Training in Cultural Competence for Mental Health Care: A Mixed-Methods Study of Students, Faculty, and Practitioners from India and USA.

Although the need to train clinicians to provide effective mental health care to individuals from diverse backgrounds has been recognized worldwide, a bulk of what we know about training in cultural competence (CC) is based on research conducted in the United States. Research on CC in mental health training from different world populations is needed due to the context-dependent nature of CC. Focusing on India and USA, two diverse countries that provide complementary contexts to examine CC, we explored graduate students', practicing clinicians', and faculty members' perspectives regarding CC training they received/provided and future training needs using mixed-methods. The data were collected using focus groups (n = 25 groups total: 15 in India, 11 in USA), and a survey (n = 800: 450 in India, 350 in USA). Our data highlight the salient social identities in these countries, and the corresponding constituents of CC training. Participants in India described a practical emphasis to their CC training (e.g., learning about CC through life experiences and clinical practice experiences) more so than through coursework, whereas participants in USA described varying levels of coursework related to CC along with practice. Participants in both countries considered enormity of CC as a challenge, while those in the US also identified CC training limited to a white, straight, male perspective, hesitancy in engaging with diversity topics, and limited time and competence of the faculty. Strengths of CC training in India and USA are mutually informative in generating recommendations for enhancing the training in both countries.

Behavioral Outcomes of Children With In-Utero Opioid Exposure Age 2-7 and Parenting Self-Efficacy.

BACKGROUND: The relationship between behavior difficulties and parenting self-efficacy in children with in-utero opioid exposure (IOE) remains a significant gap that needs to be addressed for providers to better understand the mental health trajectories of children with IOE and help these families. AIMS: In this study, caregivers' perception of their child's behavior and potential relationships between parenting self-efficacy, child temperament, and behavior difficulties were investigated. METHODS: A descriptive survey design with a convenience sample of 143 caregivers of 2- to 7-year-old children with IOE who had follow-up visits in a Neonatal Abstinence Syndrome (NAS) clinic was used for this study. Data were collected using a survey of demographics, the Children's Behavior Questionnaire, the Strengths and Difficulties Questionnaire, and the Parenting Sense of Competence Scale. RESULTS: The overall sample scored in the average range of behavior difficulties, but a subgroup of children with very high difficulties was identified who exhibited a negative temperament, and caregivers reported a lower sense of parenting competence. There were no differences between groups on demographic variables. CONCLUSIONS: High negative affect and low effortful control are predictive of later internalizing and externalizing problems, as well as broader problems in self-regulation, school readiness, and socioemotional competence. Thus, although a large percentage of children treated for NAS appear to be functioning at the same level as their peers, a subset of children appears to be at higher risk. Child behavior as well as caregiver self-efficacy should be assessed during all provider encounters.

Resilience in mothers during the COVID-19 pandemic.

The coronavirus disease (COVID-19) pandemic has brought immense psychological pressure and disruptions to daily life for all individuals, and particularly children, parents, and families. Despite these difficulties, parents are able to show resilience through adaptive coping and positive parenting behaviors. Although there is robust research on resilience in children, very little research has tested predictors of parental resilience. The present study presents descriptive information about mothers' pandemic-related stressors and positive changes and then tests whether prepandemic maternal well-being and child effortful control predicted mothers' resilient parental outcomes (positive behavior and coping) through the mediators of maternal self-compassion, adherence to family routines, and child coping. The sample comprised 95 mothers (95.38% European American, 3.2% African American, and 1.1% Asian American) with a mean age of 38.21 years (SD = 5.71 years, Range = 25.72-51.60 years) and education ranging from a high school to an advanced degree (M = 16.26 years, SD = 2.28 years, Range = 12-21 years). Results revealed that prepandemic maternal well-being predicted adaptive coping both directly and indirectly through self-compassion. Children's effortful control predicted maternal adaptive coping indirectly through children's own adaptive coping, and predicted mothers' positive parenting behaviors directly. Posthoc models revealed adherence to routines to be a correlate and outcome, rather than predictor, of positive parenting and bidirectional relations between parent and child coping. This study provides evidence for parent, child, and family-level factors related to parental resilience during the COVID-19 pandemic. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

An Academic-Health Department Community Partnership to Expand Disease Investigation and Contact Tracing Capacity and Efficiency During the COVID-19 Pandemic.

