Colonialism

C CAM ▶ Alternative and complementary medicine Cambodia CHRISTOPHER A. KENEDI1, KRISTEN G. SHIREY2 1 Auckland District Health Board, Auckland, New Zealand 2 Departments of Psychiatry and Behavioral Sciences and Medicine, Duke University Medical Center, Durham, NC, USA The health of Cambodian immigrants cannot be separated from the political history and the impact of the Khmer Rouge whose rule saw the deaths of approximately 21% of the Cambodian population – 1.7 million people – between 1975 and 1979. A 2005 community survey of Cambodians who had immigrated to the USA before 1993 reported that 99% had experienced neardeath due to starvation and 90% had a friend or family member murdered. Background Most Cambodians consider themselves to be Khmers and descendants of the Angkor Empire that was the dominant force in Southeast Asia for hundreds of years from the tenth to the thirteenth century. The empire declined over the next 500 years and the country was invaded and sacked by various neighbors, although a monarchy endured. In the nineteenth century, attacks from the west (Thai) and the east (Cham/modern-day Vietnamese) led to Cambodia seeking French protection and becoming a part of French Indochina. Vichy French Colonial administrators were allowed to maintain control of Cambodia during most of World War II, and unlike Vietnam there was little impact from the Japanese occupation. Cambodia gained independence from France in 1953 and remained a constitutional monarchy until open conflict with the communist (Maoist) Khmer Rouge began in 1970. Some scholars believe the US intervention in Cambodian politics supported an unpopular government that endorsed the US war effort in Vietnam, but made Cambodia more susceptible to the Khmer Rouge guerillas. Fighting continued until the Khmer Rouge gained control of the country in 1975 – at the same time the North Vietnamese gained control of South Vietnam and unified their country. Khmer Rouge and Genocide Within days of capturing the capital, Phnom Penh, the Khmer Rouge led by Pol Pot began to locate and kill military and political leaders, monks, teachers, doctors, scientists, lawyers, engineers, and anyone who wore glasses; these were all people thought to be contaminated by capitalism. Because ammunition was in short supply, the majority were killed by stakes or bludgeoned to death with iron bars after they had been forced to dig their own graves in what became popularly known as “The Killing Fields.” Hundreds of thousands of people were known to have died in this manner based on excavated gravesites. Based on large-scale “experiments” that Pol Pot had carried out on villages the Khmer Rouge had captured in previous years, he believed that society had to be radically destabilized to break all previous bonds and ensure absolute loyalty to the communist party. The campaign was called “Year Zero,” a takeoff on the ideals of the French Revolution. To accomplish this, the cities and villages were emptied to become ghost towns and the population forced into the countryside despite signs of an oncoming famine in the wake of the civil war. The displacement campaign was organized to remove traditional bonds such as family, village ties, Sana Loue & Martha Sajatovic (eds.), Encyclopedia of Immigrant Health, DOI 10.1007/978-1-4419-5659-0, Springer Science+Business Media, LLC 2012 (USA) # 332 C Cambodia and faith in Buddhism. The farming practices proved to be poorly planned and executed due to the lack of expertise by the Khmer Rouge administrators. This led to an ongoing agricultural catastrophe, resulting in famine and starvation across the country. The Khmer Rouge administration was an ally of the People’s Republic of China. Cambodia was invaded by Vietnam (a client state of the Soviet Union) in 1978 and despite a limited Chinese invasion of Vietnam in 1979 to support their Cambodian allies, the capital Phnom Penh fell to the Vietnamese in the same year, ending the genocidal reign of the Khmer Rouge 4 years and almost 2 million lives after it began. During the 1980s, the Khmer Rouge operated as a guerilla movement from the jungles of Western Cambodia and sometimes across the Thai border. Ten years of ongoing civil war ended with a peace agreement in 1991 that was policed by 20,000 UN Peacekeepers, although sporadic fighting continued for 8 more years. The last remnants of the Khmer Rouge surrendered in 1999. Since the peace accords in 1991, there have been elections in 1993, 1998, 2003, and 2008 that have been generally peaceful – with the exception of a coup in 1997. Despite increasing security and political stability, the scars of the Khmer Rouge linger on in many Cambodians’ minds. There is almost no access to mental health resources within Cambodia. Posttraumatic stress disorder and other mental illnesses appear to have a high prevalence among the generation of Cambodians that survived as well as those that perpetrated the genocide and conflict. Gang Rape Because of the genocide of the 1970s and the conflict that followed, 50% of Cambodia’s population is less than 21 years old. They tend to have limited education and skills training because most of the teachers were killed by the Khmer Rouge, schools were destroyed, and the following decades of conflict resulted in limited investment in an education infrastructure. Combined with the intentional destruction of Cambodian culture by the Khmer Rouge and the social structure that was lost with it, this has led to some challenging social trends. One is an increasing recognition of the widespread practice of “bauk,” which translates to “plus” in Khmer. It is a practice of group sex that appears to be gang rape more often than not. The process involves a group of – up to a dozen – youths luring a woman, usually but not always, a prostitute to a room. The expressed sentiment is that they are paying “full price” so it is cheaper to split the cost. There appear to be no prosecutions for bauk despite it being well documented. One survey of 580 youths aged 13–28 in Cambodia reported that only 13% of men and 13% of women felt it was inherently wrong; 33% of men and 41% of women felt bauk was dangerous mostly because of STD transmission; 13% of men and 8% of women said gang rape was okay because the women were prostitutes and see “many men” anyway; and 13% of men and 17% of women said it was better to happen to prostitutes than “other women.” Thirty-four percent of high-school students said they knew at least one person who had participated in bauk. Sixty percent of university students said they knew of someone who had participated. One trend noted anecdotally by women’s-rights NGOs is that non-Khmer-speaking women (prostitutes or not) seem to be more common targets of bauk/gang rape, perhaps because their foreignness/otherness as immigrants appears to make it more acceptable to the men involved. Trafficking Another issue that comes along with a large population of unskilled Cambodian youths is unemployment and a susceptibility to human trafficking. Human trafficking is a form of exploitation that involves controlling and transporting people through the use of force, deception, or coercion. It is reported to be the third most profitable criminal activity in the world after drug and gun smuggling, and resulted in estimated worldwide profits of $31 Billion USD in 2008. Cambodian men, women, and children are trafficked for sexual and labor exploitation in Thailand, Malaysia, Macao, and Taiwan. The traffickers are reportedly organized crime syndicates, parents, relatives, friends, intimate partners, and neighbors. Cambodian men are trafficked into commercial fisheries, seafood-processing plants, and for farm, industrial, and construction labor. The trafficking of women commonly occurs for exploitation as sex workers. It is also common to find Vietnamese and Chinese women trafficked into Cambodia working as prostitutes, commonly from ages 15 to 18. This is partly so not only because agents in both places act as Cambodia way-stations to move the women on to industrialized nations, but also because within the local sex industry of each nation the foreign women are perceived to be more compliant and less resistant when they are in a strange country with an unfamiliar language, customs, and geography. In a foreign land they will be unaware of any resources to help them escape and may be subject to prosecution as illegal immigrants if they approach the police. Psychologically, they feel isolated and may see their captors as their only hope for survival. Even their employers or customers, who do not speak Khmer, may not realize that they are unwilling participants. In Cambodia, a local nongovernmental agency study found that 76% of trafficked children sent to Thailand came from families who owned land, 93% owned their own house and had no debt on the land or house, and 47% stated that their mother was the facilitator. Young Cambodian girls who are virgins are also highly sought after by traffickers, as clients will see them as being free from HIV or STDs. They are also thought to convey increased vigor to their male clients, an animist belief common throughout eastern Asia. Reports state that they are bought for a “week of use” and confined to a hotel or guesthouse room for the duration. Landmines Other residual effects from the conflicts include the remaining land mines and unexploded military ordinance that many of the different warring groups (US, Vietnamese, Royal Cambodian, Thai, Khmer Rouge, and other military forces) in Cambodia left behind. Cambodia is one of the most heavily mined areas in the world. In 2009, more than 10 years after the last of the Khmer Rouge surrendered, the Cambodian Mine Action Centre found and destroyed 19,511 mines and 133,164 artillery shells and bombs. It is estimated that two to four million mines remain. Cambodia has one amputee for every 290 people, one of the highest ratios in the world. This is especially tragic considering the youthful demographic of the population. UNICEF estimates that children account for half of landmine casualties in Cambodia. Many of these victims will not have access to modern prosthetics and will be at a severe disadvantage for work in a crowded labor market. They also have no access to physical medicine and rehabilitation specialists that amputees in developed C 333 countries would normally see. These victims also have unmet mental health needs and commonly express symptoms of PTSD and chronic depression. Refugees From 1975 to 1993, over 500,000 Cambodians fled into Thailand and another 100,000 entered Vietnam. At least 300,000 of those Cambodians permanently fled the region with more than 179,000 ending up in the USA, 50,000 in France, and 45,000 in Australia. Most of the refugees left Cambodia after the genocide because the Khmer Rouge would generally not allow the population to leave Cambodia. For instance, only 300 Cambodians arrived in the USA in 1977. After the fall of the Khmer Rouge from power in 1979 and as the Vietnamese came into Cambodia, a large amount of the Cambodian population made their way westward. In 1979, 6,000 Cambodian refugees entered the USA. A year later, 16,000 more refugees followed. The year 1981 saw the largest number of Cambodian refugees enter the USA, 27,100. The Cambodian refugees who fled to Thailand overwhelmed resources at the border. In 1979, an international response led to the opening of several refugee camps within Thailand for some 160,000 refugees; another 350,000 lived in Thailand outside of the camps. Several hundred thousand returned to Cambodia after the arrival of United Nations Peacekeepers in the 1990s. Gangs Cambodian refugees resettled in the developing world have been associated with limited assimilation to their adopted culture and a higher rate of gang activity. This is thought to come from a series of factors: poor skills base on arrival, difficulty learning a language, familiarity with weapons, a higher rate of untreated mental illness and desensitization to violence, lack of parental guidance and role models, and settling in low-income/ high-crime neighborhoods where some communities may have the need to band together to protect themselves. In Los Angeles 46% of Cambodians were found to be living below the poverty line as opposed to 27% of Vietnamese. Cambodians who have had negative experiences with the Khmer Rouge and then in refugee camps before arriving in the USA often show a fear of and distrust towards authority. This may make them C 334 C Cambodia less prone to cooperation and more likely to turn within their own community for support and perceived protection. In the USA, gang-associated violence or misdemeanor crimes of suspected gang members can be a cause for deportation if immigrants have not achieved US citizenship, which many Cambodian immigrants in the USA have not. This had not been an issue in the past, as prior to 2001 there was not a treaty regulating deportation. The number of deportees is rising with several thousand pending return to Cambodia, despite the fact that many speak Khmer poorly or are not acclimatized to life in Cambodia. This is of concern to health care workers who treat suspected gang members or drug abusers who may be at risk for deportation. Health Care in Cambodia In addition to problems arising from the Khmer Rouge genocide and displacement, Cambodia faces problems that similar developing nations have to contend with, such as corruption, infectious diseases, poverty, and a significant lack of basic infrastructure. In developing countries, local economics determine illness exposure, and Cambodia is not an exception. Seventy-five percent of the country is engaged in agriculture and 35% of the population lives below a very marginal poverty line. Stability is beginning to pay off, however, the government-funded public health system is reportedly ineffectual, with up to 100% of the funds and equipment lost to corruption and diverted to private clinics – NGOs are stepping in to provide networks of clinic and birthing services. Cultural Issues Cambodian men are the traditional heads of household, but women have always had a role as “purse keepers” and masters of the household budget in Cambodia. After the genocide and years of war, in many households divorced, widowed, or separated women are accepted as the head. Age has traditionally been very important in Cambodian culture. Extended families often look to an older parent or grandparent for adjudication or structure and for Cambodian refugees; this can be stressful as the younger generation may be more likely to adapt to local customs. Younger members of refugee families may be expected to act as caregivers, translators, and transportation assistants for older family members requiring medical care. This can set up situations where health care is neglected, as older members feel they do not want to intrude or cannot ask younger members to help them access care. Respect for the elderly is essential in a Cambodian family setting, and the oldest members should be greeted first and last in a family meeting. Communication can be very frustrating for Western-trained health care workers as it is unusual for older Cambodians to respond negatively or say “no.” Synonyms for no may be a lack of response to the question, statements such as “it’s ok” or “no problem,” or even an unconvincing “yes.” It is generally of little value to press directly for answers. Emotion, including anger, frustration, or loud, cheerful, or overly familiar behavior, is often out of place and Cambodians, like Thai, prize equanimity in the face of distress and confrontation. Translators may have difficulty conveying tone or Western concepts in psychological or psychiatric assessment. It is important that health care providers address these challenges in communication; using a translator that is incompatible for gender, age, or other reasons will lead to false or limited information. Children Cambodians see compliments or unnecessary attention to children as bad luck. Cambodian society also sees corporal punishment as a common and acceptable method of feedback. Cambodians in Western society may be distressed at the lack of restraint and structure that schools provide and sometimes blame this for the high rate of gang involvement described above. Childhood immunizations are generally accepted. Physical Touching Greeting is by the Sampeah gesture, pressing the hands together and bowing the head. The bottom of the foot is considered unclean and should never be pointed at a