Developing a global medicine student pre- and post-travel curriculum.

BACKGROUND: The popularity of short-term global health experiences amongst US medical students has been increasing. However, it remains a challenge for medical schools to comprehensively prepare students to work in an international environment and to contribute in ethically responsible and meaningful ways. Students of the Global Medicine program (GMED) of the UIC College of Medicine Center for Global Health set out to develop a pre-and-post travel curriculum that addresses some of these challenges. METHODS: The students surveyed the literature of 66 published global health curricula and identified aspects of pre-and-post travel training that were found to be under-addressed. They then developed a curriculum in conjunction with GMED faculty that incorporated these identified aspects of pre-and-post travel training. RESULTS: Five aspects of pre-and-post travel training were identified as being under-addressed in the literature while traveling. These domains include: [1] examining power relations associated with neo-colonization between and within countries; [2] training for bi-directional learning; [3] examining motivations and goals for participating in global health; [4] addressing personal resiliency and psychosocial wellbeing related to students' travel, and; [5] reflecting on the challenging aspects of the fieldwork experience. CONCLUSIONS: The student-driven curriculum is being integrated into the GMED program through structured didactic sessions, one-on-one mentor meetings and small group discussions. Once students have traveled, the curriculum will be evaluated with the foreign partners they visited.

A global health capstone: an innovative educational approach in a competency-based curriculum for medical students.

BACKGROUND: Global health educational programs for medical and public health professionals have grown substantially in recent years. The University of Illinois Chicago College of Medicine (UICOM) began a global medicine (GMED) program for selected students in 2012 and has since graduated four classes. As part of the four-year curriculum, students complete a longitudinal global health capstone project. This paper describes the global health capstone project as an innovative educational tool within a competency-based curriculum. METHODS: The authors define and describe the longitudinal global health capstone including specific requirements, student deliverables, and examples of how the global health capstone may be used as part of a larger curriculum to teach the competency domains identified by the Consortium of Universities for Global Health. The authors also reviewed the final capstone projects for 35 graduates to describe characteristics of capstone projects completed. RESULTS: The global health capstone was developed as one educational tool within a broader global health curriculum for medical students. Of the 35 capstones, 26 projects involved original research (74%), and 25 involved international travel (71%). Nine projects led to a conference abstract/presentation (26%) while five led to a publication (14%). Twenty-one projects (60%) had subject matter-focused faculty mentorship. CONCLUSIONS: A longitudinal global health capstone is a feasible tool to teach targeted global health competencies and can provide meaningful opportunities for research and career mentorship. Further refinement of the capstone process is needed to strengthen mentorship, and additional assessment methods are needed.

Building Online and Telephone Psychological First Aid Services in a Low Resource Setting During COVID-19: The Case of Kosovo.

The COVID-19 pandemic and the measures brought for prevention of infections are associated with considerable psychosocial and psychological morbidity in the general population. Providing continuous mental health services during the pandemics is a challenge worldwide, especially in low- and middle-income countries (LMICs). This paper reports on the strategies and activities taken to protect public mental health during the COVID-19 pandemic in Kosovo. This included establishing online and phone psychological first aid services and developing psychoeducational videos and webinars. The paper concludes with several lessons learned during the process of establishing and maintaining these interventions, such as: initial political endorsement is crucial to gain and maintain the momentum of services; continuous training of volunteers is crucial for both addressing the needs/problems, which arise during the process of work and maintain the motivation of volunteers; promotion of the services is crucial; academic curricula training mental health professionals should include digital mental health related courses and manualization on how to establish this kind of services in midst of crisis is crucial in order to ensure quick operationalization when needed again especially in LMIC settings. The interventions developed provide opportunity for further research especially by evaluating the impact of the services and exploring how online and provision of mental health and psychoeducation services online could help to cover services gap in times of isolation, limited movement and situations similar to pandemics in settings with limited mental health services and resources. The situation with pandemics with COVID 19 is still far from ending. Future waves of infections and restriction could again spike the mental health and psychosocial and psychological strain of the general population, therefore being prepared in provisions of psychological first aid and other mental health services online is crucial.

Violent Extremism, Community-Based Violence Prevention, and Mental Health Professionals.

New community-based initiatives being developed to address violent extremism in the United States are utilizing mental health services and leadership. This article reviews current approaches to preventing violent extremism, the contribution that mental illness and psychosocial problems can make to violent extremism, and the rationale for integrating mental health strategies into preventing violent extremism. The authors describe a community-based targeted violence prevention model and the potential roles of mental health professionals. This model consists of a multidisciplinary team that assesses at-risk individuals with comprehensive threat and behavioral evaluations, arranges for ongoing support and treatment, conducts follow-up evaluations, and offers outreach, education, and resources for communities. This model would enable mental health professionals in local communities to play key roles in preventing violent extremism through their practice and leadership.

