Health inequities and social determinants of health in refugee and immigrant communities.

This article evaluates and elucidates the intersections across social and economic determinants of health and social structures that maintain current inequities and structural violence with a focus on the impact on imMigrants (immigrants and migrants), refugees, and those who remain invisible (e.g., people without immigration status who reside in the United States) from Black, Indigenous, and People of Color communities. Psychology has a history of treating individuals and families without adequately considering how trauma is cyclically and generationally maintained by structural violence, inequitable resources, and access to services. The field has not fully developed collaboration within an interdisciplinary framework or learning from best practices through international/global partnerships. Psychology has also been inattentive to the impact of structural violence prominent in impoverished communities. This structural harm has taken the form of the criminalization of imMigrants and refugees through detention, incarceration, and asylum citizenship processes. Most recently, the simultaneous occurrence of multiple catastrophic events, such as COVID-19, political polarization and unrest, police violence, and acceleration of climate change, has created a hypercomplex emergency for marginalized and vulnerable groups. We advance a framework that psychologists can use to inform, guide, and integrate their work. The foundation of this framework is select United Nations Sustainable Development Goals to address health inequities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Counseling Patients in Primary Care: Evidence-Based Strategies.

Family physicians spend substantial time counseling patients with psychiatric conditions, unhealthy behaviors, and medical adherence issues. Maintaining efficiency while providing counseling is a major challenge. There are several effective, structured counseling strategies developed for use in primary care settings. The transtheoretical (stages of change) model assesses patients' motivation for change so that the physician can select the optimal counseling approach. Structured sequential strategies such as the five A's (ask, advise, assess, assist, arrange) and FRAMES (feedback, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement) are effective for patients who are responsive to education about health risk behavior. For patients ambivalent about change, motivational interviewing is more likely to be successful. Capitalizing on a teachable moment may enhance the effectiveness of health behavior change counseling. The BATHE (background, affect, troubles, handling, and empathy) strategy is useful for patients with psychiatric conditions and psychosocial issues. Patients should be referred for subspecialty mental health or substance abuse treatment if they do not respond to these brief interventions.

Complementary and alternative therapies for pediatric attention deficit hyperactivity disorder: a descriptive review.

Attention deficit hyperactivity disorder (AD/HD), characterized by impulsivity, distractibility, and inattention, has an estimated pediatric population prevalence of 6-8%. Family physicians and pediatricians evaluate and treat the majority of children with this condition. The evidence-based treatment of choice for ADHD, stimulant medication, continues to be a source of public controversy. Surveys suggest that among parents of children with ADHD, there is considerable interest in complementary and alternative medicine (CAM). These therapies include herbal preparations, mineral supplements, sugar restriction, and polyunsaturated fatty acids. Other AD/HD therapies include neuro-feedback, cognitive training, mindfulness meditation, and exposure to "green space." In order to assist physicians and mental health professionals in responding to patient and parent queries, this paper briefly describes these CAM therapies and current research regarding their effectiveness. While investigations in this area are hampered by research design issues such as sample size and the absence of double-blind placebo-controlled trials, there is some evidence that omega three fatty acids, zinc supplements, and neuro-feedback may have some efficacy.

Efficient counseling techniques for the primary care physician.

Up to 60% of ambulatory primary care patients have psychosocial factors contributing to their symptom presentation. Counseling, although helpful, is seen as requiring specialized training that most primary care physicians lack, as well as being complex and time-consuming. Several counseling methods have been developed that are brief, relatively easy for the physician to learn and implement, and patient-centered. These include the BATHE technique, the FRAMES strategy, the Stages of Change (Transtheoretical Model) approach, and Motivational Interviewing. Although limited, available research suggests that carefully targeted brief counseling in medical settings does produce meaningful change.

Preventing alcohol-exposed pregnancies.

Fetal alcohol exposure affects approximately 1% to 3% of live births in the United States. Family physicians are in a unique position to reduce the incidence of alcohol-exposed pregnancy. Fetal alcohol exposure can be minimized through 2 general approaches: reducing alcohol consumption or increasing effective contraception among childbearing-aged women who engage in "at-risk" drinking and encouraging pregnant women to abstain from alcohol. Although no safe level of alcohol consumption during pregnancy is established, women who binge drink are more likely to deliver infants with physical and cognitive-developmental anomalies. Screening tools, such as quantity/frequency questions, the TWEAK and the T-ACE, developed specifically for prenatal care, are more useful with women than the CAGE and Michigan Alcohol Screening Test (MAST). Screening alone seems to reduce alcohol use among pregnant women. Brief interventions, including education about alcohol's effects on the developing fetus, are effective among women not responding to screening. Unfortunately, many barriers exist to effective implementation of alcohol-exposed pregnancy (AEP) prevention in the clinical setting. Designing effective office base systems so the entire burden of implementing AEP prevention activities does fall solely on the family physician is critical.