Cambodian. Touching of the head is thought to impact the soul, and should be done only after obtaining permission during a physical examination. Names and Language The Khmer language places the family name ahead of a given name and both are used in many cases to show respect within a family and by strangers. Women Cambodia usually keep their father’s surname after marriage. Names of Cambodians in Western Arabic spelling are usually adaptations that were taken on arrival at refugee centers in Thailand or on arrival to their adopted country. Different family members may have slightly different spellings if they arrived separately. The Khmer language is not always as precise as Western languages in terms of medical symptoms. For instance, “Krun” is commonly translated as fever, but may actually refer to malaise, “hot and cold,” or flushing. However, “Krun jang” usually refers to high fevers and rigors and is associated with malaria. Traditional Medicine Practices Although Cambodians are primarily Buddhist, there is an extensive range of animist and Chinese influences. Cupping, acupressure, acupuncture, massage, and traditional medications such as bark or animal products may be used for a variety of ailments. It is not uncommon to mix traditional therapies with alcohol. Spiritual practices are wide and varied; tattoos may be used for protection, amulets may be thought to convey healing powers or protection, and “Yuan,” inscriptions over windows or doors, may be used for protection against spirits. Cambodians may use a combination of traditional, spiritual, and complementary medicine practices and see no sense of exclusivity about them. It is common that they associate medications with symptoms of distress and stop the medications when the symptoms alleviate. C survey conducted on the mental health of Southeast Asian refugees, 84% of Cambodian households had at least one member under a physician’s care in comparison to 45% of Vietnamese households. This is thought to reflect psychiatric as well as psychosomatic issues from past traumatic experiences. A number of case reports discuss specific PTSD symptoms surrounding episodes of cannibalism that were witnessed or experienced by child and adult survivors of the Khmer Rouge and the famine that resulted. Culture-Bound Syndromes “Koucharang,” or “thinking too much illness,” is associated with past trauma and symptoms of headaches, behavioral changes, and other somatic complaints. “Khyol,” or “wind illness,” may also refer to dizziness and fever, but commonly describes a disturbance of balance that can be due to a variety of illnesses. “Sore neck syndrome” may entail headaches, blurry vision, tinnitus, dizziness, and palpitations/shortness of breath. This is thought to be a manifestation of panic disorder. Pregnancy and Childbirth Traditionally childbirth was at home, but among refugees and in Cambodia this is switching to hospitalbased midwives or birth attendants (chmop). There is often a strong preference for female attendants. Delivery is thought to leave women susceptible to cold. Cambodian women are anecdotally noted to be stoic during childbirth. Mental Health A report in the Journal of the American Medical Association stated that 62% of Cambodian refugees who came to America to escape the Khmer Rouge are suffering from posttraumatic stress disorder. Another 51% suffer from severe depression. Mental illness in the Cambodian community is often only addressed indirectly and reluctantly. Animist influences suggest it is due to spirit possession and Buddhist influences suggest a role for bad karma from previous acts and shame, both leading to stigma within the community. Initial presentations for mental distress will often be to local Buddhist religious figures and traditional medicine practitioners. Only if these are unsuccessful will an attempt generally be made to engage Western practitioners. In a 1985 California Infections Cambodia is noted to have a very high burden of tuberculosis (TB) with 64% of the population infected and an average annual death rate from TB of 13,000 people. Cambodian refugees are at even higher risk of infection due to crowded conditions in some camps. Multidrug resistance is known within Cambodia and some refugees may have been partially treated due to being moved between camps in Thailand. Infections remain the leading cause of death and disability in Cambodia according to the World Health Organization. The current HIV prevalence rate is estimated at 0.8% as of 2007. However 40–50% of the prostitutes in Cambodia are thought to be HIV positive, and Cambodian emigrants thought to have practiced 335 C 336 C Canada prostitution should be tested for a range of sexually transmitted diseases including HIV, syphilis, gonorrhea, and chlamydia. Other infections seen in refugees and Cambodian immigrants include: amebiasis, angiostrongyliasis, anthrax, capillariasis, chikungunya, cholera, cryptococcosis, cryptosporidiosis, cysticercosis, dengue, Japanese encephalitis, filariasis, gnathostomiasis, helminthiasis, hepatitis B (15% of the population in some studies), leishmaniasis, leprosy, leptospirosis, malaria, melioidosis, mycetoma, strongyloidiasis, trenatodes, tropical sprue, typhus, and yaws. Cambodians are at also at a distinct risk for oral cancer associated with betel leaf exposure that is commonly chewed and kept like loose tobacco as a quid at the gum. Cambodian Mine Action Centre. Global summary progress report. Retrieved March 11, 2010, from http://www.cmac.gov.kh/page. php?key=progress_summary_report Gender and Development for Cambodia NGO. (2010). Paupers and princelings: Youth attitudes toward gangs, violence, rape, drugs and theft. Retrieved March 11, 2010, from http://cambodia.ahrchk. net/mainfile.php/news200304/595 United Nations Inter-Agency Project on Human Trafficking. Global summary progress report. Retrieved March 11, 2010, from http:// www.no-trafficking.org/cambodia.html United States Department of State. (2009, June 16). Trafficking in persons report 2009 – Cambodia. Retrieved March 9, 2010, from http://www.unhcr.org/refworld/docid/4a4214c82d.html University of Washington. (2010). EthnoMed. Retrieved March 11, 2010, from http://ethnomed.org/clinical/culture-bound-syndromes/ ethnographic-study-among-seattle-cambodians Yale University. (2010). Cambodian genocide program. Retrieved March 11, 2010, from http://www.yale.edu/cgp/cgpintro.html Related Topics ▶ Alternative and complementary medicine ▶ Betel nut ▶ Explanatory model of illness ▶ Health beliefs ▶ Posttraumatic stress disorder ▶ Refugee ▶ Refugee camp ▶ Refugee health and screening ▶ Refugee resettlement ▶ Refugee youth ▶ Trafficking ▶ Trauma ▶ Trauma exposure Suggested Readings Dugger, C. (2006, January 8). Cambodia tries nonprofit path to health care. New York Times. Hinton, D. E., Um, K., & Ba, P. (2001). A unique panic-disorder presentation among Khmer refugees: The sore-neck syndrome. Culture, Medicine and Psychiatry, 25, 297–316. Kemp, C., & Rasbridge, L. A. (2005). Refugee and immigrant health: A handbook for health professionals (pp. 101–109). Cambridge: Cambridge University Press. Marshall, G. N., et al. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of American Medical Association, 294, 571–579. Suggested Resources Belser, P., et al. (2010). Forced labor and human trafficking: Estimating the profits. Retrieved March 3, 2010, from Cornell University/ International Labor Organization http://digitalcommons.ilr. cornell.edu/forcedlabor/17/ Canada AMY N. SHARPTON Department of Veterans Affairs, Louis Stokes DVA Medical Center Cleveland, Brecksville, OH, USA History Canada’s history spans thousands of years – from the Paleo-Indians to the present day. Aboriginal people inhabited Canada for millennia, evolving trade networks, distinct spiritual beliefs, and social hierarchies. Long since faded before the arrival of the first Europeans, some of these civilizations were discovered through archaeological investigations. Through the years, various treaties and laws have been enacted between European settlers and the Aboriginal populations. In the late fifteenth century, French and British explorers settled along Canada’s Atlantic coast. After the Seven Years’ War, in 1763, France ceded to Britain nearly all of its North American colonies. Shortly thereafter, Canada was formed as a federal dominion of four provinces. This marks the beginning of a rapid accumulation of provinces and territories and of increasing autonomy from the British Empire. Complete autonomy came with the Statute of Westminster of 1931 and was finalized in the Canada Act of 1982 – which severed all remnants of legal dependence on Britain’s parliament. Canada Over the centuries, aspects of Aboriginal, French, British, and more recent immigrant customs have melded to form a rich Canadian culture. Canada has been influenced greatly by the United States; the two countries are similar in terms of geography, linguistics, and economics. Post–World War II, Canada has been committed to a policy that espouses socioeconomic development domestically and multilateralism abroad, contending that broad goals – such as nuclear disarmament – are best addressed with the cooperative assistance of many nations. Today, Canada is comprised of ten provinces and three territories and is governed as both a parliamentary democracy and a constitutional monarchy with Queen Elizabeth II as its head of state. Geography Canada’s national motto is “from sea to sea,” as it includes most of the northern portion of North America, occupying 41% of the continent. In terms of total area, Canada is second only to Russia. Its territory spans an immense distance, from the Pacific Ocean to the west, the Atlantic Ocean to the east, the Arctic Ocean to the north, and the contiguous United States to the south. The country covers 9,984,670 km2, with a land mass of 9,093,507 km2. The northernmost settlement in the world is found in Canada, at the Canadian Forces Station (CFS) Alert. It is positioned on the northern tip of Ellesmere Island, just north of Alert, Nunavut – a mere 834 km from the North Pole. Culture Historically, Canadian culture was influenced heavily by European traditions, in particular those of Great Britain and France. Over time, aspects of the cultures of Canada’s Aboriginal peoples and immigrant populations have become part of the fabric of the broader Canadian culture. The Aboriginal peoples include members of the First Nations, a term of ethnicity that refers to those whose ancestry is characterized as belonging to the indigenous peoples of the Americas. Canada’s Aboriginal peoples are neither Inuit (Arcticsituated) nor Métis (mixed European-First Nations ancestry). Today, there are more than 630 recognized First Nations governments or bands spread across Canada; approximately 50% of its nearly 700,000 peoples are located in Ontario and British Columbia. C The Canadian government has influenced the culture in specific ways, one of which is through the use of Crown Corporations, Canada’s various governmentsponsored programs, laws, and institutions that promote and affect the culture through media endeavors such as the Canadian Broadcasting Corporation and the National Film Board of Canada. The government promotes numerous events that support Canadian traditions. Also, the government has tried to shape the culture going forward by regulating various media by setting and enforcing legal minimums on Canadian content. They accomplish this through the efforts of oversight bodies such as the Canadian Radio-television and Telecommunications Commission (CRTC). The CRTC is responsible for the regulation of all Canadian broadcasting and telecommunications activities. The best-known of these regulations is known collectively as the Canadian content rules. Canadian content, or CanCon, refers to the requirements that radio and television broadcasters must broadcast a certain percentage of content that was contributed to by persons from Canada. The rules apply to specialty channels as well, and they extend to the nature of the content itself. The CanCon rules are controversial, with one side contending that they preserve the legacy of a rich heritage that is uniquely Canadian, and the other contending that the rules are undemocratic and allow for the trampling of individual consumers’ rights. As Canada’s territory was developed later than other European colonies in the Americas, symbols of pioneers, trappers, and traders were important in the early development of Canadian culture. Francophone is used to describe a natively French-speaking person, whether referring to individuals, groups, or places. The term refers specifically to people whose cultural background is associated primarily with the French language, regardless of ethnic and geographical differences. The Francophone culture beyond Europe is the legacy of the French colonial empire and the Belgian colonial empire. The British conquest of Canada in 1759 brought a large Francophone population under British rule, and the migration of Loyalists from the 13 Colonies brought in British and American influences, thus creating the demand for compromise and accommodation. Comparatively, Canada’s initial interactions with First Nations and Inuit populations were relatively 337 C 338 C Canada peaceful as compared to the United States’ initial interactions with its native peoples. Combined with an economic structure that developed later than other European interests, this served to allow the native people of Canada to have a significant influence on the national culture while simultaneously preserving their own unique identity. Multiculturalism thrives in Canada and is manifest in various regional, aboriginal, and ethnic subcultures – such as the French Canadian of Quebec and the Celtic influences in Nova Scotia and Newfoundland. The Quebec Act of 1774 was an act of the Parliament of Great Britain; it outlined procedures for governance in the Province of Quebec. Key among the Act’s components was the restoration of the use of French civil law for private matters, while the English law was preserved for common law, including criminal prosecution. The Act is viewed as critical to French Canada’s early history. Canada’s multicultural heritage is protected Section 27 of the Canadian Charter of Rights and Freedoms, a bill of rights entrenched in the Constitution of Canada. In this section is written that interpretation should be consistent with the preservation of the multicultural heritage of Canadians. In many of the major cities, Montreal, Vancouver, and Toronto, multiculturalism is robust and part of the cultural norm, with diversity uniting the community. Political System The Canadian government is unusual in that it borrows from both the British and American models of government; it is both a federal system of parliamentary government with strong democratic traditions and a parliamentary democracy. At the signing of the Constitution Act, 1867, governance was established as a constitutional monarchy, wherein the Canadian Crown acts as the core of Canada’s Westminster-style parliamentary democracy. In a constitutional monarchy, a monarch (an individual who rules for life) acts as head of state (the official leader of a nation) within the guidelines of a constitution, which can be written, unwritten, or blended. A constitutional monarchy differs from an absolute monarchy in that an absolute monarch is not legally bound by a constitution of any form and serves as the only source of political power. The Crown is likened to a corporation, with the monarch at the center and the power of the whole shared by multiple institutions of government that act under the sovereign’s authority. In this way, the Crown is the foundation of Canada’s executive, legislative, and judicial branches. Aspects of governance are detailed in the Constitution of Canada. Notably, included in the document are items that have been developed over hundreds of years such as written statutes, court rulings, and conventions. The head of Canada’s executive branch is the king or queen of the United Kingdom, entrusted with powers over the legislative and judicial branches. Historically, this position is honorary rather than enforced, though should they decide, the monarch could assert considerable power over Canada. As they are geographically quite far apart, the monarch appoints a Canadian governor-general to oversee the executive powers. Although the executive branch typically bows to the will of parliament and the constitution, it does