Engagement and premature dropout among Latinx and non-Latinx White patients in a cognitive-behavioral intervention for anxiety
Previous research suggests that there are disparities in mental health service use, and specifically treatment engagement, between Latinx and their non-Latinx counterparts. These disparities in engagement include not only service use (typically defined as past-six month, or past-year service use), but continued participation in psychotherapy following the initial uptake of services, including premature dropout. Although a number of factors have been shown to influence Latinx service use, there is a dearth of research on reasons for ethnic disparities in premature dropout. This dissertation examines reasons for differential premature dropout in a sample of 96 Latinx and 257 non-Latinx White patients receiving cognitive-behavioral therapy for anxiety disorders in primary care. Study 1 utilized Andersen’s Behavioral Model of Health Service Use as a theoretical framework to examine whether individual level pretreatment factors mediate the relationship between ethnicity and premature dropout. Most individual level factors did not explain ethnic disparities in premature dropout, with the exception of low levels of social support and high levels of somatization. Studies 2 and 3 aimed to examine the predictive power of time-varying treatment-specific factors. Study 2 examined the extent to which patient understanding of CBT principles early in treatment explains the relationship between ethnicity and therapeutic engagement. Early CBT understanding mediated the relationship between ethnicity and premature dropout. Early CBT understanding was also associated with other engagement outcomes, including homework adherence, and patient commitment to therapy in the whole sample. Study 3 examined whether anxiety severity and rate of anxiety symptom change over the course of treatment differentially influenced time to dropout between Latinx and non-Latinx White patients. Change in symptoms throughout treatment and their interaction with baseline symptom severity did not explain ethnic differences in time to dropout. Overall, individual characteristics and symptom levels at pretreatment and over the course of treatment did not explain ethnic disparities in premature dropout, with the potential exception of social support and somatization. However, early patient understanding of CBT principles may be an important and understudied factor in predicting premature dropout. Results from this dissertation highlight a need for the measurement and examination of broader cultural and environmental factors in understanding Latinx engagement in psychosocial interventions.