Utilizing an Ecomap to Visualize the Impact of Social Determinants of Health in an Interprofessional Forum.

INTRODUCTION: Graphical representations of a case study can help learners recognize how systems and institutions impact health. The impact of the social determinants of health (SDoH) on individual and community health is well established, yet it may be challenging for students to visualize the impact of these components within a case study. PURPOSE: This study explored the use of ecomaps in an interprofessional forum and examined the perceptions from students and faculty regarding use of this educational tool. METHODS: This tool was assessed over two semesters, Fall 2021 (n=968) and Fall 2022 (n= 835) to evaluate student and faculty perceptions of the use of the tool along with faculty's assessment of student completion of the tool within a rubric. RESULTS: Nearly all students (99%) came prepared to the forum and presented their ecomaps to others during the small group discussion to facilitate conversation as they explored the role of SDoH related to the case study. Both students and faculty rated the use of this tool favorably. DISCUSSION: In conclusion, ecomaps were viewed favorably by both students and faculty. This visual exploration of SDoH helps students to visualize both positive and negative factors that impact a patient's experience.

Adaptation of the All Aspects of Health Literacy Scale (AAHLS) for Karen refugees: factor analysis.

Health literacy has been identified as a significant predictor of healthcare utilization among refugee and immigrant communities. Considering its potential impact on their health outcomes, accurately measuring levels of health literacy among limited English proficiency (LEP) populations is an important area of investigation. This study examined the psychometric properties of a modified version of the All Aspects of Health Literacy Scale (AAHLS), based on Nutbeam's model of health literacy, using an exploratory factor (EFA) and confirmatory factor (CFA) analysis among a sample of Karen refugees, an ethnic minority group from Burma. Results of the EFA confirmed a 3-factor model in our sample. CFA results indicated good model fits, demonstrating a promising use of the AAHLS in assessing health literacy among Karen refugees. The findings of this study support the validity of using this measure among this population and suggest some necessary adjustments to incorporate factors unique to the refugee experience that may affect the interpretation and application of items in the AAHLS. Further replication using other LEP samples is necessary to confirm the psychometric properties of the AAHLS and its ability to assess health literacy using Nutbeam's theoretical model of health literacy.

Social Determinants of Mental Health Among Karen Refugees from Burma.

Extant literature has documented a higher level of mental health issues among refugee populations compared with that of the general population. Mental health problems may significantly decrease refugees' quality of life and interfere with a successful transition to their country of resettlement. Using the social determinants of mental health framework, we examined factors affecting psychological distress among Karen refugees from Burma residing in a mid-size city in a northeastern state in the United States. A total of 201 participants completed face-to-face interviews conducted in the Karen language. Results showed that trauma and religious participation were positively associated and education and health status were negatively associated with psychological distress. The findings of this study reiterate the importance of trauma and health conditions to mental health and suggest potential points of interventions among the resettled Karen refugees.

"Mental Health Is for Crazy People": Perceptions and Barriers to Mental Health Service Use among Refugees from Burma.

Good mental health is essential to successful integration for refugee populations that resettle in the U.S. We explored perceptions of mental illnesses and barriers to mental health service use as well as solutions to current mental health problems from the perspective of refugees. The interviews with a convenience sampling of 11 community leaders (6 men and 5 women) from various Burmese ethnic communities revealed three major categories, including sources of mental illnesses (e.g. traumatic experiences and post-resettlement challenges), barriers to service use (e.g. lack of understanding about mental health, linguistic challenges, cultural stigma, alternative treatments, and unresponsive system), and proposed community solutions (e.g. community education, culturally-competent providers, and beyond mental health treatment). The findings suggest that the ethnic community can be a source of potential solutions to mitigate barriers to mental health service use.

Simple contents and good readability: Improving health literacy for LEP populations.

Accessing and receiving quality healthcare in an unfamiliar health system is a significant challenge for many new immigrants and refugees. This study aims to provide a three-phase model to develop a web-based health information website that helps populations with limited English proficiency (LEP) increase health literacy and improve healthcare service access. METHOD: First, we conducted a needs assessment from community leaders and service providers. Second, we developed contents from credible sources and tested each item using multiple readability tests. Last, we revised each item to lower the readability and retest its readability. RESULTS: The average reading level for the original 99 topics was assessed at 10.84 (SD= 3.26). After revisions, we were able to lower the readability to 8.56 (SD= 2.96), which was around two grade levels lower, on average. CONCLUSION: the main purpose for building an English based health information website was to assist the population with LEP. By using simple English with lower readability, it will ease the translation process. This study demonstrates a process to develop suitable contents for populations in need. In the future, incorporating visual aid and other multimedia will be beneficial in user engagement and knowledge retention.