so by tradition rather than law. Economy Canada, one of the world’s wealthiest nations, has the ninth largest economy worldwide and is a member of the Organization for Economic Co-operation and Development and Group of Eight. Canada resembles the USA in its market-oriented economic system and production pattern. As of November 2010, Canada was still recovering from the recent global financial crises; its national unemployment rate was 7.6%, with a range of 5.0% in Saskatchewan to 13.8% in Newfoundland and Labrador. In 2008, Canada had 69 companies on Forbes’s list of the 2,000 largest companies in the world. As of 2008, Canada’s total government debt burden was the lowest in the G8. Canada has considerable natural resources, for example, the fishing industry (British Columbia) and the oil and gas industry (Alberta, Saskatchewan, Newfoundland, and Labrador). Northern Ontario holds numerous mines, and historically the fishing industry has been of chief importance to the Atlantic Provinces. Mineral resources include coal, copper, iron ore, and gold. The Canadian economy relies heavily on the international trade of its natural resources. In 2009, agricultural, energy, forestry, and mining exports accounted for nearly 60% of its total exports, while Canada machinery, equipment, automotive products, and other manufactures comprised 38% of exports. The United States is Canada’s largest trading partner, accounting roughly for 73% of exports and 63% of imports. Healthcare Healthcare is delivered through a publicly funded system that is, for the most part free at the point of use, with most services provided by private entities. The system is guided by the Canada Health Act (CHA) of 1984. The CHA contains the stipulations with which the provincial and territorial health insurance programs must conform to receive federal payments. Criteria include universal coverage without copayments for all “insured persons” for all “medically necessary” hospital and physician services. The government establishes quality controls through federal standards; however, it is not involved in day-to-day care. Providers are responsible for handling insurance claims against the provincial insurer; the patient is not involved in the claims process. Private insurance is involved minimally in the overall health care system. Although costs are paid primarily through funding from income taxes, three provinces impose an additional monthly premium. Pharmaceutical medications for the elderly or indigent are covered by public funds or through employment-based private insurance. To control costs, drug prices are negotiated between the federal government and suppliers. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by the family physician. Emphasis is placed on preventive care; annual checkups are encouraged. Canada’s Immigration Policy and Trends Relative to its current population, Canada accepts more than twice as many legal immigrants than the United States. Boasting the world’s second largest land mass, Canada has had a longstanding immigrant-friendly migration policy. In the 1960s, two key developments had far-reaching effects on the country’s policy: the establishment of a point system that favors the highly skilled and the abolishment of provisions that allowed for the screening out of non-Whites. These events provided the possibility of admission to minorities C who had been shut out previously. A large wave of immigrants quickly followed, with Chinese, Indians, and Filipinos arriving in the greatest numbers. With the second largest land mass worldwide and a population only one-ninth that of the USA, Canada has tremendous growth potential. The point system has served to influence positively public perception of immigration. It promotes the theme that Canada is receiving immigrants that it needs, immigrants that are vital to its growth and economy. Other factors that support immigration include: children of immigrants typically do well academically and socially; Canada’s economic downturn has been fairly mild in comparison to other developed countries; and the virtual absence of illegal immigration has removed a dominant source of the conflict that surrounds immigration in other countries such as the United States. Multiculturalism is pervasive throughout Canada, permeating a political culture that is accommodating and attractive to immigrants. While intense debates over immigration are seen in many developed nations, from Australia to Sweden to the USA, Canada is nearly devoid of such anti-immigration sentiment. In fact, few nations accept more immigrants per capita. Recently, the Canadian province of Manitoba petitioned and won the right to bring greater numbers of foreigners in. As they select ethnic and occupational groups judged most likely to stay, currently approximately 600 immigrants each month arrive in and around the province. Related Topics ▶ Health care ▶ Multiculturalism Suggested Readings Morton, D. (2006). A short history of Canada (6th ed.). Toronto: McClelland & Stewart. O’Neill, J. E., & O’Neill, D. M. (2007). Health status, health care and inequality: Canada vs. the US. Forum for Health Economics & Policy, 10(1), 1–43. Suggested Resources For information on the Canadian Broadcasting Corporation. http:// www.cbc.ca/ For information on the governance of Canada. http://canada.gc.ca/ home.html 339 C 340 C Cancer Cancer ELLEN SCHLEICHER PLISKA Family and Community Health, Association of State and Territorial Health Officials (ASTHO), Arlington, VA, USA Cancer Prevalence In 2007, there were over 12 million new cancer cases worldwide, with 5.4 million diagnosed in developed countries and 6.7 million diagnosed in developing countries. Globally, there were approximately 20,000 cancer deaths per day. Of the 7.6 million deaths per year, 2.9 and 4.7 million occurred in developed and developing countries, respectively. In developed countries, the three most common cancers among men were prostate, lung, and colorectal, and among women are breast, colorectal, and lung. In developing countries, the three most common cancers among men were lung, stomach, and liver, and among women were breast, cervix, and stomach. There are regional differences in cancer types depending on the availability and quality of prevention and treatment services, prevalence of risk factors, age of population, and reporting mechanisms. Rates of specific cancers in regions are crucial as the incidence of cancer for new immigrants closely mirrors their home country’s rates. Cervical cancer is the most common cancer of Eastern and Southern Africa, Central America, and South Central Asia. Breast cancer is the most common cancer in Northern and Western Africa, South America, Western Asia, and Northern and Western Europe. Prostate cancer is the most common cancer in the Caribbean and North America. Lung cancer is the most common cancer in Southeast Asia, Eastern and Southern Europe, and Micronesia. The remaining regions of the world have the following most common cancers: Kaposi sarcoma (Middle Africa), stomach (Eastern Asia), colon and rectum (Australia/New Zealand), and oral cavity (Melanesia). Cancer Incidence and the Healthy Migrant Effect Data from the US National Institutes of Health’s Surveillance Epidemiology and End Results (SEER), a dataset of regional cancer registries in the USA and other countries, found that cancer rates from new immigrants to the USA were the same as rates from their native country. Latino immigrants to the USA suffer from relatively rare cancers in their new country but have lower rates of common cancers. However, the immigrants’ future generations experience similar cancers and cancer rates as the host country. In their move to Western countries, within a generation immigrants from Africa and Asia have the same cancer rates as that of their host country, even when rates in their country of origin are low. Also called the healthy migrant effect, new immigrants often are healthier and less likely to die from cancer. Assimilation to the new country’s pollution levels, diet, smoking, and other behaviors over time changes one’s susceptibility to cancer over the life span. Disparities Tobacco Use and Cancer Tobacco use is one of the greatest risk factors for cancer. Differences in tobacco use between developed and developing countries are great: adults in developing countries use tobacco nearly 1.5 times greater than developed countries. However, there is a large variation among regions and countries and frequency of use. While Asian-Americans have the lowest smoking rates in the USA, Asian immigrant groups have the highest smoking rates of all US residents, ranging from 34% to 43% for Asian immigrants versus 10.4% for US-born Asians. Smoking cessation programs are unevenly accessed by immigrant populations, despite their desire to quit. Latino smokers in the USA are half as likely to have ever used nicotine replacement therapy compared to Whites. Barriers to accessing these programs include lack of insurance, lack of awareness of the benefits of a cessation method, and receiving no information on how to quit from a physician. Diet and Colorectal Cancer Colon and rectal cancer (CRC) is the fourth and third most common cancer worldwide for men and women, respectively. However, CRC incidence is markedly higher among developed countries (third and second most common) than developing countries (fifth most Cancer common for men and women). Immigrants from countries with lower CRC rates continue to have lower rates after they migrated to a high CRC country. However, the immigrant’s offspring experiences similar to or higher than the country’s nonimmigrant populations. Changes in CRC rates over the generations point to dietary changes. CRC risk factors include a diet high in animal fats and low in fiber, fruits, and vegetables. Other risk factors include alcohol use, obesity, physical inactivity, and smoking. Acculturation to a new country’s diet, such as Asian and South Asian immigrants’ children in the USA, increases their CRC risk. Preventive Care Unfamiliarity with prevention and early detection of cancer prevents many immigrants from being screened. Without symptoms, many foreign-born populations feel they do not need to visit a physician. When a doctor does not recommend regular examinations, cancer screening is often viewed as pointless. In studies on cervical cancer, foreign-born women said that women only go to the gynecologist when they had pain, unexplained bleeding, or were pregnant. Viruses cause approximately 18% of cancers globally, with a larger percentage (26%) affecting developing nations than in developed countries (8%). Cancers such as cervical, liver, and stomach cancers and Burkitt’s lymphoma are all caused by viruses. Vaccines for the human papillomavirus (HPV), the virus that causes cervical cancer, and hepatitis B and C, the viruses that cause liver cancer, are available but are often expensive and difficult to find in developing countries. Immigrants without these vaccines may migrate to a new country already infected with the virus or have no knowledge of a vaccine that can protect them. Barriers to Care Cultural Beliefs and Cervical and Breast Cancer Cultural beliefs play a large role in cervical and breast cancer screening. Women from many cultures believe cervical cancer is caused by sexual activity and lack of hygiene and not the human papillomavirus (HPV). Latina immigrants are most likely to associate cervical cancer with lack of genital cleanliness after sex. Other C thought causes of the cancer include sex during menstruation, sex at an early age, rape, and general poor hygiene. Mexican- and Salvadorian-born women report physical trauma to the breast, from accidental bumps to falling on something sharp to rough breastfeeding, can cause breast cancer. Breast and cervical cancer is also associated with karma or fate. In these cases, foreign-born women feel that those with cervical cancer are being punished for improper behavior. Younger Asian and Pacific Islander immigrants associate cervical cancer with promiscuity. Women from Southeast Asia and Cambodia linked cervical cancer to karma and were less likely to be screened. Foreign-born Latinas are more likely than native-born Latinas to feel that God gives people breast cancer for leading bad lives. Many cultures feel that following behavioral standards and norms will keep the body healthy. Foreign-born physicians may also hold these views and not recommend Pap smears and breast exams for younger, unmarried patients. Foreign-born women with fatalistic attitudes associated with breast and cervical cancer are less likely to be screened for breast and cervical cancer. Latina immigrants are more likely to believe that having cancer is a death sentence. Holding fatalistic views make immigrants less likely to seek preventive care. Screening is seen as pointless if cancer is unavoidable. Acculturation The length of time immigrants spend in their host country affects the probability they will be screened for cancer. For all cancer screening, naturalized citizens are more likely to be screened for cancer than noncitizens of the same nationality. Women residing in the USA less than 10 years were up to 20% less likely to receive cervical cancer screening than women residing longer. Latina women who spoke mostly Spanish are the least likely immigrant group in the USA to have had a Pap smear in the last 3 years. The more acculturated an individual is, the more likely they will be screened for cancer. Language and Health Literacy Speaking the host country’s dominant language and being able to understand health information and services greatly affect access to care. Studies show that language barriers with a health care provider lower 341 C 342 C Cancer patient satisfaction and increase feelings that his or her questions and concerns were not addressed. Women who do not speak the host country’s native language are less likely to receive breast and cervical cancer screening according to guidelines. While hiring interpreters decreases language barriers, the delays caused in scheduling and recruiting can lead to stress for both the patient and the provider. Likewise, while patient education materials are often written in multiple languages, they are seldom written at or below a sixth-grade reading level. Knowledge of cancer screening guidelines is a strong predictor of being screened for cancer among all immigrant groups. Korean immigrants were three times more likely to have regular Pap regular screenings if they knew the recommended Pap smear guidelines. Both language and lack of health literacy are a major obstacle to education on cancer risks, prevention practices, and the benefits of screening. Geography Physical location can determine the likelihood of receiving cancer-related services. Immigrants living in urban locations, while commonly more equipped with cancer screening facilities, often face barriers with transportation and parking costs and availability and scheduling of services. Neighborhood safety of affordable services may be a factor in obtaining screening and treatment. Immigrants living in rural areas face a different set of obstacles. In remote areas of many countries, health services may be few and far between, requiring the patient to travel hours for appropriate services. Lack of public health infrastructure in these areas puts the burden on the individual to find cancer-related information. In large countries, like the USA, there may also be regional differences in cancer care. Mexican women were found to have different cancer screening rates across different states within the USA. With each state governing their own public health infrastructure and differing access to local resources, a country may have varying resources and barriers to care for immigrants. Insurance Access Access to health care insurance in countries like the USA is vital to accessing a continuous source of care. Compared to the native-born, immigrants are more likely to be uninsured and less likely to have been treated by a physician in the last year. While the uninsured rate for US-born citizens is 13.4%, naturalized citizens, foreign-born individuals, and noncitizens were uninsured at 17.9%, 33.6%, and 43.6%, respectively. The uninsured are less likely to have had routine examinations, including cancer screening tests. Uninsured patients, in general, are more likely to be diagnosed with late-stage cancer than those with insurance. Private insurance is often expensive, the number one reason for