Behavioral science education and the international medical graduate.

PURPOSE: International medical graduates (IMGs), many of whom are recent immigrants to the United States, are filling an increasing proportion of U.S. family medicine residency positions. Therefore, assumptions about the training experiences of first-year residents may no longer apply to a large percentage of incoming residents. The authors sought to improve the behavioral science education in their residency program by learning about IMGs' previous training and experience in behavioral science before coming to the United States. METHOD: Ten first-, second-, and third-year family medicine residents, representing medical school training from India, Macedonia, Bosnia-Herzegovina, The Philippines, Egypt, and Iraq, were individually interviewed using an inductive, qualitative approach. Transcripts were reviewed and double coded. Categories and story lines were identified, and member checking was employed. RESULTS: Segments were classified into seven categories: residents' behavioral medicine training prior to coming to the United States; reflections on the inclusion of mental health and psychosocial content in clinical family medicine; training in medical interviewing; reflections on the physician-patient relationship; perceptions of U.S. family life; recommendations for improving IMGs' understanding of psychosocial aspects of patient care; and specific challenges residents face as IMGs. CONCLUSIONS: The narrative data suggested several possible modifications to the family medicine curriculum, including expanding new resident orientation content about U.S. health care, introducing behavioral science content sooner, and having IMGs observe quality physician-patient interactions. Interview data also yielded concrete suggestions for improving residents' psychiatric interview knowledge and skills, such as instruction in specific wording of questions.

"It's like playing with your destiny": Bosnian immigrants' views of advance directives and end-of-life decision-making.

Patient autonomy is a primary value in US health care. It is assumed that patients want to be fully and directly informed about serious health conditions and want to engage in advance planning about medical care at the end-of-life. Written advance directives and proxy decision-makers are vehicles to promote autonomy when patients are no longer able to represent their wishes. Cross-cultural studies have raised questions about the universal acceptance of these health care values among all ethnicities. In the current investigation, Bosnian immigrants were interviewed about their views of physician-patient communication, advance directives, and locus of decision-making in serious illness. Many of the respondents indicated that they did not want to be directly informed of a serious illness. There was an expressed preference for physician- or family-based health care decisions. Advance directives and formally appointed proxies were typically seen as unnecessary and inconsistent with many respondents' personal values. The findings suggest that the value of individual autonomy and control over the health care decisions may not be applicable to cultures with a collectivist orientation.

Cultural diversity at the end of life: issues and guidelines for family physicians.

Ethnic minorities currently compose approximately one third of the population of the United States. The U.S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of "bad news"; locus of decision making; and attitudes toward advance directives and end-of-life care. In contrast to the emphasis on "truth telling" in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Similarly, with regard to decision making, the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physician- and family-based decision making among some cultures. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences.

Bosnian immigrants' perceptions of the United States health care system: a qualitative interview study.

During the 1990s, approximately 300,000 Bosnian immigrants came to the United States as a result of the Balkan wars. In contrast to immigrants from less developed countries, Bosnian refugees were typically older, had experienced significant war related trauma, and were accustomed to universal health insurance coverage. There is little information about Bosnian immigrants' transition to the U.S. health care system. As part of a related project, 12 Bosnian immigrants were interviewed about their perceptions of the U.S. health care system and their experiences as patients. Participants were universally critical of the U.S. system and described several core issues: confusion about insurance coverage, personalized quality of care, access to primary and specialty care; and a perception of U.S. health care as bureaucratic. Participants compared their experience with prewar Bosnian health care along these dimensions. Implications of the findings and suggestions for improving care to the Bosnian immigrant population are provided.

Psychosocial knowledge and allopathic medicine: points of convergence and departure.

The past 15 years have witnessed a call for allopathic medicine to incorporate psychosocial perspectives into education and clinical practice. While a biopsychosocial perspective has influenced academic medicine in areas such as primary care and psychiatry, its direct impact on clinical medicine has been questionable. One barrier to the incorporation of psychosocial information into medicine which has only recently received attention has been different cultural assumptions which govern medicine versus the social-behavioral sciences. These assumptions are examined in the context of four issues: knowledge paradigms, models of education, acculturation of psychosocial knowledge into medicine, and patient autonomy. This cultural analysis provides a vantage point for understanding similarities as well as points of divergence between psychosocial and biomedical knowledge and practice.