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A Clinical Practice Model to Promote Health Equity for Adolescents and Young Adults: A Practical Guide
Abstract
Creating a clinical model to promote health equity demands a modern philosophy of care, which requires a different mindset that is distinct from the prevailing healthcare model. Using evidence-based components and guided by best practices in the delivery of care, this chapter outlines critical components that should be considered when designing healthcare programming with adolescents and young adults from non-dominant cultures or backgrounds or with any youth at risk of discrimination or vulnerable to multiple social determinants of health. These components are (1) work on internal bias; (2) cultural tailoring or appropriateness; (3) patient activation; (4) welcoming empathy; (5) navigation skills; (6) cross-sector, integrated care; (7) systems of care; (8) family-centered care; (9) foster identity development (ethnic identity in particular); (10) coach around discrimination and biases; (11) two-level advocacy; and (12) sustainability. Combining these components provides a practical framework for clinicians to promote health equity in clinical practice settings.
... Consider for example: Table 1 More than being against it: antiracism and antioppression in mental health services [7] Elements of an antiracism and antioppression framework Focus on activation Activation is creating the realization and validation that one can use one's strengths as tools for growth, developing a strong identity. Activation involves creating awareness of one's strengths, agency, and possibilities, and paths through thoughtful listening and validation [9]. Promote antiracism education Antiracism is committed to educating people about the notions of race, racism, and the position of privilege held by white people. ...
... Adolescent development strives toward a positive sense of self and self-esteem, which can only be accomplished within a psychosocial context that is nurturing and validates diversity for positive youth development [9]. A positive youth development [32] framework must move away from outdated notations of colorblindness to serve as an example of how to be an antiracist. ...
... If psychologists do not appreciate how these realities constrain individual opportunities, we will mistakenly assign sole responsibility for difficulties to the individual (e.g., their thoughts and emotions), perhaps contributing to their internalization of blame. Equity in health will not be achieved without developing this "structural competency" (Svetaz et al., 2019), and Clinical Psychology should integrate this competency into the training curriculum, on par with other core competencies. ...
This chapter provides a narrative of the early training experiences that shaped my career as well as an accounting of how my thinking about research and clinical practice has evolved over the years. I share examples from my research focused on family and ecological influences on mental health, concentrating in particular on research with families who have immigrant and refugee backgrounds and the interventions we have developed based on this research. I attempt to illustrate how my research has grown to become increasingly community-engaged, increasingly focused on building strengths in addition to understanding challenges, and increasingly framed within a social justice lens. I also discuss my clinical perspective on working with children and adolescents, which is grounded in family systems and developmental psychopathology models. My perspectives on assessment and intervention include the importance of self-reflection, striving for cultural safety and humility, identifying the implicit assumptions we make about mental health, and bringing an understanding of structural inequities into case conceptualizations and treatment plans. These developments in my thinking mirror changes in the field of clinical psychology more broadly. Finally, I share some future directions and lessons learned over the years that transcend specific research or clinical activities.
Difficult social circumstances contribute to numerous problems among Latino youth, which can include risky behaviors, school disengagement, health disparities, and relatively high rates of unintended pregnancy, sexually transmitted diseases, and HIV/AIDS. To promote health and healthy development in spite of exposure to substantial social challenge, it is important to identify factors that contribute to resilience among Latino youth. We examine focus group data from the ¡Encuentro! study (10 youth groups, four parent groups) to learn elements identified by Latino youth and parents that support adolescents in reaching their goals. Honoring principles of community-based participatory research, a community–university analysis team coded data for emerging themes and identified protective factors within Masten’s resilience framework. All individual, social, and sociocultural protective factors in Masten’s framework were evident, including positive cultural standards, rituals, relationships, and supports. Challenges to resilience specific to Latino youth included prejudice and discrimination related to race/ethnicity and immigration.
Background
The theory of fundamental causes explains why health disparities persist over time, even as risk factors, mechanisms, and diseases change. Using an intersectional framework, we evaluated multifactorial discrimination as a fundamental cause of mental health disparities. Methods
Using baseline data from the Project STRIDE: Stress, Identity, and Mental Health study, we examined the health effects of discrimination among individuals who self-identified as lesbian, gay, or bisexual. We used logistic and linear regression to assess whether multifactorial discrimination met the four criteria designating a fundamental cause, namely that the cause: 1) influences multiple health outcomes, 2) affects multiple risk factors, 3) involves access to resources that can be leveraged to reduce consequences of disease, and 4) reproduces itself in varied contexts through changing mechanisms. ResultsMultifactorial discrimination predicted high depression scores, psychological well-being, and substance use disorder diagnosis. Discrimination was positively associated with risk factors for high depression scores: chronic strain and total number of stressful life events. Discrimination was associated with significantly lower levels of mastery and self-esteem, protective factors for depressive symptomatology. Even after controlling for risk factors, discrimination remained a significant predictor for high depression scores. Among subjects with low depression scores, multifactorial discrimination also predicted anxiety and aggregate mental health scores. Conclusions
Multifactorial discrimination should be considered a fundamental cause of mental health inequities and may be an important cause of broad health disparities among populations with intersecting social identities.