being uninsured. Immigrants are less likely to have employer-based insurance and insurance coverage through a spouse. While legislation like the US Patient Protection and Affordable Care Act, enacted in 2010, provides assistance for citizens and legal immigrants to purchase health insurance through an employer or a health insurance exchange, it does not provide assistance to undocumented immigrants. Private health insurance also commonly requires a co-pay, which is often cost prohibitive to low-income immigrants. In the USA, immigrants’ access to federal programs is dependent on their immigrant status and income. Legal permanent residents (LPRs) – immigrants legally granted the privilege of residing permanently in the USA – with 40 work quarters (10 years of work) are eligible for Medicaid, a health program for low-income families. Noncitizen nationals (people born in American Samoa or Swain’s Island), members (born outside the USA) of Indian tribes, and members of Hmong or Highland Laotian tribes that helped the US military during the Vietnam era who are legally living in the USA, their spouses or surviving spouses, and dependent children are eligible for Medicaid given they meet other income requirements. Asylees, refugees granted asylum, Cuban or Haitian entrants, Amerasian immigrants, and LPRs with a military connection are eligible for Medicaid benefits without a waiting period. The State Children’s Health Insurance Program (SCHIP), a health insurance program for low-income children, gives access to children of LPRs after the first 5 years of residency. Some states opt to use state money to cover children of LPRs during the waiting period. Refugee children are eligible for SCHIP during the first 7 years of their residency. The majority of immigrants in the USA do not qualify for Medicaid; these populations have minimal Cancer options for cancer care. The Emergency Medicaid Treatment and Active Labor Act (EMTALA) requires hospitals and medical facilities to provide emergency care to individuals regardless of citizenship status, legal status, or their ability to pay. Emergency Medicaid does not cover patient’s needs after treatment, including follow-up appointments, long-term medication, and follow-up tests. Community health centers are required to give care to everyone regardless of their ability to pay. While neither EMTALA nor community health centers are required to collect citizenship status, undocumented immigrants are less likely to seek care if they think they may be asked for documentation. Continuity of Care Uninsured patients are significantly less likely to have a continuous source of care. The uninsured are more likely to visit community health centers, urgent care centers, and emergency rooms – facilities that are not equipped to handle long-term diseases like cancer. Having a continuous source of care, no matter the type of doctor, increases a patient’s access to preventive health care. Korean and Filipino women with a prior preventive health exam were three and five times more likely to have been screened for breast and cervical cancer than women without a checkup. Similarly, women seeing a doctor for their current pregnancy were nearly 250% more likely to have ever had a Pap smear and over 775% more likely to have had one within the last 3 years. Immigrants without a regular source of care are more likely to rely on emergency rooms when their condition becomes unbearable and commonly miss routine cancer screenings that could find cancer at a more treatable stage. Low Socioeconomic Status Immigrants’ socioeconomic status – an intersection of income, education, and occupation – heavily affects their ability to access cancer screening and treatment. Co-pays associated with health insurance, designed to prevent overuse of services, can be a deterrent to care. Even when health care is free, there are other costs that may make screening prohibitive. Cambodian immigrants in the USA reported that lack of affordable transportation to services was one of the biggest reasons for not receiving cancer screening. C Immigrants tend to work in the lowest paying jobs without the option to take time off for doctor appointments. Rates of cervical cancer incidence increase with lower socioeconomic status across all ethnic groups. Being poor is one of the biggest predictors of a latestage cancer diagnosis. Often, immigrants must choose between health care and other necessities, such as food or heat, or between getting care and losing their job. Regardless of country of origin or ethnicity, people with low socioeconomic backgrounds have worse cancer outcomes. Related Topics ▶ Acculturation ▶ Cancer health disparities ▶ Cancer mortality ▶ Health barriers ▶ Health beliefs ▶ Health literacy ▶ Healthy immigrant ▶ Immigration status ▶ Language barriers ▶ Public health ▶ Public health insurance ▶ Smoking ▶ Tobacco ▶ Tobacco use ▶ Undocumented Suggested Readings Aday, L. A. (2001). At risk in America: The health and health care needs of vulnerable populations in the United States. San Francisco: Jossey-Bass. Aguirre-Molina, M., & Molina, C. W. (2003). Latina health in the United States. San Francisco: Jossey-Bass. Bigby, J. (2003). Cross-cultural medicine. Philadelphia: American College of Physicians. Epstein, P. (1998). Global migration: The health care implications of immigration and population movements. Washington, DC: American Nurses Association. Gropper, R. (1996). Culture and the clinical encounter: An intercultural sensitizer for the health professions. Boston: Intercultural Press. Gulliford, M., & Morgan, M. (2005). International bibliography of the social sciences: Sociology. London: Routledge. Hahn, R., & Harris, K. (1999). Anthropology in public health. Oxford, NY: Oxford University Press. Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. Koh, H. A. (2009). Toward the elimination of cancer disparities: Clinical and public health perspectives. Dordrecht: Springer. 343 C 344 C Cancer Health Disparities Kosoko-Lasaki, S., Cook, C. T., & O’Brien, R. L. (2009). Cultural proficiency in addressing health disparities. Sudbury: Jones & Bartlett. LaVeist, T. A. (2002). Race, ethnicity, and health (1st ed.). San Francisco: Jossey-Bass. Schleicher, E. (2007). Immigrant women and cervical cancer prevention in the United States. Baltimore: Women’s and Children’s Health Policy Center, Johns Hopkins Bloomberg School of Public Health. Suggested Resources American Cancer Society. (2007). Global cancer facts and figures. Retrieved May 10, 2010, from http://www.cancer.org/downloads/STT/Global_Facts_and_Figures_2007_rev2.pdf New York University School of Medicine. (2010). Immigrant cancer portal project. Retrieved May 13, 2010, from http://www.med. nyu.edu/cih/cancer/background.html Surveillance Epidemiology and End Results (SEER). (2010). Cancer incidence in U.S. immigrant populations. National Cancer Institute. Retrieved May 1, 2010, from: http://seer.cancer.gov/studies/ surveillance/study5.html Cancer Health Disparities CLAUDIA BAQUET1, SHIVONNE LAIRD2 1 Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA 2 Formerly of Office of Policy and Planning, University of Maryland School of Medicine, Baltimore, MD, USA Immigrants to the USA may have health-related protective and/or detrimental health behaviors, cultural beliefs that contribute to their perception of health and health care, their view of the disease called cancer, or preexisting conditions. It should be noted, however, that the new resources available in the USA, the resident culture of Americans and assimilated migrants, and the immigrant experience itself may affect their health outcomes and health-seeking behavior over time. Thus, health outcomes found in donor countries do not necessarily correspond to outcomes for migrants to the USA. Cancer is a group of diseases characterized by abnormal cell growth and spread or metastasis. There are over 100 different types of cancer. Cancer is the second leading cause of death in the USA and accounts for significant morbidity and mortality globally. The National Cancer Institute (NCI) defines “cancer health disparities” as “differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific population groups in the United States.” Cancer survivorship disparities are included in this definition. Health disparities are defined as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.”A health disparity population is one in which there are significant differences in the overall rate of disease incidence, prevalence, morbidity, mortality, or survival rates in the population as compared to the health status of the general population. Complex and interrelated factors contribute to the observed disparities in cancer incidence and death among racial, ethnic, and underserved groups including immigrants. Health behaviors, cultural factors and language barriers, health care access, satisfaction with health care, and risk/exposures from the “parent country” all have significant influences on cancer disparities. When describing, monitoring, and addressing cancer disparities for immigrants, it is critical to consider worldwide cancer rates in the parent country as well as US rates. Contributing factors include: ● Major risk/exposures including tobacco use, occu- ● ● ● ● ● ● pational exposures, SES, alcohol intake, viral (EBV, HBV, BCV, HPV) Health care seeking and access to health care Advanced stage at diagnosis Culture, language, and beliefs Participation in clinical trials Discrimination in the health care delivery system Biology Immigrant Factors Identification and understanding of factors unique to immigrant communities are essential to address cancer health disparities in such richly diverse communities. ● Migration factors and related differential risk/expo- sures and generational issues: documented for many immigrants including Japanese immigrants, Latinos, and some African immigrants. Cancer Health Disparities C ● Acculturation: Documented for Latino/Hispanic ● Hmong refugees from Vietnam, Laos, and Thailand communities especially for dietary patterns and nutritional consumption. ● Language and cultural influences: Related to access to health care, health literacy, treatment regimen, and medication compliance. It is also related to gender factors for Latino and Asian females who often prefer a female health care professional. ● Discrimination, satisfaction with health care, and racial/ethnic concordance between patient and provider: Documented for Latino/Hispanic, Asian, and African immigrants. settled in California Korean-Americans Pacific Islanders and Alaska Natives African and Asian men: cancer of the penis Asians and esophageal cancer and stomach cancer Migrant farm workers in California, many of whom were recent Mexican immigrants: – Lack of access to care, including screening programs and treatment was identified as a contributor to cancer disparities for migrant farm workers. – Higher incidences of brain cancer and leukemia were attributed to occupational exposures, particularly to pesticides. Cancer incidence patterns among first-generation immigrants are often nearly identical to those of their native country. Through subsequent generations, these patterns evolve to resemble those found in the USA especially for hormone-related cancers, such as breast, prostate, and ovarian cancer and neoplasms of the uterine corpus and cancers attributable to westernized diets, such as colorectal malignancies. Longer residence in the USA appears to lead to lower rates of cancers attributed to Asian diets, such as stomach cancer associated with the highly salted and nitrite-containing foods common in Asia. Studies have documented the following: ● Known viral-related cancers include primary liver cancer caused by hepatitis B and C. ● Helicobacter pylori related to stomach cancer incidence. ● Cervical cancer caused by human papillomavirus (HPV) has been documented as a worldwide cause of elevated cervical cancer rates in Latin America, Mexico, Africa, and parts of Asia. ● Environmental factors and cancer in immigrants: nasopharyngeal cancer associated with exposure to smoke from stoves used for cooking in the home and salivary cancer associated with cold, dark environments that produce vitamin A deficiencies. Cancer disparities and immigrant studies have been reported, with an emphasis on environmental factors and cancer risk. This includes: ● First- and second-generation Japanese immigrants living in Hawaii ● Asian-American women ● Africans including primary liver cancer ● Vietnamese-Americans ● ● ● ● ● Cancer mortality is related to the interaction of complex factors such as stage at diagnosis, cell type and tumor biology, access to quality oncology care, and follow-up. Cultural and language influences of new and existing immigrants to the USA are related to cancer outcomes. Disparities in Racial/Ethnic Groups Overall, African-American males develop cancer 15% more frequently than White males. African-American woman have a lower breast cancer rate, but higher death rate than White women. For all cancers combined, Blacks have the greatest burden, with incidence and death rates higher than any other racial/ethnic group, specifically a death rate 25% higher than Whites. Although Whites have the highest breast cancer rate, for all ages combined, of any racial/ethnic group, Blacks are more likely to die from this disease. This may be caused by lack of medical coverage and late detection, as well as unequal access to improvements in medicine. There is also some research that shows that Blacks and Latinas are more likely to have a more aggressive form of breast cancer than other races. Latinas and Black women also have the highest rates of cervical cancer, with Black women having a higher death rate. This high rate is due to the lack of screening and persistent infection with certain strains of HPV. African-American men have the highest incidence and death rate for prostate cancer, with a death rate twice that of Whites. Blacks have higher incidence and death rates of both colorectal and lung/bronchus cancers. 