COVID-19 Interconnectedness: Health Inequity, the Climate Crisis, and Collective Trauma.

The COVID-19 pandemic brings to the forefront the complex interconnected dilemmas of globalization, health equity, economic security, environmental justice, and collective trauma, severely impacting the marginalized and people of color in the United States. This lack of access to and the quality of healthcare, affordable housing, and lack of financial resources also continue to have a more significant impact on documented and undocumented immigrants. This paper aims at examining these critical issues and developing a framework for family therapists to address these challenges by focusing on four interrelated dimensions: cultural values, social determinants of health, collective trauma, and the ethical and moral responsibility of family therapists. Given the fact that family therapists may unwittingly function as the best ally of an economic and political system that perpetuates institutionalized racism and class discrimination, we need to utilize a set of principles, values, and practices that are not just palliative or after the fact but bring forth into the psychotherapeutic and policy work a politics of care. Therefore, a strong call to promote and advocate for the broader continuum of health and critical thinking preparing professionals to meet the challenges of health equity, as well as economic and environmental justice, is needed. The issues discussed in this paper are specific to the United States despite their relevance to family therapy as a field. We are mindful not to generalize the United States' reality to the rest of the world, recognizing that issues discussed in this paper could potentially contribute to international discourse.

La pandemia de la COVID-19 ha puesto en primer plano los dilemas complejos e interconectados de la globalización, la equidad sanitaria, la seguridad económica, la justicia ambiental y el trauma colectivo, afectando gravemente a las personas marginadas y de color de los Estados Unidos. Esta falta de acceso a asistencia sanitaria de calidad, a viviendas asequibles, y la falta de recursos económicos también continúan teniendo un efecto más significativo en los inmigrantes documentados e indocumentados. Este artículo tiene como finalidad analizar estas cuestiones críticas y desarrollar un marco para que los terapeutas familiares aborden estas dificultades centrándose en cuatro dimensiones interrelacionadas: valores culturales, determinantes sociales de salud, trauma colectivo, y responsabilidad ética y moral de los terapeutas familiares. Teniendo en cuenta el hecho de que los terapeutas familiares pueden funcionar inconscientemente como los mejores aliados de un sistema económico y político que perpetúa el racismo institucionalizado y el clasismo, necesitamos utilizar un conjunto de principios, valores y prácticas que no sea solo paliativo o a posteriori, sino que genere en el trabajo político y psicoterapéutico una política de asistencia. Por lo tanto, es necesario un reclamo firme de promover y abogar por un continuo más amplio de la salud y un pensamiento crítico que prepare a los profesionales para responder a las dificultades de la equidad sanitaria, así como de la justicia económica y ambiental, si fuera necesario. Las cuestiones tratadas en este artículo son específicas de los Estados Unidos a pesar de su relevancia para la terapia familiar como área. Somos conscientes de no generalizar la realidad de los Estados Unidos para el resto del mundo, y reconocemos que las cuestiones tratadas en este artículo podrían contribuir al discurso internacional.

Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions.

PURPOSE: We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODS: We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict. RESULTS: Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS: Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations.

The implementation of health promotion in primary and community care: a qualitative analysis of the 'Prescribe Vida Saludable' strategy.

BACKGROUND: The impact of lifestyle on health is undeniable and effective healthy lifestyle promotion interventions do exist. However, this is not a fundamental part of routine primary care clinical practice. We describe factors that determine changes in performance of primary health care centers involved in piloting the health promotion innovation 'Prescribe Vida Saludable' (PVS) phase II. METHODS: We engaged four primary health care centers of the Basque Healthcare Service in an action research project aimed at changing preventive health practices. Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable) is focused on designing, planning, implementing and evaluating innovative programs to promote multiple healthy habits, feasible to be performed in routine primary health care conditions. After 2 years of piloting, centers were categorized as having high, medium, or low implementation effectiveness. We completed qualitative inductive and deductive analysis of five focus groups with the staff of the centers. Themes generated through consensual grounded qualitative analysis were compared between centers to identify the dimensions that explain the variation in actual implementation of PVS, and retrospectively organized and assessed against the Consolidated Framework for Implementation Research (CFIR). RESULTS: Of the 36 CFIR constructs, 11 were directly related to the level of implementation performance: intervention source, evidence strength and quality, adaptability, design quality and packaging, tension for change, learning climate, self-efficacy, planning, champions, executing, and reflecting and evaluating, with -organizational tracking added as a new sub-construct. Additionally, another seven constructs emerged in the participants' discourse but were not related to center performance: relative advantage, complexity, patients' needs and resources, external policy and incentives, structural characteristics, available resources, and formally appointed internal implementation leaders. Our findings indicate that the success of the implementation seems to be associated with the following components: the context, the implementation process, and the collaborative modelling. CONCLUSIONS: Identifying barriers and enablers is useful for designing implementation strategies for health promotion in primary health care centers that are essential for innovation success. An implementation model is proposed to highlight the relationships between the CFIR constructs in the context of health promotion in primary care.