The objective was to quantify the activities required for patient-centered medical home (PCMH) transformation in a sample of small to medium-sized National Committee for Quality Assurance (NCQA) recognized practices, and explore barriers and facilitators to transformation. Eleven small to medium-sized PCMH practices in Southeastern Pennsylvania completed a survey, which was adapted from the 2011 NCQA standards. Semistructured follow-up interviews were conducted, descriptive statistics were computed for the quantitative analysis, and a process of thematic coding was deployed for the qualitative analysis. Practices had considerable quantitative variation in their workforce composition and the PCMH-related activities they implemented. Most practices improved access and continuity through staff training and team-based care as well as expanded data collection for population management. The barriers to PCMH recognition were least burdensome for the largest practices. The heterogeneity of the small PCMH practices within the study sample underscore the need to understand the key transformation issues as efforts to disseminate the PCMH model continue.
The objective of this study was to document barriers to care, help-seeking behaviors, and the impact of a community-based patient navigation intervention on patient activation levels among Bhutanese refugees in the U.S. Data sources comprised 35 intake and 34 post-intervention interviews with program participants, 14 intake and 14 post-intervention interviews with patient navigators, and 164 case notes. Textual data were analyzed using the constant comparison method. Patient activation level was assessed at both time points. Participants had limited English proficiency (97 %), limited literacy (69 %), and the lowest level of patient activation (69 %). Participants routinely experienced complex insurance access, coverage, and payment problems and had limited healthcare-related life skills. Help-seeking began within social networks, with high reliance on bilingual, literate family members perceived to have experience with "the system." Help-seeking was not stigmatized and was instead consistent with societal norms valuing mutual assistance. Participants preferred helpers to act as proxies and required repeated social modeling by peers to gain confidence applying healthcare-related life skills. Following the intervention, only one-third reported the lowest level of patient activation (35 %) and one-third were highly activated (32 %). Bhutanese refugees overcome healthcare access barriers by seeking help from a network of support that begins within the community. Community health workers serving as patient navigators are readily sought out, and this approach is concordant with cultural expectations for mutual assistance. Community health workers serving immigrant groups should model healthcare-related life skills in addition to providing direct assistance.
The links between discrimination and adjustment in U.S. Latino/a immigrant adolescents is an important but understudied phenomenon. We aimed to investigate the longitudinal associations (across 1 year) among discrimination, prosocial behaviors, and depressive symptoms in U.S. Latino immigrant adolescents using two competing models: associations between discrimination and prosocial behaviors via depressive symptoms (mental health strain model), and associations between discrimination and depressive symptoms via prosocial behaviors (prosociality strain model). Participants were 302 Latino/a recent immigrant adolescents (53.3 % boys, M age = 14.51 years at Time 1, SD = .88 years) who completed measures of discrimination, depressive symptoms, and prosocial behaviors at 6-month intervals. The results provided support for both proposed models. The discussion examines the importance of prosocial behaviors in understanding adjustment and effects of discrimination among recently immigrated U.S. Latino adolescents.
The Determinants of young Adult Social well-being and Health longitudinal study draws on life-course models to understand ethnic differences in health. A key hypothesis relates to the role of psychosocial factors in nurturing the health and well-being of ethnic minorities growing up in the UK. We report the effects of culturally patterned exposures in childhood.
In 2002/2003, 6643 11-13 year olds in London, ~80 % ethnic minorities, participated in the baseline survey. In 2005/2006, 4782 were followed-up. In 2012-2014, 665 took part in a pilot follow-up aged 21-23 years, including 42 qualitative interviews. Measures of socioeconomic and psychosocial factors and health were collected.
Ethnic minority adolescents reported better mental health than White British, despite more adversity (e.g. economic disadvantage, racism). It is unclear what explains this resilience but findings support a role for cultural factors. Racism was an adverse influence on mental health, while family care and connectedness, religious involvement and ethnic diversity of friendships were protective. While mental health resilience was a feature throughout adolescence, a less positive picture emerged for cardio-respiratory health. Both, mental health and cultural factors played a role. These patterns largely endured in early 20s with family support reducing stressful transitions to adulthood. Education levels, however, signal potential for socio-economic parity across ethnic groups.