345 C 346 C Cancer Health Disparities Latinas and Black women have the highest rates of cervical cancer, and though Black women have a higher death rate, Latinas have a higher incidence rate. This high rate is likely due to the lack of screening and persistent infection with certain strains of HPV. Latinos have the lowest rates of colorectal and lung cancer of any US racial/ethnic group. Overall cancer incidence rates are lower for Asians and Pacific Islanders living in the USA than nonHispanic Whites, with the exception of Native Hawaiian women, who have statistically higher all cancer combined rates than White women. The Asian and Pacific Islander (API) population have the highest rates of liver and stomach cancers. They suffer more often from cancers that are related to certain infections, though more study is needed. Asian and Pacific Islanders should not be viewed as one, homogenous group, however, especially regarding cancer disparities. For example, Barry Miller and colleagues examined varying patterns in cancer incidence and mortality among the API population. A majority of the sample for this study was born outside the USA, with the exception of Native Hawaiians and JapaneseAmericans. They found that liver cancer is highest among Laotian men, though liver cancer incidence and death rates were higher than non-Hispanic Whites for both men and women. The presumed cause was hepatitis B and C infection, which are endemic in Asian, Middle Eastern, and African countries. Laotian men also had the highest rates of liver, prostate, and stomach cancers, while Japanese men and women had the highest colorectal cancer rates. Stomach cancer rates were also high for many of the API groups, with the exception of Asian Indians/Pakistanis and Filipinos. Samoan and Native Hawaiian men were found to have the highest overall cancer rates, because of high rates of prostate and lung cancers, but they are not higher than those of White men. Lung cancer was among the four cancers most frequently experienced by all the API women groups, as was colorectal cancer (for those for whom they had enough data). Native Hawaiian, Samoan, and Tongan women have the highest overall cancer rates, higher even that White women. Breast cancer was highest among Native Hawaiian women. Vietnamese women were found to have higher rates of cervical cancer than White women, along with Kampuchean, Korean, and Laotian women. In another study, Chinese and several Southeast Asian immigrants have also been found to be at increased risk for nasopharyngeal cancer, with suggested causes including high consumption of preserved foods from an early age. Alaska Natives have higher rates of colon and rectal cancer than the national average. American Indians have the lowest cancer survival rates of any US ethnic group. Native American data are not representative, but they have been shown to have higher rates of kidney and renal pelvis cancers than other racial/ethnic groups. Eleven million cases of cancer occur annually worldwide, six million of them in low- and middleincome countries. In recent years, four million deaths from cancer have occurred each year in low- and middle-income countries. High smoking rates in these countries have made lung cancer the most common form. Of the approximately 1.1 billion smokers in the world, 80% of them live in low/middle-income countries. In developing countries, 26% of all cancers are attributable to infectious agents, compared to about 8% in high-income countries. Nearly 300,000 women die every year from cervical cancer every year, 85% of them from low/middleincome countries; the likely cause is infection with one of several strains of human papilloma virus (HPV). Disparities in cancer outcomes worldwide pertain to children as well as adults. One hundred and sixty thousand children worldwide are diagnosed with cancer; currently, 80% of US children under 15 are cured, while 80% of children in low/middle-income countries die because of late diagnosis and lack of treatment. In developing countries, most cancers may already be incurable when first noted, because cancer stage at time of detection is typically much further advanced than in wealthier countries. Patients in low/middle-income countries also tend to have additional health problems that may make their recovery from cancer more difficult. Approaches to Address Cancer Disparities in Immigrants The unique cultural and cancer patterns of immigrants require careful strategies and program development to successfully address cancer disparities in such diverse communities. Going beyond translation services is Cancer Incidence mandated. Assuring culturally competent and relevant prevention, screening and early detection and quality treatment necessitates bidirectional community engagement between communities and the health care delivery system. Models such as WINCART, AANCART, Redes En Accion, and the New York Center for Immigrant Health’s Cancer Disparities Program are examples of community engaged and tailored programs, including for immigrants, which address cancer health disparities for diverse communities. Related Topics ▶ Barriers to care ▶ Breast cancer screening ▶ Cancer mortality ▶ Cultural competence ▶ Environmental exposure ▶ Ethnicity Suggested Readings Freedman, L. S., Edwards, B. K., Ries, L. A. G., & Young, J. L. (Eds.). (2006). Cancer incidence in four member countries (Cyprus, Egypt, Israel, and Jordan) of the Middle East Cancer Consortium (MECC) compared with US SEER [NIH Pub. No. 06-5873]. Bethesda, MD: National Cancer Institute. Gomez, S. L., Clarke, C. A., Shema, S. J., Chang, E. T., & Keegan, T. H. M. (2010). Disparities in breast cancer survival among Asian women by ethnicity and immigrant status: A populationbased study. American Journal of Public Health, 100(5), 861–869. Epub 2010 Mar 18. [PubMed]. Gomez, S. L., Quach, T., Horn-Ross, P. L., Pham, J. T., Cockburn, M., Chang, E. T., Keegan, T. H. M., Glaser, S. L., & Clarke, C. A. (2010). Hidden breast cancer disparities in Asian women: Disaggregating incidence rates by ethnicity and migrant status. American Journal of Public Health, 100(Suppl. 1), S125–S131. Epub 2010 Feb 10. [PubMed]. Henderson, B. E., Kolonel, L. N., Dworsky, R., Kerford, D., Mori, E., Singh, K., & Thevenot, H. (1985). Cancer incidence in islands of the Pacific. Journal of the National Cancer Institute, 69, 73–81. Kolonel, L. N., Hinds, M. W., & Hankin, J. H. (1980). Cancer patterns among migrant and native-born Japanese in Hawaii in relation to smoking, drinking, and dietary habits. In H. V. Gelboin et al. (Eds.), Genetic and environmental factors in experimental and human cancer (pp. 327–340). Tokyo: Japan Science Society Press. Lanier, A. P., Bender, T. R., Blot, W. J., Fraumeni, J. F., Jr., & Hurlburt, W. B. (1976). Cancer incidence in Alaska Natives. International Journal of Cancer, 18, 409–412. Le, G. M., Gomez, S. L., Clarke, C. A., Glaser, S. L., & West, D. W. (2002). Cancer incidence patterns among Vietnamese in the United States and Ha Noi, Vietnam. International Journal of Cancer, 102, 412–427. Erratum in: Int J Cancer 2003;104(6):798. C National Cancer Institute, Center to Reduce Cancer Health Disparities. (2000). Minority Health and Health Disparities Research and Education Act United States Public Law 106–525, p. 2498. Ziegler, R. G., Hoover, R. N., Pike, M. C., Hildesheim, A., Nomura, A. M., West, D. W., Wu-Williams, A. H., Kolonel, L. N., HornRoss, P. L., Rosenthal, J. F., & Hyer, M. B. (1993). Migration patterns and breast cancer risk in Asian-American women. Journal of the National Cancer Institute, 85, 1819–1827. Cancer Incidence CLAUDIA AYASH New York University Langone Medical Center, CORE (Cancer Outreach, Outcomes, and Research for Equity) Center, New York University Cancer Institute, New York, NY, USA According to the current population survey, 28.4 million immigrants now reside in the United States, a 43% increase since 1990. Many immigrants that settle in the United States bring with them age-old traditions and practices that may be different from Western customs. Cultural factors may affect their risks for certain diseases such as cancer as well as impact their use of the American health care system. Therefore, the study of disease patterns in immigrant populations has become an important area of research in the field of public health. There are differences in the incidence, prevalence, mortality, and burden of cancer among specific population groups in the United States. This has created opportunities for research and much debate about the causes of health disparities between ethnic and racial groups. Addressing cancer health disparities has become a priority for the United States government’s principal agency on cancer research, the National Cancer Institute (NCI) and other major cancer organizations like the American Cancer Society (ACS), in addition to medical centers and community-based organizations. Cancer trends may give researchers some insight into how different aspects of culture like diet, exercise, and religious beliefs and practices may affect risks for cancer in addition to health care access issues. Studies have shown that cancer incidence patterns of immigrants tend to mirror those of their native countries. Through 347 C 348 C Cancer Mortality subsequent generations, however, cancer incidence patterns change to resemble those in the United States, particularly in cancers related to hormones, such as breast, prostate, and ovarian cancer and cancers related to Westernized diets, like colorectal cancers. Later generations tend to abandon some of their cultural practices and adopt an American lifestyle that typically includes a diet high in fat and processed foods. An example of this phenomenon is that Asians living in the Far East have lower incidence of breast and prostate cancers than their American counterparts. However, when Asians migrate to the United States, in time their risk of breast and prostate cancer becomes similar to those of people in this country. These changes typically start to take effect with the second generation and become more prominent by the third generation. There are methodological issues that may impede research on cancer incidence among immigrant populations as well as cultural factors. The population-based Surveillance, Epidemiology, and End Results (SEER) program of the NCI is an important resource for the study of cancer incidence and prevalence among immigrant and minority populations. SEER collects and publishes cancer incidence and survival data including patient demographics, primary tumor site, tumor morphology and stage at diagnosis, first course of treatment, and follow-up for vital status from population-based cancer registries covering approximately 26% of the US population. Collecting information on place of birth is an important variable for studies of immigrants. Although these data are collected by SEER registries, the information is often missing for a significant number of patients. SEER registries rely on hospitals for this information, many of which do not have uniform data collection systems and birthplace information if often not included. Additionally, many immigrants do not know certain aspects of their medical history including their family history because of distance between family members and customs that may prohibit discussions about cancer diagnoses. They may not know if any of their relatives had cancers that could potentially put them at a higher risk of one day developing the disease. Knowing a patient’s family history is important for research purposes and to also help practitioners to determine a patient’s risk for familial cancers and an appropriate screening schedule. Health disparities research will likely continue to be a priority in areas with large immigrant populations. Understanding incidence rates among different populations is important to help health practitioners and health educators to develop tailored culturally appropriate education and early detection campaigns in addition to effective treatments. Information gleaned from this research could also have far-reaching effects by improving cancer outreach and treatments efforts worldwide through international collaborations. Related Topics ▶ Cancer health disparities ▶ Cancer mortality ▶ Cancer prevention ▶ Health barriers ▶ Health beliefs ▶ Health disparities Suggested Resources American Cancer Society. http://Cancer.org Current population survey. http://www.census.gov/cps/ National Cancer Institute Center to Reduce Cancer Health Disparities. http://crchd.cancer.gov/disparities/defined.html Orom, H., Coté, M. L., González, H., Underwood, W., & Schwartz, A. G. (2008). Family history of cancer: Is it an accurate indicator of cancer risk in the immigrant population? Cancer. doi:10.1002/ cncr.23173. Published Online: December 10, 2007. Surveillance, epidemiology, and end results. http://seer.cancer.gov/ Cancer Mortality MELINA ARNOLD Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany Cancer mortality is determined by the risk of developing cancer (cancer incidence) and factors that influence the survival after cancer diagnosis. Some cancers, such as colorectal or breast cancer, are better detectable and treatable than others as opposed to, for example, liver, stomach, and pancreatic cancer, which are less curable. Survival from the former can be influenced by adequate Cancer Mortality prevention, screening, and therapy. Disparities in cancer mortality and survival may therefore be ascribed to differences in (i) disease susceptibilities, (ii) exposures to carcinogens, (iii) access to cancer prevention and (iv) quality of treatment. Cancer burden, particularly cancer mortality, shows substantial variation within and across populations. Individual and area-based differences in socioeconomic position – comprising education, occupation, income, housing situation and social environments – are associated with poor access to prevention measures, suboptimal treatment, and follow-up as well as a higher mortality within certain population groups. Disparities in cancer mortality across populations, for example, between allochthonous (immigrant) and indigenous (native) people of a country may reflect the importance of another prognostic factor: ethnicity. Several studies suggest negative correlations and a close connection between the two, since immigrants are often likely to be socially disadvantaged in their country of residence. In this context, immigrants are defined as persons or groups that leave their country of origin in order to settle permanently in another, whereas ethnicity corresponds to a social construct that is based on shared beliefs, views, lifestyles, and cultural habits – mostly also common origin. Thus, immigrants usually belong to (or consider themselves members of) a certain ethnic minority group and are therefore of “foreign ethnicity.” In less well-developed regions of the world, infectious diseases still dominate as primary causes of disease and death. However, due to the epidemiologic health transition, low-income countries undergo a shift of global burden of disease, entailing ageing populations and an increasing occurrence of chronic conditions like cancer. Still, cancer incidence is rather low in these countries, but cancer mortality plays a big role in comparison to more developed regions. Immigrants from non-Western/low income countries retain some features of their countries of origin and carry their cancer risk profile (characterized by low incidences but high mortality) to their new country of residence, where they face new exposures and environments. Several studies confirm that migrants show substantial risk diversity in comparison to the indigenous population and indicate elevated risks for cancers that are associated with infections, like cervical, liver, or C stomach cancer. Those risks strongly relate to exposures experienced in early life/childhood and thus underscore the importance of the life-course perspective in carcinogenesis. Lower risks are observed for lifestyle-related cancers such as breast, colorectal, or prostate cancer. Several studies show that African Americans are disproportionally more likely to develop and to die from cancer than any other ethnicity. This applies to all cancer sites combined as well as in particular to cancer of the esophagus, oral cavity, stomach, liver, and prostate where large discrepancies exist and risks are often more than twice as high compared to Whites. Moreover, even mortality from cancers associated to lifestyle factors is elevated in this population group (i.e. breast, lung, and colorectal cancer); however, this pattern is more pronounced among men. Migrants from Asia often exhibit high mortality rates for cancers of the oral cavity, nasopharynx, stomach, and liver. Similar observations have been made for immigrant populations residing in European countries. South American migrants were found to be more likely to die from cancer of the nasopharynx, stomach, liver, gallbladder, and cervix as well as Hodgkin’s disease; migrants from Turkey show high mortality rates for cancer of the nasopharynx, stomach, liver, thyroid gland, and Hodgkin’s disease in comparison to autochthonous populations of their western host countries, respectively. Key factors that may explain disparities in cancer mortality across ethnicities are differences in stage of disease at diagnosis as well as treatment, compliance, and survivorship. Cancer Stage at Diagnosis Cancer burden could be decreased significantly if patients with cancer would be detected and treated early and thus more effectively. Early detection implies recognizing symptoms in due time and immediate seeking of medical care. Regular attendance in screening programs helps identifying early or pre-cancerous stages for some cancer sites, before any obvious symptoms occur. Several studies report that immigrants are more likely to be non-attendees in screening programs and tend to present at later and less curable stages of cancer than indigenous populations of their host countries. 