Model based on COVID-19 evidence to predict and improve pandemic control.

Based on the extensive data accumulated during the COVID-19 pandemic, we put forward simple to implement indicators, that should alert authorities and provide early warnings of an impending sanitary crisis. In fact, Testing, Tracing, and Isolation (TTI) in conjunction with disciplined social distancing and vaccination were expected to achieve negligible COVID-19 contagion levels; however, they proved to be insufficient, and their implementation has led to controversial social, economic and ethical challenges. This paper focuses on the development of simple indicators, based on the experience gained by COVID-19 data, which provide a sort of yellow light as to when an epidemic might expand, despite some short term decrements. We show that if case growth is not stopped during the 7 to 14 days after onset, the growth risk increases considerably, and warrants immediate attention. Our model examines not only the COVID contagion propagation speed, but also how it accelerates as a function of time. We identify trends that emerge under the various policies that were applied, as well as their differences among countries. The data for all countries was obtained from ourworldindata.org. Our main conclusion is that if the reduction spread is lost during one, or at most two weeks, urgent measures should be implemented to avoid scenarios in which the epidemic gains strong impetus.

Interpersonal and Intimate Violence in Mexican Youth: Drug Use, Depression, Anxiety, and Stress during the COVID-19 Pandemic.

The COVID-19 pandemic may have increased interpersonal and intimate violence, harmful use of alcohol and other drugs (AODs), and mental health problems. This study uses a valid path model to describe relationships between these conditions of young Mexicans during the second year of the pandemic. A sample of 7420 Mexicans ages 18 to 24-two-thirds of whom are women-completed the Life Events Checklist, the Alcohol, Smoking, and Substance Involvement Screening Test, the Major Depressive Episode Checklist, the Generalized Anxiety Scale, and the Post-traumatic Stress Disorder (PTSD) Checklist. Young Mexicans reported higher rates of victimization and perpetration of interpersonal and intimate violence and mental health symptomatology than those noted pre- and in the first year of the pandemic. The harmful use of AOD rates were similar to those reported by adolescents before. The findings suggest asymmetric victimization and perpetration of intimate violence by gender (with women at a higher risk). More men than women have engaged in the harmful use of AODs (except for sedatives, which more women abuse). More women than men were at risk of all mental health conditions. The path model indicates that being a victim of intimate violence predicts the harmful use of tobacco, alcohol, cocaine, and sedatives, depression, anxiety, and specific PTSD symptoms (such as re-experimentation and avoidance symptoms). Being a victim of interpersonal violence resulted in severe PTSD symptoms (including avoidance, negative alterations in cognition-mood, and hyperarousal signs). The harmful use of sedatives predicted depressive symptoms. Men's victimizing intimate violence model contrasted with that of women, which included being the victim of interpersonal violence and severe PTSD symptoms. The high school youth model had three paths: victimizing intimate violence, victimizing interpersonal abuse, and sedative use, which predicted depression. Our findings could serve as the basis for future studies exploring the mechanisms that predict violence to develop cost-effective preventive programs and public policies and to address mental health conditions during community emergencies.

Virtualizing intimacy: information communication technologies and transnational families in therapy.

Information communication technologies (ICTs) are a ubiquitous feature of immigrant family life. Affordable, widely accessible, and highly adaptable ICTs have transformed the immigrant experience into a transnational process with family networks redesigned but not lost. Being a transnational family is not a new phenomenon. Transnationalism, however, has historically been reserved for the wealthier professional and political immigrant class who were able to freely travel and use expensive forms of communication before the emergence of accessible technologies. This paper systematically reviews the research literature to investigate the potential impact of ICTs on the lives of transnational families and how these families utilize them. The wide penetration of ICTs also puts into question some of the ways in which scholars have conceptualized the immigrant experience. The appropriate use of technology in family therapy should strengthen culturally competent and equity-based approaches to address the needs of these families. A family therapy with a transnational family illuminates some of the potential that these technologies introduce in the practice of relational clinicians.