Efforts in the field of multicultural education for the health professions have focused on increasing trainees' knowledge base and awareness of other cultures, and on teaching technical communication skills in cross-cultural encounters. Yet to be adequately addressed in training are profound issues of racial bias and the often awkward challenge of cross-racial dialogue, both of which likely play some part in well-documented racial disparities in health care encounters. We seek to establish the need for the skill of dialoguing explicitly with patients, colleagues, and others about race and racism and its implications for patient well-being, for clinical practice, and for the ongoing personal and professional development of health care professionals. We present evidence establishing the need to go beyond training in interview skills that efficiently "extract" relevant cultural and clinical information from patients. This evidence includes concepts from social psychology that include implicit bias, explicit bias, and aversive racism. Aiming to connect the dots of diverse literatures, we believe health professions educators and institutional leaders can play a pivotal role in reducing racial disparities in health care encounters by actively promoting, nurturing, and participating in this dialogue, modeling its value as an indispensable skill and institutional priority. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Categorization plays a fundamental role in organizing daily interactions with the social world. However, there is increasing recognition that social categorization is often complex, both because category membership can be ambiguous (e.g., multiracial or transgender identities) and because different categorical identities (e.g., race and gender) may interact to determine the meaning of category membership. These complex identities simultaneously impact social perceivers' impressions and social targets' own experiences of identity, thereby shaping perceptions, experiences, and interactions in fundamental ways. This review examines recent research on the perception and experience of the complex, multifaceted identities that both complicate and enrich our lives. Although research has historically tended to focus more on difficulties and challenges associated with multiple identities, increasing attention is being paid to opportunities that emerge from the possession of identities that include multiple distinct or overlapping groups. We consider how these opportunities might benefit both perceivers and targets. Expected final online publication date for the Annual Review of Psychology Volume 66 is November 30, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
The construction of an ethnic or racial identity is considered an important developmental milestone for youth of color. This review summarizes research on links between ethnic and racial identity (ERI) with psychosocial, academic, and health risk outcomes among ethnic minority adolescents. With notable exceptions, aspects of ERI are generally associated with adaptive outcomes. ERI are generally beneficial for African American adolescents' adjustment across all three domains, whereas the evidence is somewhat mixed for Latino and American Indian youth. There is a dearth of research for academic and health risk outcomes among Asian American and Pacific Islander adolescents. The review concludes with suggestions for future research on ERI among minority youth.
One point of intersection in ethnic and racial identity research is the conceptual attention paid to how positively youth feel about their ethnicity or race, or positive ethnic–racial affect. This article reports results of a series of meta-analyses based on 46 studies of this dimension and psychosocial, academic, and health risk outcomes among ethnic and racial minority youth. The overall pattern of results suggests that positive ethnic–racial affect exhibited small to medium associations (r range = |.11| to |.37|) with depressive symptoms, positive social functioning, self-esteem, well-being, internalizing, externalizing, academic achievement, academic attitudes, and health risk outcomes. Implications for theory and research about the role of positive ethnic–racial affect among youth growing up in an increasingly diverse society are discussed.
Although ethnic and racial identity (ERI) are central to the normative development of youth of color, there have been few efforts to bring scholars together to discuss the theoretical complexities of these constructs and provide a synthesis of existing work. The Ethnic and Racial Identity in the 21st Century Study Group was assembled for this purpose. This article provides an overview of the interface of ERI with developmental and contextual issues across development, with an emphasis on adolescence and young adulthood. It proposes a metaconstruct to capture experiences that reflect both individuals’ ethnic background and their racialized experiences in a specific sociohistorical context. Finally, it presents milestones in the development of ERI across developmental periods.
This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to forces that influence health outcomes at levels above individual interactions. It reviews existing structural approaches to stigma and health inequalities developed outside of medicine, and proposes changes to U.S. medical education that will infuse clinical training with a structural focus. The approach, termed "structural competency," consists of training in five core competencies: 1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) rearticulating "cultural" formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility. Examples are provided of structural health scholarship that should be adopted into medical didactic curricula, and of structural interventions that can provide participant-observation opportunities for clinical trainees. The paper ultimately argues that increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes then needs to be better coupled with medical models for structural change.