Disease investigation and contact tracing are long-standing public health strategies used to control the spread of infectious disease. Throughout the COVID-19 pandemic, health departments across the country have lacked the internal workforce capacity and technology needed to efficiently isolate positive cases and quarantine close contacts to slow the spread of SARS-CoV-2. This article describes an innovative disease investigation and contact tracing program developed through a formalized community partnership between a local county health department and local university. This innovative new program added 108 contact tracers to the county's public health workforce, as well as enabled these contact tracers to work remotely using a call center app and secure cloud-based platform to manage the county's caseload of cases and contacts. An overview of the requirements needed to develop this program (eg, hiring, health data security protocols, data source management), as well as lessons learned is discussed.

Drinking Water Quality and Provision in Six Low-Income, Peri-Urban Communities of Lusaka, Zambia.

Lusaka, Zambia, is a rapidly growing city located on a vulnerable karstic dolomite aquifer that provides most of the city's drinking water. Over 65% of residents live in peri-urban communities with inadequate sanitation leading to widespread groundwater contamination and the spread of waterborne diseases such as cholera. To fill the water service gap, Water Trusts were created: public/private partnerships designed to provide clean water to peri-urban community residents. Water Trusts extract groundwater via boreholes, treat it with chlorine, and distribute it to residents via public kiosks. We investigated the efficacy of drinking water provision to residents in six of Lusaka's peri-urban communities with Water Trusts. Water samples were collected from Water Trust boreholes and kiosks, privately owned boreholes, and shallow wells during four sampling efforts. To assess potential risk to human health, water samples were analyzed for Escherichia coli (E. coli) and nitrate. Shallow wells were significantly more contaminated with E. coli than Water Trust boreholes, kiosks, and private boreholes (Tukey-adjusted p values of 9.9 × 10-6). Shallow wells and private boreholes had significantly higher nitrate-N concentrations (mean of 29.6 mg/L) than the Water Trust boreholes and kiosks (mean of 8.8 mg/L) (p value = 1.1 × 10-4). In 2016, a questionnaire was distributed to Water Trust managers to assess their ability to meet demands. In the six communities studied, Water Trusts served only about 60% of their residents. Water Trusts provide a much safer alternative to shallow wells with respect to nitrate and E. coli, but they struggle to keep pace with growing demand.

Curricular Models and Learning Objectives for Undergraduate Minors in Global Health.

Background: A growing number of institutions of higher education offer undergraduate educational programs in global health. Objective: To identify all undergraduate minors in global health being offered in the United States during the 2019-20 academic year, categorize the curricula being used by secondary programs of study, evaluate the content of required foundational courses, and examine the types of experiential learning opportunities that are offered. Methods: A working group of the Consortium of Universities for Global Health (CUGH) conducted a systematic review of the websites of all accredited 4-year colleges and universities, identifying 84 institutions offering general global health minors. Findings: A typical global health minor consists of one introduction to global health course, one epidemiology or health research methods course, several additional required or selective courses, and one applied learning experience. Within this general structure, five curricular models are currently being used for global health minors: (1) intensive minors composed of specialty global health courses, (2) global public health minors built on a core set of public health courses, (3) multidisciplinary minors requiring courses in the sciences and social sciences, (4) anthropology centric minors, and (5) flexible minors. Conclusions: CUGH recommends ten undergraduate student learning objectives in global health that encompass the history and functions of global health; globalization and health; social determinants of health; environmental health; health and human rights; comparative health systems; global health agencies and organizations; the global burden of disease; global health interventions; and interdisciplinary and interprofessional perspectives.

Practice to research: integrating evidence-based practices with culture and context.

There are ways to integrate culturally competent services (CCS) and evidence-based practices (EBP) which can improve the experiences of patients and their families and communities when faced with health problems, as well as the effectiveness and positive experiences of practitioners. CCS and EBP evidence should be jointly deployed for helping patients and clinicians. Partnership research models are useful for achieving the integration of CCS and EBP, since they involve close observation of and participation by clinicians and practitioners in the research process, and often use integrated qualitative and quantitative mixed methods. We illustrate this with 3 examples of work that can help integrate CCS and EBP: ongoing collection of information from patients, clinicians and staff, or "evidence farming"; close study and continuous improvement of activities and accommodations; and use of evidence of tacit, implicit cultural scripts and norms, such as being "productive," as well as explicit scripts. From a research practice point of view, collaborative partnerships will likely produce research with culture and context bracketed in, and will contribute stronger research models, methods, and units of analysis.

