Exposure to Starvation: Associations with HbA1c, Anthropometrics, and Trauma Symptoms Four Decades Later Among Cambodians Resettled in the USA.

BACKGROUND: Epidemiological data suggest that populations exposed to starvation show increased incidence of type 2 diabetes but these studies are limited by lack of person-level data. Cambodians resettled in the USA survived severe malnutrition during distinct historical eras. We examined the relationship of individual exposure to starvation with current HbA1c, anthropometrics, and trauma symptoms among Cambodian Americans. METHODS: Participants were excluded for extant diabetes but all had elevated risk factors for type 2 diabetes and depression. Participants identified images on a 5-point scale that best depicted their body size during four distinct periods: before 1970 (peacetime), 1970-1975 (USA bombing campaign, widespread hunger), 1975-1979 (Pol Pot regime, mass starvation), and "now" (2016-2019, resettled in the USA). They reported trauma symptoms and provided anthropometrics and a blood sample. RESULTS: The n = 189 participants were mean = 55 years old and had glycosylated hemoglobin (HbA1c) mean = 5.5%. Self-reported body size showed excellent validity by strong correlations between body thinness "now" and objectively measured waist circumference (r = -0.35), weight (r = -0.50), and body mass index (r = -0.50). Whereas there was some variability, modal self-reported body size started as normal during peacetime, became thinner during the USA bombing campaign, became emaciated during the Pol Pot regime, and rebounded to normal/slightly heavy "now." Body size during Pol Pot showed the strongest associations with long-term outcomes; thinner body size (greater starvation) was associated with higher trauma symptoms and higher HbA1c even after controlling for age, current waist circumference, and current body mass index. CONCLUSION: Greater degree of starvation was associated with higher HbA1c and trauma symptoms four decades later.

SNAP participation moderates the association between household food insecurity and HbA1c among Cambodian Americans with depression.

OBJECTIVES: We tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) moderated the relation between household food insecurity and HbA1c among Cambodian Americans with depression enrolled in a diabetes prevention trial. METHODS: Community health workers assessed household food insecurity and SNAP participation. HbA1c was ascertained using direct enzymatic assay. RESULTS: Among the n = 189 respondents, 19% were food insecure, 41% received SNAP benefits, and mean HbA1c = 5.5%. There was a significant interaction between SNAP and food insecurity. HbA1c was highest among participants without SNAP who were food insecure. Simple effects analysis revealed a significant difference within the no SNAP group [Mean (SD): Secure = 5.38 (0.38), Insecure = 5.78 (0.36)] and no difference within the SNAP group [Secure = 5.61(0.44), Insecure = 5.61(0.55)]. Differences remained significant after controlling for demographic, socioeconomic, and clinical indicators. CONCLUSIONS: SNAP may protect against the deleterious association between household food insecurity and HbA1c.

Remote Peer Learning Between US and Cambodian Lay Health Workers to Improve Outcomes for Cambodians with Type 2 Diabetes: a Pilot Study.

BACKGROUND: This paper reports a single-group, pre-post pilot of a peer-learning intervention between community health workers (CHWs) in the USA and Village Health Support Guides (Guides) in Cambodia to improve outcomes for Cambodians with type 2 diabetes (T2D). METHOD: Two US-based CHWs were trained in a culturally derived cardiometabolic education curriculum called Eat, Walk, Sleep (EWS) and they were also trained in principles of peer learning. They in turn trained five Cambodia-based Guides remotely through videoconference with a phablet in EWS. Finally, Cambodia-based Guides met with 58 patients with diabetes, face-to-face in their villages, monthly for 6 months to deliver EWS. US-based CHWs and Cambodia-based Guides responded to surveys at baseline and post-treatment. Patients responded to surveys and provided blood pressure and blood samples at baseline and post-treatment. RESULTS: For US-based CHWs, scores on all surveys of diabetes knowledge, self-evaluation, job satisfaction, and information technology improved, though no statistical tests were run due to sample size. For Cambodia-based Guides, all scores on these same measures improved except for job satisfaction. For patients, n = 60 consented, 2 withdrew, and 7 were lost to follow-up leaving n = 51 for analysis. In paired t tests, patients showed significantly decreased A1c, decreased systolic and diastolic blood pressures, improved attitudes toward medicines, and a trend for switching from all-white to part-brown rice. No changes were detected in self-reported physical activity, medication adherence, sleep quality, or frequency or amount of rice consumed. CONCLUSION: If proven effective in a controlled trial, cross-country peer learning could eventually help other diaspora communities.