Background:
While evidence of the contribution of racial discrimination to ethnic health disparities has increased significantly, there has been less research examining relationships between ascribed racial/ethnic categories and health. It has been hypothesized that in racially-stratified societies being assigned as belonging to the dominant racial/ethnic group may be associated with health advantage. This study aimed to investigate associations between socially-assigned ethnicity, self-identified ethnicity, and health, and to consider the role of self-reported experience of racial discrimination in any relationships between socially-assigned ethnicity and health.
Methods:
The study used data from the 2006/07 New Zealand Health Survey (n = 12,488), a nationally representative cross-sectional survey of adults 15 years and over. Racial discrimination was measured as reported individual-level experiences across five domains. Health outcome measures examined were self-reported general health and psychological distress.
Results:
The study identified varying levels of agreement between participants' self-identified and socially-assigned ethnicities. Individuals who reported both self-identifying and being socially-assigned as always belonging to the dominant European grouping tended to have more socioeconomic advantage and experience less racial discrimination. This group also had the highest odds of reporting optimal self-rated health and lower mean levels of psychological distress. These differences were attenuated in models adjusting for socioeconomic measures and individual-level racial discrimination.
Conclusions:
The results suggest health advantage accrues to individuals who self-identify and are socially-assigned as belonging to the dominant European ethnic grouping in New Zealand, operating in part through socioeconomic advantage and lower exposure to individual-level racial discrimination. This is consistent with the broader evidence of the negative impacts of racism on health and ethnic inequalities that result from the inequitable distribution of health determinants, the harm and chronic stress linked to experiences of racial discrimination, and via the processes and consequences of racialization at a societal level.
Objectives: This article presents a systematic review of the literature on evaluative studies of truancy interventions. Method: Included studies evaluating truancy interventions appearing in peer-reviewed academic journals from 1990 to 2007. Findings: In total, 16 studies were assessed. Eight studies used group comparison designs and eight studies used one-group pretest/posttest designs. Studies varied on sample sizes, definitions of truant behavior, focus of interventions, and dependent measures. Conclusions: Six studies produced useful and promising interventions including contingency management, school reorganization, punitive measures, community partnerships, and family-oriented activities. The substantial methodological shortcomings, inconsistent definitions, and lack of replication demonstrate a need for more and better evaluation studies to provide a more definitive knowledge base to guide effective truancy interventions for practitioners.
This meta-analysis synthesized the results of 27 studies examining the relations of racial identity, ethnic identity, and racial socialization to discrimination–distress for Black Americans. The purpose was to uncover which constructs connected to racial identity, ethnic identity, and racial socialization most strongly correlate with racial discrimination and psychological distress. Discrimination significantly related to aspects of racial identity, including immersion-emersion, public regard, encounter, Afrocentricity/racial centrality/private regard, and internalization. Distress significantly correlated with preencounter/assimilation, encounter, public regard, immersion-emersion, and Afrocentricity/racial centrality/private regard. Several of these relationships were significantly moderated by the measure of racial identity or demographic variables (gender or age). Implications of these findings are discussed.
Background and objectives:
Effective treatment of childhood obesity remains elusive. Integration of clinical and community systems may achieve effective and sustainable treatment. However, the feasibility and effectiveness of this integrated model are unknown.
Methods:
We conducted a randomized clinical trial among children aged 5 to 11 presenting for obesity treatment. We randomized participants to clinical care or clinical care plus community-based programming at a local parks and recreation facility. Primary outcomes were the change in child BMI at 6 months and the intensity of the program in treatment hours. Secondary outcomes included health behaviors, fitness, attrition, and quality of life.
Results:
We enrolled 97 children with obesity, and retention at 6 months was 70%. Participants had a mean age of 9.1 years and a mean baseline BMI z score of 2.28, and 70% were living in poverty. Intervention participants achieved more treatment hours than controls (11.4 vs 4.4, SD: 15.3 and 1.6, respectively). We did not observe differences in child BMI z score or percent of the 95th percentile at 6 months. Intervention participants had significantly greater improvements in physical activity (P = .010) and quality of life (P = .008).
Conclusions:
An integrated clinic-community model of child obesity treatment is feasible to deliver in a low-income and racially diverse population. As compared with multidisciplinary treatment, the integrated model provides more treatment hours, improves physical activity, and increases quality of life. Parks and recreation departments hold significant promise as a partner agency to deliver child obesity treatment.
Purpose
Few studies have examined the early development of a broad range of health issues of importance in adolescence in Latina (female) youth, despite their being potentially a vulnerable group. This study compared suicide and depressive symptoms, substance use, violence exposure, injury prevention, obesity, and health-related quality of life among Latina, African-American, and white females as well as Latino (male) youth in fifth grade, as well as differences related to immigrant generational status for Latinas.
