IMMIGRANT WOMENS’ PROJECT

1. IMMIGRANT WOMENS’ PROJECT Co-Principle Investigators Patricia Joyce, D.S.W. Suzanne Michael, Ph.D. Adelphi University School of Social Work and Natalie Schwartz, M.D. Sonia Das, M.D. New York Presbyterian Hospital Queens

2. GOAL To expand providers’ exploration of non-physical aspects of immigrant women’s experiences, in order to achieve more effective engagement, assessment, clinical intervention and/or referral to culturally competent services.

3. OBJECTIVES: • To administer a survey to residents to assess current • knowledge of immigrant populations. • To interview residents about their work with immigrants. • To interview immigrant women from Central and South Asian • (India, Pakistan, Bangladesh, Afghanistan) about their pre- • migration, migration and post migration experiences. • To interview community leaders about the immigrant • population and community supports: pre-migration lives, • post-arrival stressors, religion, community-based services.

4. To provide training sessions to residents to include: • SESSION I • -Immigrants in New York with focus on immigrant women • from South and Central Asia • -The cross-cultural and cross-linguistic medical interview • -Somatization and cultural bound syndromes • SESSION II • -Trauma, post traumatic stress syndrome and somatization • SESSION III • -Screening for trauma • To develop a trauma screening tool for primary care. • To pilot the trauma screening tool.

5. 12.5% US population is foreign-born (FB) population (2005) 49.5% of US FB population entered between 1990-2002 35.5% of New York City’s population is FB (2003) 45.3% of Queens County’s population is FB (2003) Queens County is ranked second in the US after Miami-Dade County in per cent of foreign-born individuals (2003) IMMIGRATION SOURCE: US Census, 2002, 2003, 2005

6. SOURCE: NYC Department of City Planning, 2004:14

7. SOURCE: NYC Department of City Planning, 2004:45

8. SOURCE: NYC Department of City Planning, 2004:16

9. SELECTED DEMOGRAPHIC AND SOCIAL CHARACTERISTICS SOURCE: NYC Department of City Planning, 2004: 150

10. SELECTED SOCIAL AND ECONOMIC CHARACTERISTICS *Federal standard for “overcrowded” is more than one person per room in housing unit SOURCE: NYC Department of City Planning, 2004: 153, 159

11. CONSIDER • World view • Educational level/literacy • Socio-economic status (pre and post-migration) • Concerns about revealing family “business” • Gender roles • Linguistic equivalents of emotions and concepts, e.g. despair, loneliness, privacy • Health beliefs and explanatory models • Functional aspects of illness • Knowledge of human body and its functions • Perception of patient’s and doctor’s roles

12. THE CROSS CULTURAL MEDICAL INTERVIEW • ENGAGEMENT • Introduce yourself • Inquire as to patient’s preference re naming, e.g. Dr., Ms., Mrs., Mr., first name • Respect physical space • Respect gender norms, e.g. modesty • Explain what is to happen

13. ASSESSMENT • Patient’s perspective of illness and treatment • What do you call your problem? • What name does it have? • What do you think caused your problem? • Why do you think it started when it did? • What is the sickness doing to you? • How does it work? • What problems has it caused you? • How long will it last? • What have you done to deal with it? • How have others reacted to your illness? • What do you think we should do about it? • What do you think will be the result of the treatment? Adapted from Kleinman, et al, 1978

14. ASSESSMENT (continued) • Physical Exam • Emotional interview • Pre-migration life • Migration process • Post-arrival experiences • Current worries or stressors • Explore impact on interpersonal functioning, job, social interactions • Family and/or community support system • Further Tests • Identify benefits and risks • Explore meanings of tests with patient and his/her family

15. DIAGNOSIS • Communicate diagnosis in terms of biomedicine but also in terms of patient’s cultural framework • Explore patient’s reactions TREATMENT PLANNING AND NEGOTIATION • Identify and describe options • Explore patient’s reactions to options • Explore ability to follow-up, e.g. time, finances, transportation, and social supports, CLOSE OF SESSION • Have patient summarize what he/she understands is the problem • Have patient summarize what he/she understands about next steps • Schedule follow up tests and/or appointment • Write down diagnosisand treatment • Provide contact information for follow up questions

