using substances would follow the advice given (Marin BV et al., 1990). Familism may have contributed to the likelihood that additional social support would have been provided to Hispanics and that Hispanics would have been more likely to follow the advice of family members. Additional social support such as this has been suggested as an important potential mechanism of change in alcohol treatment, especially for Hispanics (Arroyo et al., 1998; Gentilello et al., 1999).

Cultural scripts including simpatia and familism tend to be strongest among foreign born Hispanics and less acculturated patients (Marin & Gamba, 2003; Sabogal et al., 1987). The perceptions of US born Hispanics and highly acculturated patients tend to resemble those held by non-Hispanic Whites, both of which differ significantly from those held by immigrants and less acculturated Hispanics (Marin, 1996; Marin G & Marin M, 1997). Characteristics which are commonly ascribed to Hispanics including 1) a present time orientation that values a focus on here-and-now activities, 2) cultural emphasis on harmony in interpersonal relationships 3) a strong value for respect or deference and obedience for authority figures 4) desires for interpersonal warmth in social relations 5) preference for a group or familial orientation rather than an individualistic orientation and 6) a strong loyalty, attachment and solidarity with family members are likely stronger among immigrants and less acculturated Hispanics (Balcazar et al., 1995; Marin, 1996; Marin G & Marin M, 1997). Among less acculturated Hispanics and immigrants, these characteristics, which are closely associated with simpatia and familism, may have positively influenced drinking outcomes independent of the effect of brief intervention or ethnic matching between patient and provider during brief intervention.

Despite the potential clinical significance of the current findings, there are several limitations to the current study that should be taken into account. Follow up rates were significantly lower at six months among Hispanics in comparison to their non-Hispanic counterparts. Six month follow up was less likely among foreign born Hispanics. However, foreign born Hispanics who were randomly assigned to BMI were no more likely to be lost to follow up than those randomly assigned to TAU+. In addition, because the study took place in the trauma care setting, the current sample is predominately younger males. Additionally, the current sample consists of primarily Mexican born and Mexican - American Hispanics. These limitations should be kept in mind when interpreting the findings from this study and evaluating the potential generalizability of the current findings.

With regard to the observed findings and potential influence of cultural scripts as an underlying mechanism of change explaining the effect of ethnic matching, the following is worth noting. First, the assignment of Hispanic and non-Hispanic patients to Hispanic and non-Hispanic providers was not experimentally manipulated. Second, the study did not include a culturally adapted version of brief intervention. Third, the current study did not directly measure the use of cultural scripts. Finally, the current study does not take into account direct observation of therapist or client behavior and potential ethnic differences. Future research should account for these factors in the study design to better appreciate this potential mechanism of change among Hispanics.

While Hispanics are more likely to drink excessively and more prone to experience problems associated with at risk drinking, they are less likely to receive adequate treatment or intervention (Boyd-Ball, 2003; Galvan & Caetano, 2003; Schmidt et al., 2006). Despite these disparities, alcohol treatment often appears to be as successful for minority patients (Schmidt et al., 2006; Tonigan, 2001; Tonigan, 2003). The provision of brief intervention in medical settings such as the trauma care system provides unique opportunities to effectively intervene in this underserved population. The current findings hold significant promise for reducing alcohol problems among Hispanics using culturally tailored brief motivational interventions in the medical setting. It is worth noting that, while it has been suggested that simply including more ethnic/racial minority patients in research is one form of cultural adaptation (e.g., Chambless et al., 1996; Hohmann & Parron, 1996), these improvements in drinking outcomes were observed with relatively modest adaptations to the intervention. However, the current findings suggest that practical adaptations of evidenced based interventions including availability of Spanish speaking providers trained in brief intervention based on motivational interviewing, ethnic matching of patient and provider and the provision of care in a medical setting outside of a substance abuse treatment context may enhance treatment outcomes among Hispanics. Improvements in drinking outcomes among Hispanics may be a function of cultural scripts. Additional adaptations which specifically take into account cultural scripts among Hispanics may further enhance treatment outcomes. Significant adaptations in terms of delivery, therapeutic process, and inclusion of cultural knowledge, attitudes and behavior may lead to increased effectiveness of empirically supported treatments among ethnic-minorities such as brief interventions based on Motivational Interviewing (Atkinson et al., 2001; Miranda et al., 2005; Munoz & Mendelson, 2005; Vera et al., 2003). Training in cultural competence may further influence treatment effectiveness and may preclude the need for ethnic matching between the patient and provider. Additional research into culturally adapted evidenced based interventions among Hispanics and other ethnic minorities is clearly warranted (Whaley & Davis, 2007). Such investigations are likely to lead to more culturally competent services, improvements in treatment outcomes, increased access to formal treatment and increased involvement in self help groups such as Alcoholics Anonymous.

Table 4.

Table 4a Maximum Amount Consumed at Baseline and Follow up as a function of treatment assignment and ethnic match
BMI TAU+
Baseline 6 Months 12 Months Baseline 6 Months 12 Months
Ethnic Match 16.2 (11.1) 6.1 (7.2) 5.7 (7.6) 14.3 (9.2) 8.2 (7.8) 8.1 (7.7)
No Ethnic Match 13.6 (11.6) 6.2 (5.8) 7.2 (5.9) 14.6 (12.3) 8.5 (10.0) 9.2 (9.7)
Table 4b Effect of ethnic match between patient and provider on Maximum Amount Consumed in One Day
Step 1
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.36 .13 .006‡ −.43 .14 .003‡
Immigrant Status* −.27 .17 .10 −.61 .18 .001‡
Low Acculturation** −.44 .19 .02† −.52 .20 .01†
Medium Acculturation** −.17 .17 .30 −.18 .18 .31
Step 2
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.36 .13 .006‡ −.44 .18 .002‡
Immigrant Status* −.29 .18 .10§ −.49 .19 .009‡
Low Acculturation** −.45 .19 .02† −.44 .21 .03†
Medium Acculturation** .18 .17 .29 −.13 .18 .46
Ethnic Match .04 .16 .82 −.34 .17 .05§
Step 3
6 months 12 months
Coefficient Std Error p value Coefficient Std Error p value
Treatment −.13 .23 .59 −.10 .24 .69
Immigrant Status* −.29 .18 .10§ .51 .19 .008‡
Low Acculturation** −.45 .19 .02† −.44 .21 .03†
Medium Acculturation** −.21 .17 .22 −.18 .18 .32
Ethnic Match .21 .22 .33 −.08 .23 .73
Ethnic Match X Intervention −.35 .29 .23 −.53 .30 .08§
Open in a new tab
*

Reference:US Born

**

Reference: High Acculturation

§

p≤.10

†

p≤.05

‡

p≤.01

Acknowledgments

This work was supported by a grant (R01 013824; PI: Caetano) from the National Institute on Alcohol Abuse and Alcoholism to the University of Texas School of Public Health

The lead author would like to acknowledge the support of the NIH Health Disparities Loan Repayment Program funded by the National Center of Minority Health and Health Disparities

Footnotes

Clinical Trial Registration: NCT00132262

Work carried out at: University of Texas School of Public Health, Dallas Regional Campus, 5323 Harry Hines Blvd., V8.112, Dallas, Texas 75390-9128

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