Methods
Data were from the Healthy Passages study, including 3,349 African-American, Latina, and white females as well as Latino male fifth graders in three U.S. metropolitan areas. Self-report items and scales were used to compare status on health-related issues. Generational status was classified based on the parent report of birth location. Logistic and linear regression analyses were conducted, including adjustment for sociodemographic differences.
Results
Latinas showed higher vulnerability than white females for several health issues, whereas few remained after adjustments for sociodemographic differences (higher obesity, lower bike helmet use, and lower physical health-related quality of life). Latina's lower vulnerability compared with African-American females generally persisted after adjustments. Third generation Latinas, after adjustments, reported lower prevalence of alcohol use and fewer friends using alcohol, yet higher future intentions of alcohol use, than first and second generation Latinas. There were few differences between Latina and Latino youth.
Conclusions
Latina youth generally report low vulnerability across health issues in preadolescence. To the extent they appear at higher vulnerability than white females, this may be related to their disadvantaged sociodemographic status.
In this paper, we delineate how staff of two complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. We seek to (1) describe how staff in CCM programs talk about trauma in their patients' lives; (2) discuss how trauma concepts allow staff to understand patients’ symptoms, health-related behaviors, and responses to care as results of structural conditions; and (3) delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide. Observation and interview data gathered between February 2015 and August 2016 indicate that CCM providers define trauma expansively to include individual experiences of violence such as childhood abuse and neglect or recent assault, traumatization in the course of accessing health care and structural violence. Though CCM staff implement elements of trauma-informed care, the short-term design of CCM programs puts pressure on the staff to titrate their efforts, moving patients towards graduation or discharge. Trauma concepts enable clinicians to name structural violence in clinically legitimate language. As such, trauma-informed care and structural competency approaches can complement each other.
Racism is a pervasive stressor. Although most research focuses on direct targets, racism can also have unintended victims. Because children's lives are inevitably linked to the experiences of other individuals, and they are in critical phases of development, they are especially vulnerable to such stressors. Despite the growing body of literature on children's direct exposure to racism, little is known about the relationship between vicarious racism (i.e. secondhand exposure to racism) and child health. To examine the state of this literature, we performed a systematic review and screened 1371 articles drawn from 7 databases, with 30 studies meeting inclusion criteria. For these 30, we reviewed research methodology, including conceptualization and measurement of vicarious exposure, sample characteristics, significant associations with child health outcomes, and mediators and/or moderators of those associations. Most studies were published after 2011 in urban areas in the U.S., employed longitudinal designs, and focused on African American populations. Socioemotional and mental health outcomes were most commonly reported with statistically significant associations with vicarious racism. While all studies examined racism indirectly experienced by children, there was no standard definition of vicarious racism used. We organize the findings in a schematic diagram illustrating indirectly-experienced racism and child health outcomes to identify current gaps in the literature and ways in which to bridge those gaps. To further the field, vicarious racism should be uniformly defined and directly measured using psychometrically validated tools. Future studies should consider using children as the informants and follow children into early adulthood to better understand causal mechanisms. Given the recent national exposure to racially-charged events, a deeper understanding of the association between vicarious racism and child health is crucial in fueling research-informed social action to help children, families, and communities exposed to racism. PROSPERO registration number: CRD42016039608.
The article by Puffer et al in this month's JABFM confirms a high burnout rate (25%) among family physicians renewing their credentials, with a higher rate among young and female doctors. Recent reports confirm high burnout rates among general internists. Thus, mechanisms to monitor and improve worklife in primary care are urgently needed. We describe the Mini Z (for "zero burnout program") measure, designed for these purposes, and suggest interventions that might improve satisfaction and sustainability in primary care, including longer visits, clinician control of work schedules, scribe support for electronic medical record work, team-based care, and an explicit emphasis on work-home balance.
Background
Participatory research (PR) trials aim to achieve the dual, and at times competing, demands of producing an intervention and research process that address community perspectives and priorities, while establishing intervention effectiveness.
Objective
To identify research and community priorities that must be reconciled in the areas of collaborative processes, study design and aim and study implementation quality in order to successfully conduct a participatory trial. We describe how this reconciliation was approached in the smoking prevention participatory trial Padres Informados/Jovenes Preparados (Informed Parents/Prepared Youth) and evaluate the success of our reconciled priorities.