The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations.

BACKGROUND: The Harvard Trauma Questionnaire (HTQ) was developed 25 years ago as a cross-cultural screening instrument to document trauma exposure, head trauma and trauma-related symptoms in refugees. This article aims to: (i) outline the process of revision of Part IV of the HTQ to (a) include the new DSM-5 diagnostic criteria for PTSD, and (b) separate out and more fully develop the refugee-specific functioning items; and (ii) promote a consistent approach to the validation of the HTQ-5 when adapted for use in other cultures and language groups. METHODS: Our process involved item mapping; expert consultations; generating items according to the new DSM-5 criteria; and drafting, refinement and finalization of the revised measure focusing closely on issues of meaning, future translation into multiple languages and comprehension amongst groups with low literacy and little or no exposure to Western trauma concepts. Validity and reliability testing of the new HTQ-5 is underway. RESULTS: The HTQ symptom checklist was modified consistent with current DSM-5 diagnostic criteria to identify those refugees at risk for mental health and other symptoms associated with traumatic life events, disability and dysfunction. CONCLUSIONS: Accurate screening of post-traumatic distress and dysfunction enables those working with refugees to triage them more effectively to scarce health and mental health resources. When developing screening measures to inform public health policy and practice, it is vital that these measures can bridge the gap between western (etic) nosologies and indigenous (emic) understandings of traumatic stress.

Diabetes among refugee populations: what newly arriving refugees can learn from resettled Cambodians.

A growing body of literature suggests that cardiometabolic disease generally and type 2 diabetes specifically are problems among refugee groups. This paper reviews rates of cardiometabolic disease and type 2 diabetes among refugees and highlights their unique risk factors including history of malnutrition, psychiatric disorders, psychiatric medications, lifestyle changes toward urbanization and industrialization, social isolation, and a poor profile on the social determinants of health. Promising interventions are presented for preventing and treating diabetes in these groups. Such interventions emphasize well-coordinated medical and mental health care delivered by cross-cultural and multidisciplinary teams including community health workers that are well integrated into the community. Finally, recommendations for service, policy, and research are made. The authors draw on local data and clinical experience of our collective work with Cambodian American refugees whose 30-year trajectory illustrates the consequences of ignoring diabetes and its risk factors in more recent, and soon to be arriving, refugee cohorts.

The mental health sequelae of traumatic head injury in South Vietnamese ex-political detainees who survived torture.

Little is known about the relationship between traumatic head injury (THI) and psychiatric morbidity in torture survivors. We examine the relationship between THI and depression, PTSD, post-concussive syndrome (PCS), disability and poor health status in Vietnamese ex-political detainees who survived incarceration in Vietnamese re-education camps. A community sample of ex-political detainees (n=337) and a non-THI, non-ex-detainee comparison group (n=82) were surveyed. Seventy-eight percent of the ex-political detainees had experienced THI; 90.6% of the ex-political detainees and 3.6% of the comparison group had experienced 7 or more trauma events. Depression and PTSD were greater in ex-detainees than in the comparison group (40.9% vs 23.2% and 13.4% vs 0%). Dose-effect relationships for THI and trauma/torture in the ex-political detainee group were significant. Logistic regression in the pooled sample of ex-detainees and the comparison group confirmed the independent impact of THI from trauma/torture on psychiatric morbidity (OR for PTSD=22.4; 95% CI: 3.0-165.8). These results demonstrate important effects of THI on depression and PTSD in Vietnamese ex-detainees who have survived torture.

Comorbid mental and physical health and health access in Cambodian refugees in the US.