Challenges in health-care service use among Burmese refugees: A grounded theory approach.

The timely use of health-care services is essential to achieve the best health outcomes. We explore barriers to health-care access among refugees from Burma through interviews with key community informants who serve their community as interpreters, health-care professionals, paraprofessionals, and/or representatives. The interviews with a convenience sampling of 11 leaders from Burmese and Karen ethnic communities revealed three stages of health-care use (i.e., before, during, and after doctor's appointments), in which their community members encounter difficulties in accessing health-care services. Using grounded theory analysis approach, specific difficulties and cultural considerations for each stage were emerged. This study suggests that training programs for health-care providers on refugee populations' needs, cultural expectations, attitudes, and health behaviors may ease the process for refugees during each of these three stages. Interpreters as cultural brokers have an important role in facilitating cross-cultural communications not only before and during the appointment but also after doctor's visits, such as in the pharmacy and labs.

Trauma, Discrimination, and Psychological Distress Across Vietnamese Refugees and Immigrants: A Life Course Perspective.

Vietnamese Americans are a heterogeneous group with varied migration histories. The life course perspective (LCP) suggests that different migration histories (immigrant vs. refugee) may affect their psychological health. Using Vietnamese refugee (n = 291) and immigrant (n = 211) subsamples from the National Latino and Asian American Study, selected LCP factors relevant to foreign-born Vietnamese were examined for their associations with psychological distress. Two separate regressions were conducted to examine differential factors across the subgroups. Results showed that sex, age at immigration, and pre- and post-migration traumas were significant factors for refugees. Among immigrants, only racial discrimination was significant factor. The results suggest that applying LCP among Vietnamese Americans helps to discern factors associated with their psychological distress outcomes depending on their initial immigration status. The results also indicate that healthcare professionals should consider the migration background of foreign-born Vietnamese in screening for potential psychological issues, particularly around their trauma history and discriminatory experiences.

Trauma, Post-Migration Stress, and Mental Health: A Comparative Analysis of Refugees and Immigrants in the United States.

Numerous studies describe mental health effects of pre-migration trauma and post-resettlement stress among refugees, yet less research examines these associations with non-refugee immigrants. Additionally, few studies assess the prevalence and impact of traumatic experiences after settlement in a new country. Using a U.S.-based representative sample of Asian (n = 1637) and Latino (n = 1620) refugees and immigrants, we investigated how traumatic events prior to and after migration, and post-migration stressors, are associated with mental illness and distress. Pre-migration trauma posed risk across a broad range of psychological outcomes for Asian refugees and Latino immigrants. Deleterious effects of post-migration trauma were notable for both groups of refugees and immigrants. Discrimination, acculturative stress, and family conflict increased risk for disorder and distress across groups in complex ways. Findings highlight the importance of examining trauma and stress at pre- and post-migration phases across migrant populations, including those not labeled as refugees.

The Effects of Religious Participation and Familial Assistance on Mental Health among Older Chinese and Korean Immigrants: Multiple Mediator Analyses.

Older Asian immigrants are one of the fastest growing segments of the U.S. population and a growing number of them reside in non-traditional destination cities. However, there is a paucity of research on older Asian immigrants living in these non-traditional destination cities, and how this residential choice impacts their stress and mental health. In the current study, we examined how stressors and social support contribute to the overall mental health of older Asian immigrants who lack access to culturally responsive formal social support services. Using a convenience sample of older Chinese (n = 120) and Korean (n = 118) immigrants living in Arizona, we conducted multiple mediator analyses, focusing specifically on how ethnicity would differentially influence mediating effects of religious participation and familial assistance in the relationships between physical/acculturative stressors and mental health outcomes. The results showed that among older Chinese immigrants, religious participation significantly mediated the relationships between both physical/acculturative stressors and mental health, while there was no significant mediation effect detected among older Korean immigrants. Although Asian Americans are often perceived as a monolithic homogeneous group, the multiple mediator models suggest significant differences in the use of cultural/information resources in coping with life stressors and their impact on mental health outcomes between the older Chinese and Korean immigrants in our study. The study findings suggest a need for developing and strengthening formal social services in non-traditional destination cities that are culturally and linguistically responsive to those older Asian immigrants.

Strengthening effective preventive services for refugee populations: toward communities of solution.

Refugee populations have unequal access to primary care and may not receive appropriate health screening or preventive service recommendations. They encounter numerous health care disadvantages as a consequence of low-income status, race and ethnicity, lower educational achievement, varying degrees of health literacy, and limited English proficiency. Refugees may not initially embrace the concept of preventive care, as these services may have been unavailable in their countries of origin, or may not be congruent with their beliefs on health care. Effective interventions in primary care include the appropriate use of culturally and linguistically trained interpreters for health care visits and use of evidence-based guidelines. Effective approaches for the delivery of preventive health and wellness services require community engagement and collaborations between public health and primary care. In order to provide optimal preventive and longitudinal screening services for refugees, policies and practice should be guided by unimpeded access to robust primary care systems. These systems should implement evidence-based guidelines, comprehensive health coverage, and evaluation of process and preventive care outcomes.