Methods
Data sources to evaluate success of the reconciliations included a survey of all partners regarding collaborative group processes, intervention participant recruitment and attendance and surveys of enrolled study participants assessing intervention outcomes.
Results
While we successfully achieved our reconciled collaborative processes and implementation quality goals, we did not achieve our reconciled goals in study aim and design. Due in part to the randomized wait-list control group design chosen in the reconciliation process, we were not able to demonstrate overall efficacy of the intervention or offer timely services to families in need of support.
Conclusion
Achieving the goals of participatory trials is challenging but may yield community and research benefits. Innovative research designs are needed to better support the complex goals of participatory trials.
Objective:
To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence.
Methods:
Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I(2) statistics determined the impact of heterogeneity.
Results:
Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9).
Conclusion:
PN is effective to increase screening rates and complete care events.
Practice implications:
PN is an effective intervention for use in healthcare.
Unprecedented global forces are shaping the health and wellbeing of the largest generation of 10 to 24 year olds in human history. Population mobility, global communications, economic development, and the sustainability of ecosystems are setting the future course for this generation and, in turn, humankind. At the same time, we have come to new understandings of adolescence as a critical phase in life for achieving human potential. Adolescence is characterised by dynamic brain development in which the interaction with the social environment shapes the capabilities an individual takes forward into adult life.3 During adolescence, an individual acquires the physical, cognitive, emotional, social, and economic resources that are the foundation for later life health and wellbeing. These same resources define trajectories into the next generation. Investments in adolescent health and wellbeing bring benefits today, for decades to come, and for the next generation. Better childhood health and nutrition, extensions to education, delays in family formation, and new technologies offer the possibility of this being the healthiest generation of adolescents ever. But these are also the ages when new and different health problems related to the onset of sexual activity, emotional control, and behaviour typically emerge. Global trends include those promoting unhealthy lifestyles and commodities, the crisis of youth unemployment, less family stability, environmental degradation, armed conflict, and mass migration, all of which pose major threats to adolescent health and wellbeing. Adolescents and young adults have until recently been overlooked in global health and social policy, one reason why they have had fewer health gains with economic development than other age groups. The UN Secretary-General's Global Strategy for Women's, Children's and Adolescents' Health initiated, in September, 2015, presents an outstanding opportunity for investment in adolescent health and wellbeing. However, because of limits to resources and technical capacities at both the national and the global level, effective response has many challenges. The question of where to make the most effective investments is now pressing for the international development community. This Commission outlines the opportunities and challenges for investment at both country and global levels (panel 1).
This article focuses on a youth participatory action research (YPAR) program called the Social Justice Education Project (SJEP) that fostered young people of color’s critical consciousness. Their critical consciousness emerged through praxis (reflection/action) while focusing on preserving ethnic studies in Tucson, Arizona. Because the SJEP home was in ethnic studies, the youth also struggled to keep their program alive. The Arizona Department of Education claimed the program bred ‘radicals’ who wanted to overthrow the government and therefore lobbied the state legislature to ban K-12 ethnic studies in public schools. In January 2012, the ban went into effect, shutting down ethnic studies classes as well as the SJEP. Young people’s qualitative research on their struggle led to action to save the education that gave them hope for a more equitable and just world. The article addresses the praxis of YPAR, which sparks a thought process leading to the drive to take action. Observing and documenting educational injustices inspire the need to seek radical change of Self and schools. Through the reflection and action facilitated by YPAR, young people of color construct a message about the importance of ethnic studies for individual as well as social transformation.
We previously proposed that socioeconomic status (SES) is a fundamental cause of health inequalities and, as such, that SES inequalities in health persist over time despite radical changes in the diseases, risks, and interventions that happen to produce them at any given time. Like SES, race in the United States has an enduring connection to health and mortality. Our goals here are to evaluate whether this connection endures because systemic racism is a fundamental cause of health inequalities and, in doing so, to review a wide range of empirical data regarding racial differences in health outcomes, health risks, and health-enhancing resources such as money, knowledge, power, prestige, freedom, and beneficial social connections. We conclude that racial inequalities in health endure primarily because racism is a fundamental cause of racial differences in SES and because SES is a fundamental cause of health inequalities. In addition to these powerful connections, however, there is evidence that racism, largely via inequalities in power, prestige, freedom, neighborhood context, and health care, also has a fundamental association with health independent of SES.
Parenting adolescents poses challenges that are exacerbated by immigration. Aqui Para Ti [Here for You] (APT) is a clinic-based, healthy youth development program that provides family-centered care for Latino youth and their families who are mostly immigrants from Mexico and Latin America.