349 C 350 C Cancer Mortality There are various reasons for non-attendance, the most important barriers being personal (literacy, language skills, health knowledge), cultural (religious beliefs, differences in health seeking behaviors, perception of symptoms), and financial (health insurance status) factors. Personal beliefs about illness, especially culturally determined disease perception, have been found to have a major impact on the time of first diagnosis, survival, and mortality. Treatment, Compliance, and Survival Adequate treatment and care are essential to reduce cancer mortality. This especially applies for cancers that have high cure rates when detected at an early stage and treated according to best practice (such as breast and colorectal cancer). Cancer patients require continuous medical care and psychosocial support on how to maintain physical, emotional, social, and spiritual health and how to cope with long-term effects of therapy. Response to illness and coping mechanisms vary across ethnicities and can influence the success of treatment and may distinguish outcomes. Sociocultural factors are very important in decisionmaking processes: they may determine adherence to treatment and willingness to develop healthmaintaining behaviors as well as personal allowance for appropriate follow-up, surveillance, and posttreatment monitoring. Studies show that immigrants are all too often less likely to receive appropriate cancer care. In this regard, survival is especially poor for cancers that require complex and costly therapies (e.g., stomach cancer and leukemia). It has also been observed that cancer patients with migration backgrounds are more likely to be affected by treatment complications and are less likely to adhere to medication regimens. For example, Chinese American women decline therapy more often compared to White women and women of other ethnicities. Especially among women, often other obligations, such as care giving, family, or employment, dominate over the need for the own medical care, amplified by logistic factors like extra costs, difficult transportation, and additional time expenditure. Furthermore, evidence suggests a high prevalence of comorbidities in immigrant groups, possibly entailing poorer health outcomes and poorer cancer survival. Ineffective and insufficient treatment often results from inadequate communication between health care providers and patients. Consequently, patients with limited literacy and language skills do not always receive proper information about treatment options, possibly leading to suboptimal treatment choices. Moreover, the provision of culturally sensitive support and treatment for minority cancer patients is often hampered by the lack of relevant information available to clinicians and oncologists. Treatment plans have to incorporate culturally relevant differences in care seeking and disease coping. In conclusion, ethnicity and immigration status represent important prognostic factors for cancer survival, and disparities can partly be explained by diverse cancer risk patterns, a later stage at diagnosis and differentials in treatment and care. Thorough research has been dedicated to the role of socioeconomic determinants on cancer mortality, but the independent effect of ethnicity stays unclear and still needs to be evaluated. Differences in cancer mortality between populations may underscore existing inequalities in early detection as well as treatment and require culturally sensitive prevention programs, targeting high risk groups. Ethnic inequalities in cancer mortality are not yet adequately documented and require careful surveillance and action. Related Topics ▶ Breast cancer ▶ Cancer ▶ Cancer incidence ▶ Cancer prevention ▶ Colorectal cancer ▶ Health determinants Suggested Readings Arnold, M., Razum, O., & Coebergh, J. W. (2010). Cancer risk diversity in non-Western migrants to Europe: An overview of the literature. European Journal of Cancer, 46(14), 2647–2659. Aziz, N. M., & Rowland, J. H. (2002). Cancer survivorship research among ethnic minority and medically underserved groups. Oncology Nursing Forum, 29(5), 789–801. Bhopal, R. S. (2007). Ethnicity, race, and health in multicultural societies: Foundations for better epidemiology, public health, and health care. Oxford: Oxford University Press. Kagawa-Singer, M., Dadia, A. V., Yu, M. C., & Surbone, A. (2010). Cancer, culture, and health disparities: Time to chart a new course? CA: A Cancer Journal for Clinicians, 60(1), 12–39. Cancer Prevention Razum, O., & Twardella, D. (2002). Time travel with Oliver Twist– towards an explanation for a paradoxically low mortality among recent immigrants. Tropical Medicine & International Health, 7(1), 4–10. Schottenfeld, D., & Fraumeni, J. F. (1996). Cancer epidemiology and prevention (2nd ed.). New York/Oxford: Oxford University Press. Wong, M. D., Ettner, S. L., Boscardin, W. J., & Shapiro, M. F. (2009). The contribution of cancer incidence, stage at diagnosis and survival to racial differences in years of life expectancy. Journal of General Internal Medicine, 24(4), 475–481. Cancer Prevention MELINA ARNOLD, OLIVER RAZUM Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany Cancer is one of the most important causes of death worldwide. Cancer burden, however, varies widely across geographical regions as well as across ethnic groups. According to the World Health Organization (WHO), many cancers are associated with risk factors such as smoking, excessive alcohol consumption, certain dietary patterns, and lack of physical activity. Others are caused by infectious agents. Many cancers are therefore partly preventable. In general, cancer prevention is achieved on different levels and comprises (1) the complete prevention of the disease using methods that avert the exposure to risk factors (primary prevention), (2) early detection of disease and the limitation of its effects after diagnosis (secondary prevention), and (3) the avoidance of further disabilities in persons diagnosed with cancer (tertiary prevention). Assuring equality with regard to healthcare services and access to preventive medicine is sought by many industrialized countries and is gaining political importance. Quality of and access to healthcare are important preconditions for health and should be free from bounds to socioeconomic position and ethnic origin. Nevertheless, disparities attributable to social determinants such as education, occupation, social status, housing, and the degree of integration in social environments exist and result in social gradients of health C within countries. Concomitance of low socioeconomic status (SES) and (a foreign) ethnicity, corresponding to cultural differences and cross-country variations, are known to amplify health gaps in populations. The coherent roles of social and cultural determinants need to be disentangled in order to appreciate the detached impact of culture on health. Ethnicity is a social construct, referring to one’s sense of identity in a cultural group or society. Unlike race, ethnicity is not restricted to phenotypes and is motivated by sharing certain views, lifestyles, and cultural habits. Immigrants of non-Western origin often represent ethnic minority groups in their countries of residence and share cultural identities as well as common ideals and goals. Their individual health care needs require careful analysis and need to be addressed by sensitive targeting of prevention programs. There may be differences in cancer risk across ethnicities, meaning immigrant groups, and causal factors which determine those differences. Additionally, there are barriers in access to cancer prevention that immigrants might face. We propose how ethnic minorities should ideally be targeted with respect to cancer risk reduction. Cancer and Culture: Disease Susceptibility, Perception, and Healthcare Utilization Immigrants are equipped with unique constellations of disease risk patterns and exposures experienced before, during, and after migration. Many cancers are still relatively rare in non-Western parts of the world as compared with industrialized countries where cancer ranges among the most common causes of death. Immigrants are exposed to sudden changes of environmental risk factors between their home and their host country while their genetic disposition and cultural habits persist. Favorable risks of immigrants mostly result from persistence in healthy behaviors, for instance dietary or reproductive patterns. Elevated cancer risks among immigrants are known for cancers related to infectious diseases, experienced in early life and childhood, such as stomach, nasopharyngeal, or liver cancer. In addition, cancer mortality shows different patterns and often suggests poorer survival among persons from ethnic minority groups. Lower survival may be due to a lower participation in prevention 351 C 352 C Cancer Prevention programs, hindering early detection in this group, possibly leading to disparities in access to care and treatment. Immigrants are not a homogeneous group. Ethnicity implies diverse concepts of and attitudes toward health that have an impact on the individual utilization of health care services. Cultural roots determine disease perception and coping patterns; both need to be considered when planning preventive measures and deciding on treatment options. Prevention measures should initially focus on barriers that inhibit the uptake of adequate health care, and on ways to overcome those difficulties. Language barriers, low health literacy, insecure or unstable insurance situations, unfamiliarity/ distrust with new health care structures and systems, as well as the pursuit of religious beliefs and other cultural aspects may hamper access to healthcare. These aspects need to be addressed by developing special prevention strategies. Disparities in Cancer Care and Cancer Prevention Low participation in primary prevention and screening programs is associated with a late-stage cancer diagnosis and poorer survival. This has particularly been observed in migrant and ethnic minority groups. Barriers that are relevant in many ethnic minority groups are personal and cultural beliefs and related behavioral patterns. A very important factor is poor knowledge of the local language. Factors that also play major roles are a general fear of a cancer diagnosis and fear of pain. Lack of awareness of the need for testing due to the absence of symptoms or an inherent dislike of the idea of being screened also contribute to lower uptake of prevention measures in these groups. Many women claim other priorities in life such as strong family obligations and often fear loss of privacy or embarrassment during examination. In addition, ethnic minorities often follow alternative medicine approaches and have fatalistic views toward cancer, perceiving it as a result of personal fate. Social networks can have a considerable impact on personal decisions in the clinical context. Families or cultural communities may determine attitudes and adherence toward interventions. Economic barriers are ubiquitous in immigrant populations and may hamper access to cancer prevention services. Unstable insurance coverage as well as additional costs for screening and vaccinations influence screening uptake, in particular among immigrants who are often affected by social deprivation and a higher risk of poverty. Access to care is additionally affected by the sex and ethnicity of the health care provider. Especially, immigrant women with strong religious beliefs often only accept physical examinations by female practitioners. Furthermore, practitioners with foreign backgrounds themselves may not recommend cancer screenings to women because they do not want to intrude on their modesty. Many immigrant groups show a general mistrust toward Western medical systems, as well as a greater degree of dissatisfaction with their physicians. Primary Cancer Prevention Primary cancer prevention aims at the complete prevention of disease, applying measures that reduce the exposure to risk factors. It addresses lifestyle as well as environmental risk factors (e.g., diet, physical activity, and occupation) and should particularly stress exposures to infectious agents that are more prevalent in ethnic minority groups and may cause cancer. Awareness and acceptance of different prevention measures differ between ethnic groups and are strongly linked to health policies. Targeting ethnic minority groups according to their needs is one of the major goals of public health and health service research. This demands knowledge of risk factors that are relevant in immigrant populations and tailoring prevention programs in order to limit ethnic inequalities in cancer risk. Infections Infections, predominantly experienced during early life, may play a causal role in carcinogenesis in later life. Immigrants originating from countries where particular infections are highly prevalent may become infected in childhood and develop disease after migration to the host country. This risk mainly affects first generation migrants whereas it appears to fade in their offspring and following generations. Epstein-Barr Virus (EBV) EBV is an ubiquitous herpes virus in humans and is involved in the causation of cancers of the lymphatic Cancer Prevention system (Burkitt’s lymphoma, non-Hodgkin lymphoma, Hodgkin lymphoma), as well as nasopharyngeal and other oral cancers. EBV is most prevalent in equatorial Africa and other developing countries primarily tropical regions, and often infects HIV-infected individuals. EBV is transmitted by oropharyngeal secretions. Vaccines against the virus are currently being developed. C with chronic hepatitis, and supports the expansion of hospital services offering low cost or free screenings and vaccinations for HBV as well as adequate monitoring. Prevention measures for immigrants should focus on both families’ and individuals’ susceptibility to the virus and enhance awareness and motivation for screening and vaccination. Helicobacter pylori (H. pylori) Hepatitis Hepatitis is the most common chronic infectious disease in the world. Chronic forms can cause cirrhosis, failure, and cancer of the liver, often leading to death. It is highly endemic in parts of East Asia, sub-Saharan Africa, and Latin America. Immigrants from high risk countries are disproportionally affected by hepatitis B (HBV) and C (HCV) infections. The prevalence of HBV infection among Asian Americans is up to 10%, while only 0.1% of White Americans are affected. Liver cancer is thus the most significant health disparity affecting Asian Americans in the US. HBV infection is preventable and vaccination against the infection can lower the risk of liver cancer. There is still no vaccine against HCV. HBV transmission occurs through blood and infected bodily fluids. Mother-to-child transmission in the uterus during birth represents the most common mode of infection in many Asian populations. HCV is less contagious than HBV and mostly transmitted by injection drug use. Immigrants are often less likely than the majority of the population to receive vaccinations and blood screenings against hepatitis. There is a link between the knowledge of prevention, the level of educational attainment, and the decision to receive vaccination against HBV. Many Asian immigrants in the US are not fluent in English, which affects their ability to communicate with their primary care providers, often leading to the avoidance or delay of visits. Financial aspects certainly also contribute to lower participation in high risk immigrant groups. There is a clear need for prevention programs targeting high risk groups such as Southeast Asian migrants and increasing the awareness of the connection between hepatitis and cancer. For example, the San Francisco Hep B free campaign promotes routine blood tests, improves referral and access to care for people H. pylori infection is a risk factor for developing peptic ulcer disease and stomach cancer. Its distribution varies geographically. Incidence is highest in developing countries whereas it is low in high-income countries. H. pylori infection is relatively common in nonWestern immigrant groups who are accordingly at increased risk to develop stomach cancer. The mode of H. pylori transmission is still unknown, but the infection is typically acquired in early childhood. Crowded, unhygienic living conditions, and social deprivation are known to foster H. pylori transmission. Early detection and eradication of the virus would, if possible, be a sensible prevention strategy against stomach cancer. H. pylori can be diagnosed by checking for dyspeptic symptoms (stomach-related problems) using noninvasive such as blood antibody and stool antigen tests or invasive tests such as biopsies and tissue (histologic) examination. Human Papilloma Virus (HPV) The human papilloma virus (HPV) is typically transmitted through sexual contact. Persistent infection with one genetic type can, in rare cases, cause cancer in most cases of the cervix. The incidence of HPV infections is high among young, sexually active adults (aged 15–24) but varies greatly across populations, being highest in South Asia, sub-Saharan Africa, and Latin America. Newly developed HPV vaccines prevent infection from HPV types 16 and 18, accounting for up to 70% of cervical cancers. Vaccination is usually offered to girls starting at age 12, although implementation and administration vary greatly across countries. The introduction of HPV vaccines has caused controversy among clinicians and researchers. The protective effectiveness as well as the ideal age for administration, the number of necessary vaccinations, and the risk of side effects are still under debate. 