Little research has been conducted on the prevalence of physical health problems in Cambodian refugees and the relationship between their mental and physical health. We identified the relationship between mental and physical health problems and barriers to healthcare access in Cambodian refugee adults. We used a cross-sectional survey design with a snowball sample of 136 Cambodian refugee adult residents of Connecticut and Western Massachusetts. 61% reported being diagnosed with three or more physical conditions and 73% with depression, posttraumatic stress disorder (PTSD) or both. Language and transportation problems were the primary barriers to accessing care. Participants with probable comorbid PTSD and depression had 1.850 times more physical health problems than those without either condition (p > .001; CI 1.334-2.566). Age moderated this relationship. Participants who had been diagnosed with both depression and PTSD reported a consistent number of health conditions across the age span while those who had no mental health conditions or only one of the two reported fewer health conditions when they were younger and more when they were older. These two groups were significantly different from the group reporting both. There is a significant relationship between chronic comorbid mental and physical health diseases affecting Cambodian refugees resettled in the US Having comorbid depression and PTSD puts Cambodian refugees at risk for physical health problems no matter their age. It is vital that those treating Cambodian genocide survivors identify and treat their prevalent comorbid health conditions. Language and transportation barriers must be addressed to improve access to mental and physical health care in this population.

Psychological distress and health behaviours among Cambodian Americans at risk for developing diabetes.

This paper reports secondary data analysis of associations between psychological distress and health behaviours among Cambodian Americans. Data are from baseline assessments from a diabetes prevention trial. All participants met stucriteria for depression and were free of diabetes. Participants (n = 191) completed surveys, a food frequency assessment, and wore sleep and physical activity actigraphy devices for 7 days. A factor analysis of symptoms of post-traumatic stress, baksbat (a Cambodian culture-bound syndrome), depression, and anxiety yielded a single factor named 'psychological distress'. Multivariate models controlling for psychotropic medications were run for the following outcomes: sleep actigraphy, self-reported sleep, physical activity actigraphy, self-reported physical activity, nutrition, and substance use. For actigraphy, higher distress was associated with lower moderate/vigorous physical activity and higher mean variability of 24 h total sleep time. Higher distress was also associated with worse self-reported sleep quality as indicated by standard, and culturally-specific, sleep indicators. Higher distress was also associated with lower use of food labels, lower carbohydrate consumption, and higher alcohol consumption as a coping mechanism. Interventions to mitigate diabetes risk in high-distress populations may benefit from strategies to decrease psychological distress. The sequelae of complex trauma may transcend discrete psychiatric diagnoses.

Relationship of alcohol use and facial flushing to blood pressure and HbA1c among Cambodian populations with dysglycemia in the U.S. and in Cambodia.

BACKGROUND AND AIMS: Facial flushing after drinking alcohol, common among Asians, is a phenotype for genes involved in alcohol metabolism. METHODS: We investigated cross-sectional associations between flushing, alcohol use, blood pressure (BP) and HbA1c among (n = 287) Cambodians with dysglycemia in Cambodia and in the U.S. Participants were categorized as Abstainers, Flushers who drink, or Non-flushers who drink. RESULTS: Flushers and Non-flushers had similar alcohol use. Flushers had higher BP than Non-flushers and Abstainers, even after controlling for confounders. Findings were similar across countries. Drinkers had higher HbA1c than Abstainers. CONCLUSIONS: Future research should examine whether reducing alcohol improves cardiometabolic outcomes.

Risk factors for drug therapy problems among Cambodian Americans with complex needs: a cross-sectional, observational study.