Utilizing mental health professionals to help prevent the next attacks.

Recent high-profile cases and scientific research on lone actor terrorist attackers have indicated that there may be an association with mental illness. Simultaneously, countering violent extremism (CVE) initiatives have recently been placing more emphasis on building intervention (aka secondary prevention) programmes to address this matter, with mental health professionals possibly playing important roles in preventing lone actor terrorist attacks. Mental health professionals can contribute to intervention programmes, as practitioners and as leaders, but more so by drawing upon the threat assessment model, than because of a possible association with mental illness. A public-private partnership in Los Angeles, based on a well-regarded, community-based service for addressing targeted school violence, is attempting to further develop such services. A tabletop exercise was used as a strategy for jumpstarting interventions, so as to engage mental health and other community partners, build trust between stakeholders, and identify capacities and gaps that need to be addressed to ensure successful implementation. Further progress and future success will depend upon equitable, ethical, evidence-based, and community collaborative practices.

Condom use and intimacy among Tajik male migrants and their regular female partners in Moscow.

This study examined condom use and intimacy among Tajik male migrants and their regular female partners in Moscow, Russia. This study included a survey of 400 Tajik male labour migrants and longitudinal ethnographic interviews with 30 of the surveyed male migrants and 30 of their regular female partners. of the surveyed male migrants, 351 (88%) reported having a regular female partner in Moscow. Findings demonstrated that the migrants' and regular partners' intentions to use condoms diminished with increased intimacy, yet each party perceived intimacy differently. Migrants' intimacy with regular partners was determined by their familiarity and the perceived sexual cleanliness of their partner. Migrants believed that Muslim women were cleaner than Orthodox Christian women and reported using condoms more frequently with Orthodox Christian regular partners. Regular partners reported determining intimacy based on the perceived commitment of the male migrant. When perceived commitment faced a crisis, intimacy declined and regular partners renegotiated condom use. The association between intimacy and condom use suggests that HIV-prevention programmes should aim to help male migrants and female regular partners to dissociate their approaches to condom use from their perceptions of intimacy.

Supporting Women and Children Returning from Violent Extremist Contexts: Proposing a 5R Framework to Inform Program and Policy Development.

Women and children returning from areas formerly controlled by the Islamic State typically have experienced high levels of trauma and indoctrination, further complicating politically fraught efforts at reintegration and resettlement. Consequently, countries around the world are grappling with how best to manage the return of these women and children. To help better understand which types of programming can contribute to the successful, non-violent reintegration of these individuals, we incorporated ideas from existing Repatriation and Rehabilitation (R&R) literature, field practitioners, R&R subject matter experts, and literature from adjacent fields (e.g., refugee resettlement, criminal justice, psychological resilience) into a recommended best practice approach to supporting returning women and children. We propose a shift from "R&R" programming to what we call the "5R" framework: Repatriation/ Resettlement, Reintegration, Rehabilitation, and Resilience. This shift provides conceptual clarity related to how different program elements target proximal goals (e.g., wellbeing and personal safety, belonging and opportunity, non-violence, and dignity), and how programming can shift from more centrally- and government-held services to informal and community-based supports.

Rehabilitation and Reintegration of Women and Children Returning from Violent Extremist Contexts: A Rapid Review to Inform Program and Policy Development.

This rapid review used a systematic approach to examine the available literature on rehabilitation and reintegration (R&R) programs for women and children returning from contexts of violent extremism, examining common assumptions, inputs, activities and outcomes across diverse settings. Fifty-one documents including peer reviewed articles and grey literature were included in the analysis. The most common program activities identified included mental health services, community level social programs, promoting school and vocational enrollment, regular health services, and parenting training & education, though there was a lack of consensus around core program components. The analysis points to the need for a robust set of inputs and resources to implement R&R programs including government officials, child welfare, mental health professionals, teachers, law enforcement, healthcare, community leaders, and extended family. The review also uncovered a number of gaps. This includes the need to create clear and analytically distinct definitions of rehabilitation and reintegration that are applicable and relevant to key stakeholders, delineating age-appropriate activities and outcomes for young children, youth, and adults, defining frameworks for service delivery and coordination of stakeholders, and placing R&R programs within existing domains of public safety and restorative justice.