353 C 354 C Cancer Prevention A survey from the UK revealed a much lower awareness of HPV and a significantly lower acceptability of HPV vaccinations among immigrant women, compared to the majority population. Very low levels of awareness and acceptance were found in mothers of South Asian and African origin. Differences in cultural views toward a vaccination against a sexually transmitted disease might partly explain this pattern. It has been observed that parents with strong religious beliefs and cultural views were less likely to accept HPV vaccinations. Their concerns were most often based on social or religious reasons such as a belief that sex-related topics are taboo, monogamy, refraining from sex before marriage, a fear of promiscuity, and a fear of side effects. Environmental Carcinogens and Important Lifestyle-Related Factors In general, immigrants experience low risks of cancers that are associated with a Western lifestyle. This especially applies to breast, colorectal, and prostate cancer. Cultural views and behavioral patterns also impact on health-related habits such as physical activity, dietary, and smoking patterns. Tobacco smoking prevalence differs substantially by ethnic group, gender, age, socioeconomic position, as well as geography. Several cancers, most importantly lung and bladder cancer, are strongly attributed to tobacco smoking. A high smoking prevalence in male and low-income immigrants has been observed in several studies. Tobacco use is widespread and significantly elevated in Asian Americans and migrants from Eastern European countries, compared to the indigenous population of their host country. In many ethnic minority groups, smoking is often an important part of social functions and events. Currently, there are few smoking cessation programs that specifically target immigrants. Some studies indicate a high probability for relapse among migrants that take part in smoking cessation programs. High alcohol consumption is associated with many cancers. Many immigrants from Muslim countries, however, are likely to be total abstainers and thus at low risk for these cancers. Dietary patterns (e.g., salt, meat, fat, and fruit/ vegetable intake) and obesity are important risk factors for the development of cancers of the digestive system such as cancer of the stomach, esophagus, colon and rectum, gallbladder, and pancreas. Immigrants often show healthy dietary patterns, such as greater fruit and vegetable intake, and a strong familial persistence in different nutritional habits retained from their country of origin. In contrast, obesity has been noted to be high and increasing in many immigrant groups. This may be caused by a lack of traditional foods at affordable price and a gradual adaptation of Western dietary patterns. Dietary prevention programs require sensitive communication as well as motivation and should put emphasis on the nutritional value of cultural dishes and healthy nutrition. Often, immigrants exhibit lower degrees of physical activity compared to the native population of their host and their home country. Physical inactivity contributes to higher rates of obesity and may be involved in the development of colorectal, gallbladder, and kidney cancer. Reproductive factors play an important role in the occurrence of breast, cervical, ovary, and testicular cancer. Immigrant women are more likely to have more children and to breastfeed and are less likely to use oral contraception or hormone replacement therapies after menopause, compared to the majority population. These protective factors are associated with a decreased risk of breast and other cancers of genital organs. Most environmental and lifestyle-related factors and habits are hard to change, not only in ethnic minority groups. Cultural and religious beliefs affect behavioral patterns and determine lifestyle, diet, and sexuality. Some studies suggest a lack of adherence to medical advice regarding lifestyle and nutrition in immigrant groups. Prevention programs need to target high risk groups such as immigrant smokers, increase awareness of the link between lifestyle and cancer, and should operate on the community/family level. Secondary Cancer Prevention Immigrants are more likely to receive a latestage cancer diagnosis in comparison with the majority population. This could be due to a low uptake of secondary cancer prevention measures, such as screening, aiming for early disease detection, and the limitation of disease effects after diagnosis. Secondary cancer prevention programs are particularly important in ethnic minority groups, because they often underutilize Cancer Prevention preventive care or fail to make return medical visits, and often lack cancer awareness. However, a higher participation in screenings has been observed in immigrants who spent a higher proportion of their lifetime in the host country and an increasing uptake the longer their duration of residence. This probably is a result of an acculturation process that is related to increasing trust and familiarity with health care structures in the host country. Early detection during routine screenings for breast, cervical, colorectal, and prostate cancer represents a key factor for better survival in high risk groups. Cultural barriers to screening programs and suggested remedies are summarized in Table 1. Breast Cancer Screening Breast cancer is the most common malignancy among women worldwide. However, its frequency varies widely by country and population. Whereas the incidence in more developed regions of the world is 67.8 C per 100,000 women, it is less than half in less developed regions (23.8 per 100,000). Breast cancer mortality is 18.1 and 10.3 per 100,000, respectively. There is evidence that reproductive factors partly determine the breast cancer risk. This comprises the age at first birth, the number of children, the age at menarche/menopause, and the use oral contraceptives and/or hormones during menopause. Other established risk factors for breast cancer are familial susceptibility and excessive alcohol use. Breast cancer prevention focuses on screening. The most common methods of screening are mammography and breast self-examination. Since the introduction of breast cancer screening, the incidence of breast cancer increased whereas mortality decreased due to detection at earlier stages, implying a better chance for survival. Recent studies, however, have cast some doubt on the effectiveness of breast cancer screening. Breast cancer screening is usually recommended to start between age 40 and 50. Some studies on breast Cancer Prevention. Table 1 Cultural barriers to established cancer screening programs and suggested remedies Type of screening Barriers Breast cancer Cervical cancer Colon cancer Suggested remedies Perception of absence of symptoms, claiming health Policies that alleviate women’s anxiety Misconceptions, cancer fatalism, fear of possible diagnosis Patriarchal values, modesty Strong religious beliefs Identification and elucidation of misperceptions, fear, and fatalism Encouragement of presence of family members during screening Employment of female practitioners who understand the role of cultural beliefs, especially the expression of modesty Fear of loss of privacy, embarrassment Faith-based settings as venue for cancer education programs Distrust in system and clinician Fear of loss of privacy, embarrassment Increasing awareness, clarification of misconceptions Aversion to invasiveness of Pap smear Education of medical providers to recognize cross-cultural differences in health care to enhance their competence in engaging with minority women during medical encounters Modesty, strong cultural views Involvement of family members in decisions and allow for their presence during screening Poor communication with providers Prohibitions against examination by male health care providers Competing life priorities (e.g., familial responsibilities) Embarrassment of receiving digital rectal examinations/colonoscopy Strong cultural beliefs Increasing awareness, cancer education Offering alternative tests 355 C 356 C Cancer Prevention cancer screening uptake in ethnic minority groups reveal large ethnic disparities and a rather passive attitude of migrant women toward screenings. Foreign born women are less likely to attend screenings and show lower referral and detection rates compared to native-born women. Furthermore, a clear association between age and health screening attendance (the higher the age, the lower the attendance) was found in immigrant women. Reasons for nonattendance with screening were particularly ascribed to patriarchal values (men as decision-makers), embarrassment, and modesty. Cervical Cancer Screening Cervical cancer is the second most common cancer in women from less developed regions (incidence 19.1 per 100,000) and fourth in females from developed regions (incidence 10.3 per 100,000). Mortality from cervical cancer is 11.2 per 100,000 in less developed regions and 4.0 per 100,000 in developed regions. The main known risk factor for cervical cancer is HPV infection. In many countries, the cervical Pap (Papanicolaou) smear test is used in women aged 30–60 in order to identify abnormal cells that can turn into cancer. The implementation of Pap smears is believed to have significantly reduced incidence and mortality of cervical cancer in many Western countries, but randomized controlled trials have not yet confirmed this assumption. In many countries, screening uptake in immigrant women is far below target and significantly lower than in the majority population. Reasons for nonparticipation in cervical cancer screening are mostly related to language problems, dissatisfaction with practitioner, and the absence of symptoms. Religion also may play an important role. Among all US ethnic groups, Asian American women have the lowest participation rates, apparently determined by strong cultural views. unsaturated fat as well as physical inactivity. Screening is recommended starting around age 50 using fecal (stool) occult blood tests (FOBT) or endoscopic exams (colonoscopy or sigmoidoscopy). These measures require resources that are not available to everyone. Colorectal cancer screening uptake varies significantly across ethnic groups and tends to be lower in immigrants than in the native population of their country of residence. For example, uptake was found to be very low among Asian Americans. However, screening patterns converged toward that of the majority population with increasing time of residence in the US. Prostate Cancer Screening Prostate cancer is far more common in more developed regions compared to less developed regions (incidence 56.2 vs. 9.4 per 100,000; mortality 13.5 vs. 5.2 per 100,000). Causes of prostate cancer are still poorly understood; however, a family history of prostate cancer seems to play a role. Certain ethnic groups such as African-Americans are disproportionally affected. Prostate cancer screening is routinely done by digital rectal exams (DRE) and increasingly by prostatespecific antigen tests (PSA) which measures the level of PSA in the blood. However, there is no continuing evidence of decreases in mortality from prostate cancer due to screening. In conclusion, immigrants are significantly less likely to attend cancer screening services than natives of their host country. This has various reasons, mainly differences in cultural views, disease perception, and health care utilization patterns. Identifying and addressing cultural barriers helps to reduce existing disparities in survival and to keep mortality low. Tertiary Cancer Prevention Colorectal Cancer Screening Colorectal cancer is much more common in developed regions, being the second most common malignancy in females and the third in males. Incidence is 40.0/26.6 per 100,000 in more and 10.2/7.7 per 100,000 in less developed regions (females/males). Mortality is 17.7/ 12.3 and 6.2/4.7 per 100,000, respectively. Colorectal cancer is associated with dietary and environmental risk factors, such as a high intake of meat and Screening alone does not ensure the improvement of cancer survival. What follows the initial diagnosis and how patients with a positive test result are treated is very important. Appropriate care, therapy, and diagnostic follow-up as well as rehabilitation are crucial for optimal health outcomes. Some studies report a lower likelihood of receiving stage-appropriate treatment and a less frequent adherence to recommendations for follow-up care in Cancer Prevention immigrant populations. This may subsequently lead to poor clinical outcomes and lower survival. The Challenge of Providing Culturally Sensitive Cancer Prevention The goal of cancer prevention in immigrant populations should be to perpetuate – and if possible expand – advantageous lifestyle factors and to provide culturally adequate access to care. Culturally sensitive cancer prevention incorporates diversity of cultural beliefs, experiences, perceptions, norms, values, and behavioral patterns. Implementation demands a general awareness of cancer risk diversity and cultural aspects of cancer in every expert involved in cancer care, education, and research. Providing culturally sensitive cancer prevention is the key to diminish inequalities and increase access as well as awareness. Before planning for new prevention measures, it is important to collaborate with ethnic minority groups in order to assess their understanding and opinions on existing cancer prevention programs. Best practice definitions and guidelines could be useful in order to ensure greater consistency of use and implementation of culturally sensitive cancer programs. Cancer prevention needs to be encouraged by increasing awareness, by promoting the necessity for screenings, and by providing adequate cancer information and education. Educational materials should be developed together with members of ethnic minority groups in order to incorporate cultural beliefs in multilingual health messages that are accessible to those with limited literacy skills. High risk groups should be targeted and the stigmatizing nature of disease perceived by some ethnic groups needs to be addressed. Equal access to preventive medicine should be enhanced by providing comprehensive, well-coordinated, affordable, and culturally appropriate cancer care. Treatment plans should be developed together with the patient and other family members. Research on cancer disparities should be promoted and the inclusion of ethnic minority populations in clinical trials should be supported in order to learn more about the efficacy of treatment options for immigrants. Related Topics ▶ Cancer ▶ Cancer mortality C ▶ Cancer screening ▶ Disease prevention ▶ Health barriers ▶ Health care utilization ▶ Health literacy ▶ Heliobacter pylori ▶ Language barriers Suggested Readings Adami, H.-O., Hunter, D. J., & Trichopoulos, D. (2008). Textbook of cancer epidemiology (2nd ed.). New York/Oxford: Oxford University Press. Arnold, M., Razum, O., & Coebergh, J. W. (2010). Cancer risk diversity in non-Western migrants to Europe: An overview of the literature. European Journal of Cancer, 46, 2647–2659. Cader, F. Z., Kearns, P., Young, L., Murray, P., & Vockerodt, M. (2010). The contribution of the Epstein-Barr virus to the pathogenesis of childhood lymphomas. Cancer Treatment Reviews, 36, 348–353. Conway-Phillips, R., & Millon-Underwood, S. (2009). Breast cancer screening behaviors of African American women: A comprehensive review, analysis, and critique of nursing research. The ABNF Journal, 20(4), 97–101. De Vries, A. C., Van Driel, H. F., Richardus, J. H., Ouwendijk, M., Van Vuuren, A. J., De Man, R. A., et al. (2008). Migrant communities constitute a possible target population for primary prevention of Helicobacter pylori related complications in low incidence countries. Scandinavian Journal of Gastroenterology, 43(4), 403–409. Goss, E., Lopez, A. M., Brown, C. L., Wollins, D. S., Brawley, O. W., & Raghavan, D. (2009). American society of clinical oncology policy statement: Disparities in cancer care. Journal of Clinical Oncology, 27(17), 2881–2885. Hoffman-Goetz, L., & Friedman, D. B. (2006). A systematic review of culturally sensitive cancer prevention resources for ethnic minorities. Ethnicity & Disease, 16(4), 971–977. Jones, R. A., Steeves, R., & Williams, I. (2009). How African American men decide whether or not to get prostate cancer screening. Cancer Nursing, 32(2), 166–172. Kagawa-Singer, M., Dadia, A. V., Yu, M. C., & Surbone, A. (2010). Cancer, culture, and health disparities: Time to chart a new course? CA: A Cancer Journal for Clinicians, 60(1), 12–39. Ma, G. X., Shive, S. E., Toubbeh, J. I., Tan, Y., & Wu, D. (2008). Knowledge, attitudes, and behaviors of Chinese hepatitis B screening and vaccination. American Journal of Health Behavior, 32(2), 178–187. Ma, G. X., Tan, Y., Toubbeh, J. I., Edwards, R. L., Shive, S. E., Siu, P., et al. (2006). Asian tobacco education and cancer awareness research special population network. A model for reducing Asian American cancer health disparities. Cancer, 107(Suppl. 