BACKGROUND: Pharmaceutical drug therapy problems (DTPs) are a major public health problem. We examined patient-level risk factors for DTPs among Cambodian Americans. METHODS: Community health workers (CHWs) verbally administered surveys and completed a detailed medication review form with participants. A doctoral-level pharmacist reviewed the form with the patient and CHW to determine DTP number and type (appropriateness, effectiveness, safety, and adherence). RESULTS: Participants (n = 63) averaged 55 years old, 6 years of education, 52% were married, 87% spoke Khmer at home, with modal household income <$20,000 (41%). The percentage of participants with DTPs was: 45% appropriateness, 25% effectiveness, 64% safety, and 30% adherence, averaging 3.7 DTPs per patient. In multiple regressions, patient characteristics uniquely predicted each type of DTP. In a multiple regression controlling for number of medications, being married reduced total DTPs (IRR = 0.70) and being depressed increased total DTPs (IRR = 1.26). CONCLUSIONS: Vulnerable patients should be prioritized for pharmacist/CHW teams to identify DTPs.Trial registration: ClinicalTrials.gov identifier: NCT02502929.

Self-reported pain among Cambodian Americans with depression: patient-provider communication as an overlooked social determinant.

OBJECTIVES: Pain is common among torture survivors and refugees. Clear communication about one's pain is vital to timely and precise diagnosis and treatment but is rarely recognized as a social determinant of health. We examined whether self-reported difficulty communicating with their health care provider, along with standard social determinants, is associated with self-reported pain in Cambodian American refugees. METHODS: Secondary data analysis was conducted on n = 186 baseline assessments from a diabetes prevention trial of Cambodian Americans with depression. Bilingual, bicultural community health workers (CHWs) conducted surveys including social determinants of health and past week pain occurrence and interference. RESULTS: The sample was 78% female, modal household income = $25,000, mean age = 55 years, and mean education = 6.9 years. About one-third had private insurance and two-thirds could not speak English conversationally. The average pain score was 2.8 on a scale from 0-8 with 37% reporting no pain at all. In bivariate analyses, predictors of higher pain scores were higher difficulty understanding healthcare provider, depressive symptoms, trauma symptoms, food insecurity, and social isolation; predictors of lower pain scores were higher years of education, income, English language proficiency, social support, working, and having private insurance. In the multivariate backward elimination model only two predictors were retained: difficulty understanding healthcare provider and depressive symptoms. DISCUSSION: We propose that healthcare communication is a modifiable social determinant of health. Healthcare institutions should receive the resources necessary to secure patients' rights to clear communication including trained community health workers.

Human Rights of Forced Migrants During the COVID-19 Pandemic: An Opportunity for Mobilization and Solidarity.

The question of human mobility is inextricably tied to the COVID-19 pandemic that started in late 2019 and whose effects continue to unfold. Human mobility-especially with global advances in transportation and interconnectedness-is an important factor in the spread of the pandemic. Yet, the impact of the COVID-19 pandemic on the millions of people forced to migrate for safety and economic reasons has received little attention. In this article, we provide an overview of human rights challenges that forced migrants currently face during this pandemic. While we do not address all dimensions of the impact COVID-19, we highlight several troubling situations that have emerged for refugees and asylum seekers. These include entry restrictions into some countries that had formerly welcomed asylum seekers, overt and covert forms of exclusion of migrants from labor markets due to rising unemployment and economic hardship, and implementing new deportation policies, as well as new exclusionary policies for immigrants who would have been authorized to work in past. Without concerted efforts to amplify solidarity with all forced migrants and ensure their human rights, discriminatory and restrictionist policies enacted in the Global North over the past decade will become entrenched. As a result, fewer refugees and asylum seekers will be accorded protection and continue to face violence and persecution in their home countries.

Social disconnection and metabolic syndrome score among Cambodian Americans with depression.

AIMS: Migrants experience social disconnection and also have high risk for metabolic syndrome (MetS). This study explored associations of social alienation, social isolation, and social support with MetS among Cambodian Americans. METHODS: We conducted secondary data analysis on baseline assessments from a diabetes prevention trial for Cambodian Americans with depression and high risk for diabetes. Participants were aged 35-75, Cambodian or Cambodian-American, Khmer speaking, lived in Cambodia during the Pol Pot regime, lived in the northeastern U.S. at the time of study, endorsed elevated risk factors for diabetes and met criteria for depression by medication for depression and/or elevated depressive symptoms. They completed surveys and provided anthropometric and blood pressure measurements and fasting blood samples. RESULTS: In multiple linear regressions, greater social alienation was associated with increased risk for MetS. The social alienation-MetS association was stronger in men than women. Associations were not better accounted for by crude indicators of social isolation such as marital status, living alone, and number of people in the household. Social support was not associated with MetS and did not buffer the deleterious association between social alienation and MetS. CONCLUSIONS: Decreasing social alienation may mitigate risk for MetS among migrant populations.