Is there a role for social technologies in collaborative healthcare?

The exponential growth, variety, and sophistication of the information communication technologies (ICTs) plus their growing accessibility are transforming how clinical practitioners, patients, and their families can work together. Social technologies are the ICTs tools that augment the ability of people to communicate and collaborate despite obstacles of geography and time. There is still little empirical research on the impact of social technologies in the case of collaborative health. Defining a set of social technologies with potential for developing, sustaining, and strengthening the collaborative health agenda should prove useful for practitioners and researchers. This paper is based on an extensive review of the literature focusing on emerging technologies and the experience of the author as a consultant to health care professionals learning about social technologies. A note of caution is required: the phenomenon is complex and hard to describe in writing (a medium very different from the technologies themselves). Hardware and software are in continuous development and the iterative adaptation of the emergent social technologies for new forms of virtual communication.

"They don't want anything to do with you": patient views of primary care management of chronic pain.

OBJECTIVE: Chronic pain is one of the most frequent complaints of patients in primary care, yet both patients and providers report low satisfaction with chronic pain care. This study was designed to explore the views held by a diverse sample of patients with chronic pain complaints about their care experiences to identify ways to improve care. DESIGN: Qualitative analysis of 17 patient focus groups (size 3-7 participants). Groups used structured questions and were tape recorded, transcribed, and coded using qualitative software. Eleven groups were conducted in English, six groups in Spanish. PATIENTS: Convenience sample of 72 adult patients (68% female, 44% Latino, mean age=48.1 years) recruited from four diverse primary care practices in Central Massachusetts. RESULTS: Across all 17 groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their providers when seeking care for chronic pain. Subjects acknowledged feeling disrespected and distrusted, suspected of drug-seeking, and having their symptoms dismissed as trivial and/or not warranting medical care. Patients reported more satisfaction when they felt a provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. Patients also recommended some management techniques related to the chronic disease management model to improve pain care. CONCLUSIONS: Implementing patient-centered approaches in caring for individuals with chronic pain and using principles drawn from the chronic disease management model to improve care systems may improve both patient and provider satisfaction with chronic pain care.

The Health Equity Scholars Program: Innovation in the Leaky Pipeline.

Despite attempts to increase enrollment of under-represented minorities (URMs: primarily Black/African American, Hispanic/Latino, and Native American students) in health professional programs, limited progress has been made. Compelling reasons to rectify this situation include equity for URMs, better prepared health professionals when programs are diverse, better quality and access to health care for UMR populations, and the need for diverse talent to tackle difficult questions in health science and health care delivery. However, many students who initiate traditional "pipeline" programs designed to link URMs to professional schools in health professions and the sciences, do not complete them. In addition, program requirements often restrict entry to highly qualified students while not expanding opportunities for promising, but potentially less well-prepared candidates. The current study describes innovations in an undergraduate pipeline program, the Health Equity Scholars Program (HESP) designed to address barriers URMs experience in more traditional programs, and provides evaluative outcomes and qualitative feedback from participants. A primary outcome was timely college graduation. Eighty percent (80%) of participants, both transfer students and first time students, so far achieved this outcome, with 91% on track, compared to the campus average of 42% for all first time students and 58-67% for transfers. Grade point averages also improved (p = 0.056) after program participation. Graduates (94%) were working in health care/human services positions and three were in health-related graduate programs. Creating a more flexible program that admits a broader range of URMs has potential to expand the numbers of URM students interested and prepared to make a contribution to health equity research and clinical care.

Celiac is a social disease: family challenges and strategies.

Celiac disease is the most common autoimmune inherited disorder in the United States, affecting approximately 1% of the population. Little research exists on the impact of family processes on adherence to a gluten-free diet (GFD), the only treatment for celiac disease. The objective of this qualitative study was to examine the barriers that families with a celiac child face and the strategies they use to adhere to the recommended diet. In-depth interviews were conducted with 10 families with a child between the ages of 6 and 12 diagnosed with celiac disease. Grounded theory and narrative analysis were used to analyze interview transcripts. Social isolation and misunderstandings about celiac disease and the GFD emerged as the most significant barriers to diet adherence including the reproduction of traditional gender relations among parents. Diet adherence facilitators included various types of institutional and societal support and idiosyncratic family arrangements. Successful diet adherence strategies used by families included planning ahead and taking their own food to social functions. Family processes play a critical role in GFD adherence. Implications for health care clinicians working with families with a child with celiac disease are discussed.