Depression, coping, hassles, and body dissatisfaction: factors associated with disordered eating.

The objective was to explore what predicts first-year college women's disordered eating tendencies when they arrive on campus. The 215 first-year college women completed the surveys within the first 2weeks of classes. A structural model examined how much the Helplessness, Hopelessness, Haplessness Scale, the Brief COPE, the Brief College Student Hassle Scale, and the Body Shape Questionnaire predicted eating disordered tendencies (as measured by the Eating Attitudes Test). The Body Shape Questionnaire, the Helplessness, Hopelessness, Haplessness Scale (inversely), and the Denial subscale of the Brief COPE significantly predicted eating disorder tendencies in first-year college women. In addition, the Planning and Self-Blame subscales of the Brief COPE and the Helplessness, Hopelessness, Haplessness Scale predicted the Body Shape Questionnaire. In general, higher levels on the Helplessness, Hopelessness, Haplessness Scale and higher levels on the Brief College Student Hassle Scale related to higher levels on the Brief COPE. Coping seems to remove the direct path from stress and depression to disordered eating and body dissatisfaction.

Marketing therapeutic precision: Potential facilitators and barriers to adoption of n-of-1 trials.

BACKGROUND: N-of-1 trials may enhance therapeutic precision by predicting the long-term effectiveness of medical treatment on an individual basis. However, the n-of-1 approach has gained little traction with the clinical community. To learn why, we interviewed physicians and patients, focusing on the perceived benefits and drawbacks of n-of-1 trials and factors influencing these perceptions. METHODS: We convened focus groups and individual interviews with 21 physicians and 32 patients, most with chronic conditions. The study employed qualitative interview methods to explore and analyze subjects' views of n-of-1 trials. Analysis involved an iterative process of review and data abstraction after specific topics for coding, definitions of codes, and strategies for abstraction had been established. Previously defined domains and topics were then expanded and enriched, with key themes emerging during the analytic process. RESULTS: Physicians and patients remarked on 4 salient aspects of n-of-1 trials: scientific, relational, clinical, and logistical. Neither physicians nor patients were highly familiar with the n-of-1 concept, but both groups readily grasped the fundamental logic and appreciated the potential scientific benefits. Physicians saw n-of-1 trials as promoting an exciting but possibly threatening paradigm shift in the doctor-patient relationship, while patients viewed the relational consequences as modest. The best n-of-1 candidates were felt to be proactive, cognitively intact, reliable, motivated, and engaged in a trusting physician-patient relationship. CONCLUSIONS: Researchers interested in expanding the appeal of n-of-1 trials will need to address these concerns by carefully explaining the approach, emphasizing the benefits, and minimizing the effort required of doctors and patients.

Working the waiting room: managing fear, hope, and rage at the clinic gate.

In this article, we outline the contrasting perspectives of patients and receptionists and the different ways they experience waiting rooms in three U.S. medical clinics. We are doing this to show that a consideration of waiting rooms and the receptionists who work there is an important step in understanding the patient care-seeking experience. We describe the kinds of conflicts that emerge around patient waiting and the emotional labor that receptionists perform to reduce these conflicts by managing patient feelings. By doing this we expand the frame of the clinic visit to include the emotionally important space of the waiting room and revisit the concept of "emotional labor" as a way to understand non-medical care giving in clinic settings and the cultivation of emotions in others. In doing so we show the important role that clinic receptionists may play in shaping how and when patients receive health care.

Why patients go online: multiple sclerosis, the internet, and physician-patient communication.

BACKGROUND: The online information seeking of multiple sclerosis (MS) patients, their reasons for doing so, and its importance for physician-patient communication have not been described. METHODS: Patients (n = 61) presenting for the first time at an MS clinic from December 2003 to July 2005 were interviewed pre- and postappointment and administered standard measures of pain and health quality of life. Consultations were audio recorded. Quantitative data were analyzed in light of qualitative data. RESULTS: Eighty-two percent of patients reported gathering medical information online before their first appointment; 36% discussed this information with their physician. Qualitative reasons for Internet information seeking and for not communicating it show some signs of wariness of health care potentially leading to nonadherence. CONCLUSIONS: Most MS patients are informed by online information, but are unlikely to discuss that research with physicians for reasons that may have implications for patient adherence.

Harnessing experience: exploring the gap between evidence-based medicine and clinical practice.