16. SOMATIZATION • Idiom of distress • Anxiety, stress, depression, fear, anger, guilt, trauma are frequently associated with somatization • Symptoms may include: headaches, GI problems, chest pain, muscu-skeletal complaints, fibromyaglia, respiratory distress, cognitive impairment • May be an absence of vocabulary for felt emotions • Need to understand the symptoms and their meanings in patient’s health belief system, explanatory model • May have functional meanings for patient and his/her family, e.g. sick role, stimulus for family or community response

17. CULTURE BOUND SYNDROMES • Recurrent idioms of distress that cluster within a specific cultural group or locale – may not conform to a DSM IV diagnostic category • However, the DSM IV does include 25 specific syndromes • Some more common culture bound syndromes • Latino: Susto, Ataque de nervios • SE Asian: Amok, Koro • Korean: Hwa-byung • Senegalese: Toy • US: anorexia nervosa, bulimia nervosa. • Debate re cultural stimulus or the cultural interpretation of symptoms or illness manifestation • Reflects cultural world view and health belief systems, e.g. yin/yang, supernatural versus natural causes,

18. THE CROSS LINGUISTIC INTERVIEW • Identify the need for an interpreter. • Narrow the choice of the interpreter. • Tell interpreter and patient phases of exam/interview. • Sit or stand directly in front of the patient, the interpreter should sit behind either the patient or you. • Look directly at the patient not at the interpreter. • Avoid using the third person and use only the first or second person (“I” and “You”).

19. Elicit the patient’s explanatory models directly from the patient. • Ask for clarification directly from the patient. • Speak slowly, use short sentences and avoid jargon. • Observe non-verbal responses including volume and tone. • Have patient describe in his/her own words what s/he understands about the problem, treatment and/or next steps. • Provide in writing the diagnosis, treatment and/or specific care instructions. Adapted from materials of the Center for Immigrant Health

20. SELECTED REFERENCES • Abbass, A. (2005). Somatization: Diagnosing it sooner through emotion-focused interviewing. The Journal of Family Practice 54(3) 231-243. • Abu-Lughod, K. (2002). Do Muslim women really need saving? Anthropological reflections on cultural relativism and its others. American Anthropologist 104(3) 783-790. • Campbell, E. A. & Guiao, I.Z. (2004). Muslim culture and female self-immolation: implications for global women’s health research and practice. Health Care for Women International 25: 282-793. • Hassouneh-Phillips, D. (2003). Strength and vulnerability: Spirituality in abused American Muslim women’s lives. Issues in Mental Health Nursing 24:681-694. • Hurwitz, E. H., Gupta, J., Liu, R., Silverman, J. & Raj, A. (2006). Intimate partner violence associated with poor health outcomes in US South Asian women. Journal of Immigrant and Minority Health 8(3) 251-261. • Kirmayer, L.J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry 62 (supplement 13) 22-28. • Mak, W. W. S. & Zane, N. W.S. The phenomena of somatization among community Chinese Americans. Social Psychiatry Epidemiology 39:967-974

21. Mastrogianni, A. & Bhugra, D. (2003) Editorial: Globalization, Cultural Psychiatry and Mental Distress. International Journal of Social Psychiatry 49(3) 163-165 • Montazeri, A., Haji-Mahmoddi, M. & Jarvandi, S. (2003). Breast self-exam: do religious beliefs matter? A descriptive study. Journal of Public Health Medicine 25(2) 154-155. • New York City Department of City Planning. (2004). The Newest New Yorkers 2000. New York: City of New York • Park, Y.J., Kim, H.S., Schwartz-Barcott, D.& , Kim, JW. (2002). The conceptual structure of Hwa-Byung in middle-aged Korean women. Health Care for Women International 23: 389-397. • Polisi, C.E. (2004). Universal rights and cultural relativism: Hinduism and Islam deconstructed. World Affairs 167(1) 41-46. • Ranjith, G. & Mohan, R. (2006) Dhat syndrome as a functional somatic syndrome: Developing a socio-somatic model. Psychiatry 69(2) 142-150 • Underwood, S.M., Shaikha, L. & Bakr, D. (1999). Veiled yet vulnerable: Breast cancer screening and the Muslim way of life: Cancer Practice 7 (6) 285-290.