E-Health innovations, collaboration, and healthcare disparities: developing criteria for culturally competent evaluation.

E-Health alters how health care clinicians, institutions, patients, caregivers, families, advocates, and researchers collaborate. Few guidelines exist to evaluate the impact of social technologies on furthering family health and even less on their capacity to ameliorate health disparities. Health social media tools that help develop, sustain, and strengthen the collaborative health agenda may prove useful to ameliorate health care inequities; the linkage should not, however, be taken for granted. In this article we propose a classification of emerging social technologies in health care with the purpose of developing evaluative criteria that assess their ability to foster collaboration and positively impact health care equity. The findings are based on systematic Internet ethnographic observations, a qualitative analysis of e-health tool exemplars, and a review of the literature. To triangulate data collection and analysis, the research team consulted with social media health care experts in making recommendations for evaluation criteria. Selected cases illustrate the analytical conclusions. Lines of research that are needed to accurately rate and reliably measure the ability of social media e-health offerings to address health disparities are proposed.

Aspectos psicosociales de la enfermedad celíaca en España: una vida libre de gluten / Psychosocial aspects of celiac disease in Spain: A life free of gluten

RESUMEN Objetivo: La celiaquía como enfermedad crónica tiene una alta prevalencia en nuestra sociedad. El artículo analiza los aspectos psicosociales de la enfermedad celíaca en los diferentes entornos, valorando el impacto de la implantación de una dieta estricta libre de gluten. Métodos: Estudio cualitativo entre los meses de Enero del 2013 a Abril del 2013 en el cual, a través de la teoría fundamentada y el análisis de contenido, se ha profundizado en el análisis de las entrevistas semiestructuradas a personas con enfermedad celíaca en España. Se realizaron llamamientos a traves de las redes sociales y grupos de celíacos hasta llegar a la saturación teórica, que determinó el tamaño final de la muestra de 24 personas. Resultados: Educación Sanitaria, Aislamiento social, soledad y desconocimiento social emergieron como categorías centrales en la experiencia de adopción de la dieta libre de gluten a partir del diagnóstico de celiaquía. Conclusión: Los profesionales deben promover y apoyar estrategias de apoyo social basadas en una comprensión íntegra de las experiencias de desarraigo y marginación que los pacientes celíacos experimentan en sus relaciones sociales a través de la comida. Se requiere un aumento de la educación sanitaria para entender e integrar el impacto psicosocial del diagnóstico de celiaquía y la dieta libre de gluten.

ABSTRACT Objective: Celiac disease is a chronic disease which has a high prevalence in our society. The aim of this paper is to explore the process of adapting the celiac in different social environments, assessing the impact of the implementation of a strict gluten-free diet. Methods: A qualitative study was carried out in the months of January 2013 to April 2013 through which the grounded theory and content analysis have deepened the analysis of semi-structured interviews with people with celiac disease in Spain. Appeals via social networks and celiac groups were conducted in order to reach theoretical saturation, which determined the final sample size of 24 people. Results: Social isolation, loneliness and social ignorance are some of the categories that have emerged when we talk about celiac disease and the gluten-free diet. Conclusion: Professionals should promote and support social support strategies based on an integrated understanding of the experiences of displacement and marginalization that celiac patients experience in their social relationships through food. There should be increased health education to understand and integrate the psychosocial impact of the diagnosis of celiac disease and the gluten-free diet.

Language barriers surrounding medication use among older Latinos.

Limited English language proficiency forms a significant challenge for many Latinos in clinical settings. Although medications are commonly used by older individuals as a means of maintaining good health and managing health problems, the extent to which English proficiency is related to medication use among older Latinos is not known. Focus groups were conducted with Latino, community-residing individuals aged 50 and over in eastern Massachusetts. Qualitative evaluation of the group interviews suggests that language is a barrier in dealing with medication for these individuals. Limited English proficiency appears to be related to feelings of being discriminated against in clinical and pharmacy settings. As well, communicating directly with health professionals in a common language is associated with level of trust and confidence in medical settings. Use of formal and informal interpreters, as well as seeking Spanish-speaking physicians and pharmacies with Spanish-speaking staff, are identified as strategies for overcoming health-related obstacles surrounding language.