The complex care of a torture survivor in the United States: The case of Joshua.

INTRODUCTION: Torture is an assault on the physical and mental health of an individual, impacting the lives of survivors and their families.The survivor's interpersonal relationships, social life, and vocational functioning may be affected, and spiritual and other existential questions may intrude. Cultural and historical context will shape the meaning of torture experiences and the aftermath. To effectively treat torture survivors, providers must understand and address these factors. The Complex Care Model (CCM) aims to transform daily care for those with chronic illnesses and improve health outcomes through effective team care. METHODS: We conduct a literature review of the CCM and present an adapted Complex Care Approach (CCA) that draws on the Harvard Program in Refugee Trauma's five-domain model covering the Trauma Story, Bio-medical, Psychological, Social, and Spiritual domains.We apply the CCA to the case of "Joshua," a former tortured child soldier, and discuss the diagnosis and treatment across the five domains of care. FINDINGS: The CCA is described as an effective approach for working with torture survivors. We articulate how a CCA can be adapted to the unique historical and cultural contexts experienced by torture survivors and how its five domains serve to integrate the approach to diagnosis and treatment. The benefits of communication and coordination of care among treatment providers is emphasized. Discussion / Conclusions: Torture survivors' needs are well suited to the application of a CCA delivered by a team of providers who effectively communicate and integrate care holistically across all domains of the survivor's life.

Integrated Health Care and mHealth: A Model of Care for Refugees with Complex Health Conditions.

High rates of comorbid physical and mental health conditions are documented among refugee populations. A dearth of evidence exists on the use of mHealth technologies to support integrated health care models, with interprofessional mental and physical healthcare teams, within the field of refugee health, despite the potential for mHealth technologies to reduce barriers to health care access for vulnerable populations. This conceptual article illustrates how mHealth can facilitate integrated health care models with refugees with comorbid conditions. Implications are made to support the application of mHealth technologies within integrated health care models serving at-risk refugee populations.

Social Disconnection as a Risk Factor for Health among Cambodian Refugees and Their Offspring in the United States.

Studies of relatively recently resettled refugees have noted social disconnection, linked to various physical and mental health outcomes, as a concern. Limited studies have examined whether social disconnection and its effects persists within refugee populations resettled more than 3 decades prior. The relationship between social disconnection and self-reported health was explored in a secondary analysis of a cross-sectional needs assessment survey with a snowball sample of 100 Cambodian refugees residing in Connecticut. Social disconnectedness and comorbid health conditions were prevalent. Lack of religious and community engagement were associated with poor health outcomes, while individuals with a lack of ethnic engagement reported better overall health. This study underscores the importance of understanding the specific risks that social disconnection poses to refugees who have resettled many years before and their offspring that may assist in better serving currently settling refugees within the United States.

Child abuse and neglect in Cambodian refugee families: characteristics and implications for practice.

This study examines the characteristics and patterns of child maltreatment among Cambodian refugee families in Los Angeles and assesses the implications for child welfare practice with Cambodian refugee families. Data were extracted from 243 active Cambodian case files maintained by the Los Angeles County Department of Children and Family Services (LAC-DCFS). Some of the major findings include (1) Cambodian child maltreatment cases were most frequently reported to the LAC-DCFS among various Asian Pacific ethnic groups; (2) Cambodian refugee families were more likely to be charged with neglect, while their Asian Pacific counterparts were more likely charged with physical abuse; (3) the circumstances under which maltreatment occurred most frequently were parental substance abuse and mental illness; and (4) while fathers who maltreated their child were likely to use alcohol, mothers were also more likely to have a mental health problem such as depression. This study suggests the importance of collaboration between Child Protective Service agencies, substance abuse programs, traditional healers, mental health services, and other social service agencies for effective child abuse prevention and intervention efforts.