Female migrant sex workers in Moscow: gender and power factors and HIV risk.

This study aimed to build formative knowledge regarding HIV risks in female migrant sex workers in Moscow, focusing on gender and power. This was a collaborative ethnographic study, informed by the theory of gender and power, in which researchers conducted minimally structured interviews with 24 female sex workers who were migrants to Moscow and who provided sexual services to male migrant laborers. Overall, the female migrant sex workers engaged in HIV risk behaviors and practiced inadequate HIV protection with their clients. These behaviors were shaped by gender and power factors in the realms of labor, behavior, and cathexis. In the labor realm, because some female migrants were unable to earn enough money to support their families, they were pushed or pulled into sex work providing service to male migrants. In the behavior realm, many female migrant sex workers were intimidated by their male clients, feared violence, and lacked access to women's health care and prevention. In the cathexis realm, many had a sense of shame, social isolation, emotional distress, and lacked basic HIV knowledge and prevention skills. To prevent HIV transmission requires addressing the gender and power factors that shape HIV/AIDS risks among female migrant sex workers through multilevel intervention strategies.

Strengthening Mentorship in Global Health for US Medical Students.

US medical students demonstrate strong interest in receiving global health training. In 2012, the Center for Global Health (CGH) at the University of Illinois College of Medicine (UICOM) developed a Global Medicine (GMED) program to match this interest. From its initiation, mentorship has been a key component of the GMED program. More recently, this has been strengthened by applying additional evidence-informed approaches toward mentoring. These include the "mentor up" approach, a "network of mentors," and an individualized development plan (IDP). Applying these changes were associated with increases in the number of student abstract presentations and peer-reviewed journal publications. Mentorship based upon evidence-informed approaches should be a key component of global health education in academic medical centers.

Understanding birthing preferences of women in Benin City, Nigeria: a qualitative study.

OBJECTIVE: The aim of this study was to explore women's birthing preferences and the motivational and contextual factors that influence their preferences in Benin City, Nigeria, so as to better understand the low rates of healthcare facility usage during childbirth. SETTING: Two primary care centres, a community health centre and a church within Benin City, Nigeria. PARTICIPANTS: We conducted one-on-one in-depth interviews with 23 women, and six focus groups (FGDs) with 37 husbands of women who delivered, skilled birth attendants (SBAs), and traditional birth attendants (TBAs) in a semi-rural region of Benin City, Nigeria. RESULTS: Three themes emerged in the data: (1) women reported frequently experiencing maltreatment from SBAs in clinic settings and hearing stories of maltreatment dissuaded women from giving birth in clinics, (2) women reported that the decision of where to deliver is impacted by how they sort through a range of social, economic, cultural and environmental factors; (3) women and SBAs offered systemic and individual level solutions for increasing usage of healthcare facilities delivery, which included decreasing costs, increasing the ratio of SBAs to patients and SBAs adopting some practices of TBAs, such as providing psychosocial support to women during the perinatal period. CONCLUSION: Women in Benin City, Nigeria indicated that they want a birthing experience that is emotionally supportive, results in a healthy baby and is within their cultural scope. Adopting a woman-centred care approach may encourage more women to transition from prenatal care to childbirth with SBAs. Efforts should be placed on training SBAs as well as investigating how non-harmful cultural practices can be integrated into local healthcare systems.

Rethinking mental healthcare for refugees.

After several years of downturn in new resettlement, the United States is projected to admit 125,000 refugees in the current fiscal year. Refugee communities have known risks of developing mental health problems due to high rates of exposure to war and conflict-related trauma and chronic stressors associated with displacement and resettlement. In this commentary, we examine limitations in the current system of mental health care available to newly arriving refugee communities and make recommendations for expanding and redesigning services to better meet the needs of culturally diverse refugee communities. This includes drawing on public health and prevention frameworks to implement a continuum of services including basic services and security, trauma-informed prevention services to meet the needs of individuals, families and communities and specialized clinical care for those that need it. Across all services, we recommend robust engagement and partnership with refugee community leaders to design and deliver programs.

Trauma exposure, PTSD, and HIV sexual risk behaviors among labor migrants from Tajikistan.