To present the APT model of care and report the experiences of youth and their parents.
APT patients between 11 and 24 years (n=30) and parents (n=15). Most youth patients were female, between 11 and 17 years, and from Mexico. Most parents were female, 40 years or younger, and from Mexico.
Youth participants completed a survey and participated in an individual semi-structured interview, and parent participants attended focus groups. Descriptive statistics summarized survey data. Interviews and focus groups were transcribed and analyzed in Spanish using content analysis by two independent coders. Quantitative and qualitative findings were integrated using side-by-side comparisons. Researchers not involved in the coding process contributed with the interpretation of the findings.
Youth and parents were satisfied with the services received at APT. Youth felt listened to by their providers (100%), felt they could trust them (100%) and valued comprehensive care. Eighty-seven percent reported that their experiences at APT were better than at other clinics. Parents valued the family parallel care, confidentiality, family-centeredness, and the cultural inclusivity of the APT services.
Patients and parents were satisfied with the services offered at APT. Family parallel care could be a positive alternative to deliver confidential and family-centered services to immigrant families.
Although immigration and immigrant populations have become increasingly important foci in public health research and practice, a social determinants of health approach has seldom been applied in this area. Global patterns of morbidity and mortality follow inequities rooted in societal, political, and economic conditions produced and reproduced by social structures, policies, and institutions. The lack of dialogue between these two profoundly related phenomena-social determinants of health and immigration-has resulted in missed opportunities for public health research, practice, and policy work. In this article, we discuss primary frameworks used in recent public health literature on the health of immigrant populations, note gaps in this literature, and argue for a broader examination of immigration as both socially determined and a social determinant of health. We discuss priorities for future research and policy to understand more fully and respond appropriately to the health of the populations affected by this global phenomenon. Expected final online publication date for the Annual Review of Public Health Volume 36 is March 18, 2015. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Background:
With the growing use of electronic health record systems, there is a demand for an electronic version of the leading American pediatric preventive care guideline, Bright Futures. As computer implementation requires actionable recommendations, it is important to assess to what degree Bright Futures meets criteria for actionability.
Objectives:
We aimed to 1) determine the number of actionable recommendations in the current edition of Bright Futures and 2) to recommend a specific format for representing an important class of guidelines in a way that better facilitates computer implementation.
Methods:
We consolidated all action statements in Bright Futures into recommendations. We then used two dimensions (decidability and executability) in the Guideline Implementability Appraisal v 2.0 (GLIA) to determine the actionability of the recommendations. Decidability means the recommendation states precisely under what conditions to perform those actions. Executability means actions are stated specifically, unambiguously and in sufficient detail. The results were presented in a figure titled Service Interval Diagram (SID), describing actionable recommendations, age intervals during which they are applicable, and how frequently they should occur in that interval.
Results:
We consolidated 2161 action items into 245 recommendations and identified 52 that were actionable (21%). Almost exclusively, these recommendations addressed screening, such as newborn metabolic screening, or child safety, such as car seat use. A limited number (n=13) of recommendations for other areas of anticipatory guidance were also actionable. No recommendations on child discipline, family function or mental health met our criteria for actionability. The SID representing these recommendations is presented in a figure.
Conclusion:
Only a portion of the Bright Futures Guidelines meets criteria for actionability. Substantial work lies ahead to develop most recommendations for anticipatory guidance into a computer implementable format.
Experiences of racial discrimination and social inequality are related to higher levels of psychological distress and substance use that may contribute to health disparities among youth. This within‐group quantitative survey study tested two alternative theoretical models of the relations between perceived racial discrimination, psychological distress, alcohol, and marijuana use in a sample of 567 African American high school students (61% female; mean age = 15.6 years). Path analyses indicated most support for a model linking perceived racial discrimination to more depressive symptoms that, in turn, were associated with greater past month alcohol and marijuana use. These findings expand our understanding of the direction of effects for exposure to racial discrimination in African American youth and reinforce the need for public health policies, research, and programs for African American youth that acknowledge and address the psychological effects of exposure to racial discrimination on alcohol and marijuana use.
Healthy adolescent development and successful transition to adulthood begins in the family. Supporting families in their communities and cultures ultimately makes this support system stronger. Parenting adolescents is described as the most challenging life stage for parents. Primary care providers are in an ideal position to support families with teens. This article reviews stressors, recommends strength-based strategies, describes how health care delivery systems can be organized to address the needs of adolescents and their families, shares a case study of a family-oriented, youth-friendly primary care clinic, and provides practical strategies for developing family-centered adolescent care within primary care practices.