U.S. Cambodian refugees' use of complementary and alternative medicine for mental health problems.

OBJECTIVE: This study examined U.S. Cambodian refugees' use of complementary and alternative medicine and Western sources of care for psychiatric problems. Analyses assessed the extent to which complementary and alternative medicine was used in the absence of Western mental health treatment and whether use of complementary and alternative medicine was associated with decreased use of Western services. METHODS: Face-to-face interviews were conducted with a representative sample drawn from the largest Cambodian refugee community in the United States. The sample included 339 persons who met criteria in the past 12 months for posttraumatic stress disorder, major depression, or alcohol use disorder. Respondents described contact with complementary and alternative medicine and Western service providers for psychological problems in the preceding 12 months. Bivariate and multivariate logistic regression analyses were used. RESULTS: Seventy-two percent of the sample sought Western mental health services, and 34% relied on complementary and alternative medicine in the past year. Seeking complementary and alternative medicine was strongly and positively associated with seeking Western services, contrary to the hypothesis that use of complementary and alternative medicine inhibits seeking Western mental health treatment. CONCLUSIONS: Only a small percentage of Cambodian refugees used complementary and alternative medicine exclusively (5%), and utilization of complementary and alternative medicine was positively associated with seeking Western sources of care for mental health problems. Complementary and alternative medicine use does not appear to be a significant barrier to mental health treatment in this population, contrary to the Surgeon General's conclusion that Asian Americans' use of alternative resources may inhibit their utilization of Western mental health care.

Combating Health Disparities in Cambodian American Communities: A CBPR Approach to Building Community Capacity.

BACKGROUND: Cambodian Americans have higher rates of health problems compared with the general U.S. POPULATION: A relatively modest community capacity for collecting data contributes to these disparities. OBJECTIVES: To (1) further develop the Cambodian American community's capacity to design and conduct health research meaningful to their community via a community-based participatory research (CBPR) approach, (2) train and deploy bilingual community health workers (CHWs) to gather health-related data from their communities using mobile technology, and (3) measure the feasibility and effectiveness of our efforts. METHODS: A CBPR approach was used to engage leaders of Cambodian American communities in six states to identify their research needs, develop a short community health survey administered by CHWs, and conduct the survey using iPads programmed in Khmer spoken-language format. Administrative logs and surveys of CHWs and leaders measured feasibility and effectiveness of the project. RESULTS: CHWs, leaders, and community members reported largely positive experiences with the community health survey, despite poor/inconsistent Internet connectivity. The institutional capacity of Cambodian American community-based organizations to collect health-related data in their own communities was strengthened. Our efforts proved to be both feasible and effective. CONCLUSIONS: The use of mobile technology with spoken format can be a valuable tool in accessing input from vulnerable community members, including persons who may not be literate in any language. Trained CHWs, backed by dedicated and experienced community leaders, are an asset to their communities. Together, they are uniquely placed to make important contributions to the well-being of their community.

Rates and correlates of seeking mental health services among Cambodian refugees.

OBJECTIVES: We assessed the rates and correlates of seeking mental health services among a probability sample of Cambodian refugees who needed such services. METHODS: Interviewers conducted face-to-face interviews with a representative sample drawn from the largest US community of Cambodian refugees. The analytic sample included 339 persons who met past 12-month criteria for posttraumatic stress disorder, major depression disorder, or alcohol use disorder. Respondents described contact with service providers for psychological problems during the preceding 12 months. We examined bivariate and multivariate predictors of seeking services. RESULTS: Respondents reported high rates of contact with both medical care providers (70%) and mental health care providers (46%). Seeking services from both types of providers was associated with lack of English-speaking proficiency, unemployment, 3 or fewer years of preimmigration education, and being retired or disabled. Women, individuals with health insurance, and persons receiving government assistance also were more likely to seek services. CONCLUSIONS: Cambodian refugees with mental health problems had high rates of seeking service for psychological problems during the preceding 12 months. Research is needed to examine the effectiveness of services received by Cambodian refugees.