Little is known about the role of trauma and PTSD symptoms in the context of migration-associated HIV risk behaviors. A survey of Tajik married male seasonal labor migrants in Moscow was completed by 200 workers from 4 bazaars and 200 workers from 18 construction sites as part of a mixed method (quantitative and qualitative) study. The mean PC-PTSD score was 1.2 with one-quarter of migrants scoring at or above the cutoff of 3 indicating likely PTSD diagnosis. PC-PTSD score was directly correlated with both direct and indirect trauma exposure, but PC-PTSD score did not predict either HIV sexual risk behaviors or HIV protective behaviors. HIV sexual risk behavior was associated with higher indirect trauma exposure. PC-PTSD score was associated with some indicators of increased caution (e.g., more talking with partners about HIV and condoms; more use of condom when drinking). Qualitative findings were used to illustrate the differences between direct and indirect traumas in terms of HIV sexual risk. The study findings call for future efforts to address labor migrant's mental health needs and to integrate trauma dimensions into HIV prevention.

Labor migration and HIV risk: a systematic review of the literature.

To inform the development of multilevel strategies for addressing HIV risk among labor migrants, 97 articles from the health and social science literatures were systematically reviewed. The study locations were Africa (23 %), the Americas (26 %), Europe (7 %), South East Asia (21 %), and Western Pacific (24 %). Among the studies meeting inclusion criteria, HIV risk was associated with multilevel determinants at the levels of policy, sociocultural context, health and mental health, and sexual practices. The policy determinants most often associated with HIV risk were: prolonged and/or frequent absence, financial status, and difficult working and housing conditions. The sociocultural context determinants most often associated with HIV risk were: cultural norms, family separation, and low social support. The health and mental health factors most often associated with HIV risk were: substance use, other STIs, mental health problems, no HIV testing, and needle use. The sexual practices most often associated with increased HIV risk were: limited condom use, multiple partnering, clients of sex workers, low HIV knowledge, and low perceived HIV risk. Magnitude of effects through multivariate statistics were demonstrated more for health and mental health and sexual practices, than for policy or sociocultural context. The consistency of these findings across multiple diverse global labor migration sites underlines the need for multilevel intervention strategies. However, to better inform the development, implementation, and evaluation of multilevel interventions, additional research is needed that overcomes prior methodological limitations and focuses on building new contextually tailored interventions and policies.

Family-based mental health interventions for refugees across the migration continuum: A systematic review.

This study reviewed the literature on family-based mental health interventions for refugees across migration contexts and settings to identify types of interventions and intervention components, implementation approaches and to assess effectiveness. The review used a systematic approach, and ten intervention studies were retained for analysis. The findings identified three primary types of family-based mental health interventions used with diverse refugee communities in settings in the Global North and South-parenting groups, multiple family groups and home visiting interventions. Findings indicated that non-specialized or peer providers were frequently utilized to deliver the interventions though additional details on the workforce and workforce development strategies are needed to better understand how to sustain and support such providers. The findings suggest that family-based mental health interventions are potentially effective for improving a range of child and caregiver mental health outcomes and improving family processes and functioning among refugee families. However, the empirical evidence is quite limited to date, with a need for additional rigorous studies, especially with refugee families in humanitarian settings, to further build the evidence base.

Prevalence of Perceived Stress, Anxiety, and Depression in HCW in Kosovo during the COVID-19 Pandemic: A Cross-Sectional Survey.

A pandemic may have a negative impact on healthcare workers' (HCW) mental health. In this cross-sectional study, we assess the self-reported prevalence of stress, anxiety, and depression and identify their predictive factors among HCW in Kosovo. The online questionnaire collected data on socio-demographics (sex, age, occupation, education, workplace) and the presence and severity of depression, anxiety, and stress through the 21-item Depression, Anxiety, and Stress Scale (DASS-21) questionnaire. Descriptive statistics, t-test, and linear logistic regression were used to analyze the data. Of the 545 respondents, the majority were male (53.0%), under 60 years of age (94.7%), and married (81.7%). Most of them were physicians (78.2%), while the remaining were nurses, midwives, and other health professionals (22%). Prevalence rates for moderate to extremely high stress, anxiety, and depressive symptoms were 21.9%, 13.0%, and 13.9%, respectively. The nurses reported significantly higher mean scores for depression and anxiety than the physicians (p < 0.05). Being married, having poor health, not exercising, and reporting "burnout" from work significantly predicted higher levels of depressive, anxiety, and stress symptoms among health workers (p < 0.05). Most HCWs (71.6%) reported a mild, moderate, or severe mental health burden, and certain factors predicted higher levels of such burden.

Assessing the interrelationship between stigma, social influence, and cervical cancer prevention in an urban underserved setting: An exploratory study.