The purpose of this article is to describe a model for organizing and systematically considering 9 complex and overlapping cultural influences that counselors need to be addressing in their work: Age and generational influences, Disability, Religion, Ethnicity, Social status, Sexual orientation, Indigenous heritage, National origin, and Gender (which together form the slightly misspelled acronym ADRESSING). The ADRESSING model is particularly useful in helping counselors and educators to (a) examine their own biases and areas of inexperience regarding minority cultures and (b) consider the salience of multiple cultural influences and identities with their clients.
This article reviews the scientific research that indicates that despite marked declines in public support for negative racial attitudes in the United States, racism, in its multiple forms, remains embedded in American society. The focus of the article is on the review of empirical research that suggests that racism adversely affects the health of nondominant racial populations in multiple ways. First, institutional racism developed policies and procedures that have reduced access to housing, neighborhood and educational quality, employment opportunities, and other desirable resources in society. Second, cultural racism, at the societal and individual level, negatively affects economic status and health by creating a policy environment hostile to egalitarian policies, triggering negative stereotypes and discrimination that are pathogenic and fostering health-damaging psychological responses, such as stereotype threat and internalized racism. Finally, a large and growing body of evidence indicates that experiences of racial discrimination are an important type of psychosocial stressor that can lead to adverse changes in health status and altered behavioral patterns that increase health risks.
Theorists and practitioners have long recognised that working with trauma clients can trigger reactions in the therapist similar to those experienced by the client. Nevertheless, research in this area has been lacking. One obstacle has been confusion regarding key terms. Vicarious traumatisation is the most appropriate concept given that it relates specifically to trauma work, incorporates intrinsic and extrinsic factors, and can be located within the framework of the constructivist self-development theory. Although limited, research has identified a range of factors that influence vicarious traumatisation, such as experience, personal trauma history and coping style. Future investigation is required to examine aspects that could enhance counsellor resilience. In addition, vicarious traumatisation needs to be studied in terms of a broad range of clientele and occupations.
This article reviews the relationship between factors associated with resilience, and aspects of the individual's social ecology (environment) that promote and protect against the negative impact of exposure to traumatic events. It is shown that the Environment × Individual interactions related to resilience can be understood using three principles: (1) Resilience is not as much an individual construct as it is a quality of the environment and its capacity to facilitate growth (nurture trumps nature); (2) resilience looks both the same and different within and between populations, with the mechanisms that predict positive growth sensitive to individual, contextual, and cultural variation (differential impact); and (3) the impact that any single factor has on resilience differs by the amount of risk exposure, with the mechanisms that protect against the impact of trauma showing contextual and cultural specificity for particular individuals (cultural variation). A definition of resilience is provided that highlights the need for environments to facilitate the navigations and negotiations of individuals for the resources they need to cope with adversity. The relative nature of resilience is discussed, emphasizing that resilience can manifest as either prosocial behaviors or pathological adaptation depending on the quality of the environment.
Research evidence indicates that 2 forms of racial discrimination—perceived interpersonal discrimination and racial/ethnic residential segregation (a form of institutional discrimination)—may influence children’s health and disparities.
Although research on these 2 forms of discrimination and health has primarily focused on adults, smaller bodies of work have documented that perceived interpersonal discrimination and segregation have a negative effect on infants’ health, and that perceived interpersonal discrimination may negatively affect children’s mental health.
Three directions for research are (1) incorporating a life-course perspective into studies of discrimination and children’s health, (2) linking residential segregation with geography-of-opportunity conceptual frameworks and measures, and (3) considering residential segregation along with segregation in other contexts that influence children’s health (e.g., schools).
The past decade has brought with it a greatly increased awareness about the impact of trauma on children, which has, in turn, led to a focus on the treatment of trauma-related conditions. Much of the recent literature describes different approaches to therapy. However, there are a few consistent propositions arising from the research and clinical literature which suggest that much of the healing from trauma can take place in non-clinical settings. There is some evidence to suggest that trauma-informed living environments in which healing and growth can take place are a necessary precursor to any formal therapy that might be offered to a traumatised child. It stands to reason that the treatment of children exposed to complex trauma will itself be complex and long-lasting. However, there appears to be a remarkable consensus about the key prerequisites for healing--those critical factors or therapeutic pillars that need to be in place if healing is to take place. Although there is debate about the number of critical factors, there are three that are common to most approaches. This article outlines the three pillars of trauma-informed care: (1) safety; (2) connections; and (3) managing emotional impulses. (Contains 1 footnote.)