Beyond Trauma: Post-resettlement Factors and Mental Health Outcomes Among Latino and Asian Refugees in the United States.

War-related traumas impact refugees' mental health. Recent literature suggests that structural and sociocultural factors related to the resettlement also become critical in shaping refugees' mental health. So far, there is limited empirical evidence to support this claim among resettled refugees. Resettlement contextual factors that influence mental health outcomes were examined using Latino and Asian refugees (n = 656) from a nationally representative survey. Linear and logistic regressions predicted factors associated with the study's outcomes (self-reported mental health, mood disorders, and anxiety disorders). Post-resettlement traumas were significantly associated with mental health outcomes, but pre-resettlement traumas were not. Unemployment, everyday discrimination, and limited English were significantly associated with mental health outcomes among both Latino and Asian refugees. The outcomes indicate that resettlement contextual factors have a significant association with refugees' mental health. Therefore, future studies with refugees must pay closer attention to structural and sociocultural factors after resettlement.

Differential Patterns of Healthcare Service Use Among Chinese and Korean Immigrant Elders.

Previous studies of healthcare service use among Asian immigrant elders have been conducted in major metropolitan areas with established ethnic enclaves. The factors that affect levels of utilization by Asian immigrant elders who live in places where systematic support from an ethnic community is not readily available are unknown. This study employed the Andersen-Newman healthcare service utilization model to examine unique correlates of healthcare service use among Chinese and Korean immigrant elders. Between 2005 and 2007, we used a snowball sampling method to collect data from Chinese (n = 116) and Korean (n = 101) immigrant elders living in Arizona. We then performed two negative binomial regressions based on ethnic background to identify factors associated with the number of annual physician visits. The results indicated that the number of medical conditions they experienced was positively associated with an increased likelihood of healthcare service utilization for both subgroups. However, the results indicated that each ethnic group had distinctive predisposing (sex and length of US stay for Chinese; marital status for Korean), enabling (English proficiency and cultural gap; insurance status), and need factors (depressive symptoms; self-reported health status) for predicting healthcare service utilization. Asian immigrant elders in this study experienced unique barriers and facilitators based on their ethnic backgrounds. Communicating with these two different groups in their native languages and better understanding their cultural backgrounds are imperative to understanding the factors related to their healthcare service utilization. Thus, rather than viewing Asians as a homogeneous population, the differences found in heterogeneous ethnic groups, such as language and cultural variations, should be taken into account when planning and implementing approaches to intervention.

Depression among Korean immigrant elders living in Canada and the United States: a comparative study.

Korean immigrant elders in North America experience a high level of depression. This study explored the correlates of depression among a sample of 245 Korean immigrant elders living in metropolitan cities in Canada (n = 128) and a southwestern state in the United States (n = 117), using a stress-coping framework. Results revealed discrepancies between the 2 subgroups. Years since immigration and number of health concerns were positively associated, and English proficiency was negatively associated with depressive symptoms among Korean immigrant elders in the United States; only health status was significant among Korean immigrant elders in Canada. Implications of the study are presented.

Factors associated with mental health service use among Latino and Asian Americans.

Literature concur that there is a disparity between epidemiological prevalence and mental health services (MHS) utilization rates for Latino and Asian Americans. This study adapted the behavioral model of health service use to examine factors associated with MHS use among Latino and Asian Americans. The model consists of predisposing, enabling, and need factors. This study used the National Latino and Asian American Study data, including six ethnic groups. The outcome measure for this study was the use of MHS in the past 12 months. Age, sex, and education predicted higher odds of MHS use among Latinos, none of which were significant among Asians. Needs factors were strongly associated with higher odds of MHS use among Latinos and Asians.

The role of critical ethnic awareness and social support in the discrimination-depression relationship among Asian Americans: path analysis.