In the US, incidence and mortality from cervical cancer disproportionately affects racial/ethnic minorities and low-income women. Despite affordable access to primary and secondary prevention measures at Federally Qualified Health Centers (FQHCs), Human Papillomavirus (HPV) vaccination and screening rates are low, suggesting the presence of non-financial barriers to uptake in this population. This explanatory sequential mixed-methods study sought to explore factors that influence the acceptability of cervical cancer prevention services among parents and legal guardians of vaccine-eligible girls attending an urban FQHC and to assess social influences related to cervical cancer prevention. Participants included eight mothers, one father, and two grandparents/legal guardians. Nine participants self-identified as Black/Afro-Caribbean, or African American, two as Latinx, and one as Native American. The quantitative data suggested discordance between participants' cervical cancer prevention knowledge and their practices. Most indicated that their daughters had received the HPV vaccine but were unsure about HPV transmission modes. Qualitative data revealed that participants were comfortable disclosing information on HPV infection and vaccination status, and most women were likely to share information related to cervical cancer testing and diagnosis. Few comments indicated personal stigma on the part of participants, but there was frequent expression of perceived public stigma (shaming and blaming women), gender differences (men are indifferent to risk), and distrust of the healthcare system. Findings highlight several concepts including the disharmony between knowledge and practice, prevalent perceived public stigma, cumbersome attitudes on the part of men regarding HPV and cervical cancer, and distrust of the healthcare system.

The roles of labor migrants' wives in HIV/AIDS risk and prevention in Tajikistan.

This study aimed to build formative knowledge regarding labor migrants' wives' knowledge, attitudes, and behaviors regarding HIV/AIDS risk and protection that would inform developing innovative HIV prevention strategies. This was a collaborative ethnography in Tajikistan that included minimally structured interviews and focused field observations with 30 Tajik wives in Dushanbe married to Tajik male migrant workers currently working in Moscow. The results documented the wives' concerns over their husbands' safety in Moscow and the difficulties of living without husbands. In a male-dominated society, gender norms limit the wives' abilities to protect themselves and their husbands from HIV/AIDS. They have some awareness of HIV/AIDS, but limited abilities to speak about sexual activity, HIV/AIDS, condoms, and HIV testing. Wives do not use condoms with their husbands and depend upon their husband's role as their protector. Wives often turn for support to their "circle of friends" or to a primary care nurse for support, but seldom do these relationships focus on preventing HIV/AIDS. To respond to HIV/AIDS risks amongst the wives of Tajik male migrant workers in Moscow, preventive interventions could build upon migrants' wives' role as the primary family caregiver and their existing sources of social support from women's circles and nurses. The overall intervention strategy could be to expand their role as family caregivers to include HIV/AIDS protection, through enhancing their HIV/AIDS knowledge and prevention skills and negotiation strategies with their husbands.

Psychiatry and terrorism.

Terrorism has dominated the domestic and international landscape since 9/11. Like other fields, psychiatry was not well prepared. With the 10th anniversary of the 9/11 attack approaching, it is timely to consider what can be done to prepare before the next event. Much has been learned to provide knowledge and resources. The roles of psychiatrists are challenged by what is known of the causes of, consequences of, and responses to terrorism. Reflecting on knowledge from before and since 9/11 introduces concepts, how individuals become terrorists, how to evaluate the psychiatric and behavioral effects of terrorism, and how to expand treatments, behavioral health interventions, public policy initiatives, and other responses for its victims. New research, clinical approaches, and policy perspectives inform strategies to reduce fear and cope with the aftermath. This article identifies the psychiatric training, skills and services, and ethical considerations necessary to prevent or reduce terrorism and its tragic consequences and to enhance resilience.

Developing preventive mental health interventions for refugee families in resettlement.

In refugee resettlement, positive psychosocial outcomes for youth and adults depend to a great extent on their families. Yet refugee families find few empirically based services geared toward them. Preventive mental health interventions that aim to stop, lessen, or delay possible negative individual mental health and behavioral sequelae through improving family and community protective resources in resettled refugee families are needed. This paper describes 8 characteristics that preventive mental health interventions should address to meet the needs of refugee families, including: Feasibility, Acceptability, Culturally Tailored, Multilevel, Time Focused, Prosaicness, Effectiveness, and Adaptability. To address these 8 characteristics in the complex environment of refugee resettlement requires modifying the process of developmental research through incorporating innovative mental health services research strategies, including: resilience framework, community collaboration, mixed methods with focused ethnography, and the comprehensive dynamic trial. A preventive intervention development cycle for refugee families is proposed based on a program of research on refugees and migrants using these services research strategies. Furthering preventive mental health for refugee families also requires new policy directives, multisystemic partnerships, and research training.