RATIONALE, AIMS AND OBJECTIVES: There is mounting evidence of a gap between Evidence-based Medicine (EBM) and physician clinical practice, in part because EBM is averaged global evidence gathered from exogenous populations which may not be relevant to local circumstances. Local endogenous evidence, collected in particular and 'real world' patient populations may be more relevant, convincing and timely for clinical practice. Evidence Farming (EF) is a concept to provide such local evidence through the systematic collection of clinical experience to guide more effective practice. METHODS: We report on the findings of a pilot study of 29 individual and three focus group (n = 10) interviews exploring physicians' evaluations how they use multiple sources of information in clinical decision making and their thoughts on EF. RESULTS: Physicians recognize a gap in translating EBM to practice. Physicians reported that when making clinical decisions, they more often rely on clinical experience, the opinions of colleagues and EBM summarizing electronic clinical resources rather than refer directly to EBM literature. Confidence in making decisions based on clinical experience increases over time, yet few physicians reported having systems for tracking their clinical experience in designing treatment plans and patient outcomes. Most physicians saw EF as a promising way to track experience, thereby making scientific evidence more relevant to their own clinical practices. CONCLUSION: Clinical experience is relatively neglected by the EBM movement, but if that experience were systematically gathered through an approach such as EF, it would meet a need left unfulfilled by EBM.

Reading sensations: understanding the process of distinguishing 'fine' from 'sick'.

Sensations form the bases of our recognition that we are well, or, alternatively, that something is wrong. What is the process which transforms a sensation into a symptom? In this article, I draw on fieldwork from Lombok, Indonesia to propose a model of the processes through which sensations become symptoms. Perceptional and interpretive decisions regarding what sensations need to be attended to as potential symptoms may be the result of personal awareness of cultural ideas about vulnerability, sensation duration, and interference with activities. The interpretation of sensations is always tentative, conditional on further cultural information regarding whether the sensation should be constructed into a symptom. I conclude by suggesting a model of the processes through which sensations are interpreted, become pathologized, and are socially legitimated.

Prepared patients: internet information seeking by new rheumatology patients.

OBJECTIVE: To investigate to what extent and why new rheumatology patients access medical information online prior to first appointments and secondarily to ask whether they discuss information gained from the Internet with physicians. METHODS: Research was conducted in a teaching rheumatology clinic with a nonrandom sample of 120 English-speaking adults presenting for first appointments in rheumatology. Quantitative and qualitative data were gained in pre- and postappointment patient surveys and interviews, including online information gathering prior to first appointment, demographics, health status, information usage in patient-physician interactions, and satisfaction. Data were analyzed for significant relationships across variables and for qualitative insights into quantitative outcome measures. RESULTS: Of all patients, 87.5% looked up their symptoms or suspected condition prior to their first appointment and 62.5% of all patients sought that information on the Internet. Only 20% of online information seekers discussed that information with their physicians. Age and sex were significant predictors of Internet information seeking. Physician and patient appointment satisfaction was significantly higher when Internet information was discussed; however, most patients did not discuss their information seeking because they primarily feared being perceived as challenging their physician. CONCLUSION: The majority of patients research their conditions online prior to initial appointments, but are unlikely to discuss that research with physicians even though discussion is related to higher satisfaction. Physicians may want to consider strategies for enabling communication about online research.

What ever happened to N-of-1 trials? Insiders' perspectives and a look to the future.

CONTEXT: When feasible, randomized, blinded single-patient (n-of-1) trials are uniquely capable of establishing the best treatment in an individual patient. Despite early enthusiasm, by the turn of the twenty-first century, few academic centers were conducting n-of-1 trials on a regular basis. METHODS: The authors reviewed the literature and conducted in-depth telephone interviews with leaders in the n-of-1 trial movement. FINDINGS: N-of-1 trials can improve care by increasing therapeutic precision. However, they have not been widely adopted, in part because physicians do not sufficiently value the reduction in uncertainty they yield weighed against the inconvenience they impose. Limited evidence suggests that patients may be receptive to n-of-1 trials once they understand the benefits. CONCLUSIONS: N-of-1 trials offer a unique opportunity to individualize clinical care and enrich clinical research. While ongoing changes in drug discovery, manufacture, and marketing may ultimately spur pharmaceutical makers and health care payers to support n-of-1 trials, at present the most promising resuscitation strategy is stripping n-of-1 trials to their essentials and marketing them directly to patients. In order to optimize statistical inference from these trials, empirical Bayes methods can be used to combine individual patient data with aggregate data from comparable patients.