This study used a path analytic technique to examine associations among critical ethnic awareness, racial discrimination, social support, and depressive symptoms. Using a convenience sample from online survey of Asian American adults (N = 405), the study tested 2 main hypotheses: First, based on the empowerment theory, critical ethnic awareness would be positively associated with racial discrimination experience; and second, based on the social support deterioration model, social support would partially mediate the relationship between racial discrimination and depressive symptoms. The result of the path analysis model showed that the proposed path model was a good fit based on global fit indices, χ²(2) = 4.70, p = .10; root mean square error of approximation = 0.06; comparative fit index = 0.97; Tucker-Lewis index = 0.92; and standardized root mean square residual = 0.03. The examinations of study hypotheses demonstrated that critical ethnic awareness was directly associated (b = .11, p < .05) with the racial discrimination experience, whereas social support had a significant indirect effect (b = .48; bias-corrected 95% confidence interval [0.02, 1.26]) between the racial discrimination experience and depressive symptoms. The proposed path model illustrated that both critical ethnic awareness and social support are important mechanisms for explaining the relationship between racial discrimination and depressive symptoms among this sample of Asian Americans. This study highlights the usefulness of the critical ethnic awareness concept as a way to better understand how Asian Americans might perceive and recognize racial discrimination experiences in relation to its mental health consequences.

Emotional support, instrumental support, and gambling participation among Filipino Americans.

Using representative survey data of Filipino Americans in Honolulu and San Francisco (SF) (N = 2,259), we examined the roles of emotional support and instrumental support on gambling participation. With considerable difference in gambling environments between two regions, we conducted two sets of hierarchical regression analyses for Honolulu sample, which has restricted gambling laws, and SF sample, which has legal gambling environment, and compared the effects of two types of social support on gambling participation. The results indicated that emotional support was positively and instrumental support was negatively associated with gambling participation among Filipino Americans in Honolulu. However, neither type of social support was significantly associated with gambling participation among Filipino Americans living in SF. This study highlights the differing roles and effects of instrumental and emotional support on gambling where gambling is restricted. It also suggests that gambling behaviors of Filipino Americans are subject to situation- and environment-specific factors.

Predictors of gambling behaviors in Filipino Americans living in Honolulu or San Francisco.

This study compared the prevalence and predictors of gambling behaviors between Filipino Americans who live in San Francisco (S.F.) or Honolulu. Data from the 1998-1999 Filipino American Community Epidemiological Survey were used to answer two research questions: (1) What are the prevalence and types of gambling behaviors among Filipino Americans and (2) What are the protective/risk factors of heavy gambling for Filipino Americans in S.F. and Honolulu? Overall, S.F. Filipino Americans had a higher level of participation in gambling, and the odds of gambling increased among older age groups, males, those who were US-born, and those with more health problems. Multinomial logistic regression analyses revealed that factors associated with infrequent and regular gambling participation were different between the S.F. group (older, male, higher education) and Honolulu group (male, US-born, more health concerns). Differential gambling environments, i.e., wide open gambling in S.F. and the restrictive gambling in Honolulu, may contribute to gambling participation and predictors of risk gambling Filipino Americans living in Honolulu and S.F. Policy makers and health professionals need to be aware of these differences to serve this population more effectively.

Heavy drinking, perceived discrimination, and immigration status among Filipino Americans.

Filipino American drinkers (N = 1,443) in Honolulu and San Francisco were selected from the 1998-1999 Filipino American Community Epidemiological Survey to examine the association between perceived discrimination and heavy drinking behavior by immigration status. Results indicate that living in San Francisco, lower religious participation, and higher perceived discrimination were associated with increased odds for heavy drinking among US-born individuals, whereas being male was a risk factor among foreign-born individuals. Thus, perceived discrimination and immigration status should be considered when designing prevention and intervention strategies to address heavy drinking behavior in this population.

Risk and protective factors of alcohol use disorders among Filipino Americans: location of residence matters.

BACKGROUND: Despite the growing number of Asian Americans (AA) in the United States, research on alcohol abuse in this population is sparse. Although AA have few alcohol use disorders (AUD) as an aggregate group, within-group variations in AUD need to be explored among specific ethnic groups in this population. OBJECTIVES: This study compared correlates of 12-month prevalence of AUD between Filipino Americans who currently drink alcohol and live in San Francisco (SF) or Honolulu. METHODS: Data from the 1998-1999 Filipino American Community Epidemiological Survey (N = 537) were used to test two hypotheses: 1) current drinkers in SF and Honolulu will differ in the characteristics and prevalence of AUD and 2) current drinkers in SF and Honolulu do not share the same protective and risk factors of AUD. RESULTS: Current drinkers from the two regions substantially differed in age, years of education, age at first drink, religiosity, ethnic identity, psychological distress, the nativity status, as well as the prevalence of AUD. Logistic regression models revealed that AUD risk factors were different for SF current drinkers (higher psychological distress, U.S.-born, and lower religiosity) compared to Honolulu drinkers (more years of education and lower emotional support). CONCLUSION: Filipino American drinkers living in SF and Honolulu have different risk and protective factors for AUD. Health professionals need to be aware of this difference when screening for factors associated with AUD among Filipino Americans. SCIENTIFIC SIGNIFICANCE: The current study revealed the importance of socioenvironmental context (location of residence) in predicting AUD among an Asian ethnic group.