8), 1995–2005. Marlow, L. A., Wardle, J., Forster, A. S., & Waller, J. (2009). Ethnic differences in human papillomavirus awareness and vaccine acceptability. Journal of Epidemiology and Community Health, 63(12), 1010–1015. 357 C 358 C Cancer Screening Ogedegbe, G., Cassells, A. N., Robinson, C. M., DuHamel, K., Tobin, J. N., Sox, C. H., et al. (2005). Perceptions of barriers and facilitators of cancer early detection among low-income minority women in community health centers. Journal of the National Medical Association, 97(2), 162–170. Smith, J. S. (2008). Ethnic disparities in cervical cancer illness burden and subsequent care: A prospective view in managed care. The American Journal of Managed Care, 14(6 Suppl. 1), S193–S199. Spallek, J., Zeeb, H., & Razum, O. (2010). Prevention among immigrants: The example of Germany. BMC Public Health, 10, 92. race as well as by socioeconomic status, with screening less likely to occur among individuals in lower socioeconomic groups. Given the continued high levels and changing ethnic composition of immigrant inflows to the United States, Canada, the UK, and other countries that have significantly altered the demographic profile of these countries, the use of regular cancer screening by immigrants has become an issue of significant interest and importance to policymakers and health care professionals. Suggested Resources Globocan database, IARC 2008. http://www-dep.iarc.fr/ San Francisco Hep B free campaign. http://www.sfhepbfree.org/ Cancer Screening JAMES TED MCDONALD Department of Economics, University of New Brunswick, Fredericton, NB, Canada Cancer screening refers to a set of medical procedures intended to identify the presence of cancer before any symptoms appear, and can include physical exams, laboratory tests, and medical imaging. Regular screening offers the potential to reduce both cancer mortality and morbidity since treatment options and survival are related to stage at diagnosis for almost all forms of cancer. Estimates of the premature deaths that could have been avoided through cancer screening vary from 3% to 35%. Screening guidelines for the detection of the most commonly occurring cancers are well established, and while national health agencies such as the US National Cancer Institute (NCI) periodically review these guidelines in order to ensure that the guidelines reflect the latest research, there is little debate about the overall importance of regular cancer screening. Most developed countries actively maintain screening registries for two types of cancer affecting women – breast and cervical cancer – in order to alert women to the importance of regular screening and to remind them to get screened. Adherence to screening guidelines has been found to vary significantly by demographic factors such as Theoretical Determinants of Cancer Screening A variety of theoretical frameworks has been advanced to help explain possible differences in cancer screening among different subpopulations. One commonly used model is an adaptation of the Andersen framework of health service use that identifies three types of factors likely to be important determinants of an individual’s demand for health services: predisposing factors such as age and sex; needs factors such as health status and awareness of cancer and screening, and enabling factors such as income and education, health insurance, and community resources. For immigrants, the use of cancer screening can also be reduced by barriers arising from difficulties with host country language and unfamiliarity with the host country health system. Immigrants’ social and ethnic backgrounds can give rise to differences in attitudes about cancer and cancer screening. For example, traditions of modesty among some Asian and Hispanic populations might lead immigrants from those regions to avoid certain physical examinations. This discussion implies that patterns in cancer screening may vary significantly across immigrant subgroups even after accounting for differences in age, education level, income, and other factors. In addition, immigrants’ participation in cancer screening could also increase over time following migration, as language barriers are overcome, experience with the health system is gained, and as attitudes and behaviors increasingly reflect host country norms. Data on the Incidence of Cancer Screening Most empirical evidence is based on two main types of data. The first type includes population-based self-reported surveys such as the National Health Cancer Screening Interview Survey in the USA and the Canadian Community Health Survey in Canada. The second type includes smaller scale interview-based surveys of particular ethnic groups. In some jurisdictions, researchers may also have access to administrative data on cancer screening that are drawn from cancer screening registries. Screening for Cervical Cancer Cervical cancer is one of the most preventable forms of cancer, and deaths from cervical cancer have declined by approximately 70% since the mid-twentieth century, due in large part to the introduction of the Papanicolaou (Pap) test. The Pap test is an easily implemented and widely accessible form of cancer screening, and systematic population-wide screening has been organized by government and nongovernment agencies at all levels. Current guidelines from both the US National Cancer Institute and Health Canada suggest that adult women aged 21–65 have a Pap smear test every 1–3 years, depending on prior history and risk factors. Regardless of data type, the evidence points unequivocally to the fact that immigrant women have significantly lower participation in regular cervical cancer screening than nonimmigrant women. This result has been established for most ethnic groups of immigrants and in a number of immigrant-receiving countries. Importantly, while demographic and socioeconomic characteristics are well-established determinants of cervical cancer screening rates, lower rates of regular screening among immigrants are not explained by differences in these factors between immigrant and nonimmigrant women. Analyses based on population survey data indicate rates of Pap smear testing that are lowest for immigrants recently arrived from developing countries, with rates of testing in the last 3 years in the order of 30–50% less than for comparable nonimmigrant women. In contrast, immigrants from other English-speaking developed countries have been found to have screening rates generally comparable to nonimmigrant levels. There is also evidence that rates of testing increase with additional years in the immigrant’s new country, a result consistent with a process of acculturation to host country attitudes, as well as improved familiarity with and access to the health system. However, immigrants from Asian ethnic backgrounds do not C necessarily reach nonimmigrant rates of cervical cancer screening even after many years in their host country. More narrowly focused analyses of specific subpopulations of immigrant women suggest factors that help to explain differences in cervical cancer screening between immigrant and nonimmigrant women. For immigrant women from China, Korea, and other Asian countries, lack of knowledge of cervical cancer risk factors and of cervical cancer screening guidelines are important determinants of lower screening rates. The nature of the doctor–patient relationship is important for Asian, Hispanic, and Haitian women, including the physician’s degree of cultural awareness, the presence of a female doctor, and the communication of guidelines by the doctor to the patient. More generally, characteristics of the health system are important among various immigrant subpopulations in the USA, with both a single source of primary care and having health insurance being associated with higher screening rates. Screening for Breast Cancer Breast cancer is a common disease and leading source of cancer mortality among women. It is estimated that one of every nine women will develop breast cancer during her lifetime, while one of every 25 will die prematurely from malignancy. It is well established that early detection is essential to the effective treatment of the disease. Detection modalities include clinical and self breast examinations and mammography, though it is mammography use that has been the main focus of research in the literature. Evidence indicates that regular mammography screening among older women could reduce breast cancer mortality by one third, and current screening guidelines published by Health Canada recommend biennial mammography for asymptomatic women aged 50–69 years. Although the benefits of mammography screening are less clear for women aged 40–49, some Canadian provinces (NS, Alberta, BC) include these women in their provincial recall and screening programs. As with cervical cancer screening, rates of mammography screening are lower among immigrant women to the USA, Canada, and other developed countries than for nonimmigrant women, and the gaps are not accounted for by differences in demographic and socioeconomic factors. Low screening 359 C 360 C Cancer Screening rates are of special concern for particular immigrant subgroups such as Filipina women, who experience higher mortality rates from breast cancer than from any other disease. In contrast to what is found for cervical cancer screening, evidence is mixed about whether gaps in regular mammography screening narrow with years in the host country, although some studies find such patterns for immigrant women in the USA and Australia. Research on various immigrant subgroups identifies a number of characteristics associated with lower mammography screening rates that are more prevalent among immigrant than nonimmigrants. These include having no regular source of health care services, low education level, poor English language skills, a lack of knowledge about breast screening modalities, and a lack of health insurance. Other research has also established that certain cultural views such as traditions of modesty are associated with lower incidence of mammography screening. There is less evidence available on other modalities of breast cancer screening including clinical breast exams and self-exams, although some research suggests that greater acculturation of immigrant women and more time in the host country are both associated with a higher incidence of breast self-exams and clinical breast exams. Interestingly, one study of Chinese women in San Francisco found that while knowledge of breast cancer and the importance of selfexaminations was high (81% of women), adherence with recommended guidelines was markedly lower (54% of women). Screening for Colorectal Cancer In Canada, colorectal cancer is the third most common cancer, accounting for more than 12% of cases of cancer in both sexes, while in the USA, colorectal cancer is the fourth most common cancer. Given the occurrence of this form of cancer, research over the past decade has examined the merits and effectiveness of periodic screening in the asymptomatic population. A variety of means are available to screen for colorectal cancer, including fecal occult blood testing, sigmoidoscopy, and colonoscopy. For people at normal risk of colorectal cancer, annual or biennial testing using fecal occult blood testing (FOBT) and sigmoidoscopy are recommended for men and women aged 50–75 years. There is insufficient evidence to include colonoscopy as an initial screening test of people in this age group. While the research on the incidence of colorectal cancer screening among immigrants is limited, US evidence suggests that most subgroups of immigrants by region of origin have lower incidence of screening than nonimmigrant individuals. Similar results are found for South Asian immigrants in the UK. As with other forms of cancer screening, demographic and socioeconomic factors have been established as important correlates of colorectal cancer screening but lower incidence of screening among immigrants is not explained by differences in these factors between immigrants and nonimmigrants. Furthermore, additional years in the host country appear to increase rates of cancer screening, which approach those of the nonimmigrant population. Having a regular health care provider is also positively associated with the incidence of colorectal cancer screening. Screening for Prostate Cancer Two types of screening for prostate cancer in men include digital rectal examination (DRE) and prostate specific antigen (PSA) measurements. Both types of screening have been shown to increase the early detection of clinically significant prostate cancer. However, available research is ambiguous about whether early detection and treatment leads to any change in the natural history and outcome of prostate cancer. Thus, different health agencies in the USA and Canada vary in terms of recommendations for their use among asymptomatic men over 50 years of age, and there is no general consensus on appropriate guidelines for regular screening. Some health agencies such as the United States Preventative Services Task Force recommend against screening for prostate cancer in men aged 75 years or older. Researchers studying the incidence of screening for prostate cancer among immigrant men have noted significant variation in the regular use of both DRE and PSA screening across immigrant subgroups even after controlling for demographic characteristics and access barriers. Immigrant men in the USA who originated from Trinidad, Haiti, and Eastern Europe were all less likely than US-born White men to obtain regular screening for prostate cancer. Education and access to medical care were also important determinants of the incidence of prostate cancer screening. Cardiovascular Disease Conclusions A robust result of the extensive research on immigrant cancer screening is that rates of screening for the most commonly occurring types of cancer are significantly lower for most immigrant subgroups than for nonimmigrants, and these gaps are not explained by differences in demographic, socioeconomic, or geographic factors. Policies to encourage greater participation in cancer screening by immigrants may need to be tailored to the characteristics of specific immigrant subpopulations, particularly recent immigrants. C Weber, M. F., Banks, E., Smith, D. P., O’Connell, D., & Sitas, F. (2009). Cancer screening among migrants in an Australian cohort; crosssectional analyses from the 45 and Up Study. BMC Public Health, 15(9), 144. Suggested Resources Health Canada. Progress report on cancer control in Canada. http:// www.phac-spc.gc.ca/publicat/prccc-relccc/pdf/F244_HC_Cancer_ Rpt_English.pdf. Accessed May 3, 2011. The National Cancer Institute. Screening and testing to detect cancer. http://www.cancer.gov/cancertopics/screening. Accessed May 5, 2011. Related Topics ▶ Cancer incidence ▶ Cancer prevention ▶ Colorectal cancer ▶ Mammography ▶ Pap test ▶ Physician–patient communication Cardiovascular Disease SUJATHA SANKARAN Division of Hospital Medicine, Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA Suggested Readings Andreeva, V. A., Unger, J. B., & Pentz, M. A. (2007). Breast cancer among immigrants: A systematic review and new research directions. Journal of Immigrant and Minority Health, 9(4), 307–322. Brown, W. M., Consedine, N. S., & Magai, C. (2006). Time spent in the United States and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation? Journal of Immigrant and Minority Health, 8(4), 347–358. Goel, M., Wee, C., McCarthy, E., Davis, R., Ngo-Metzger, Q., & Phillips, R. (2003). Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care. Journal of General Internal Medicine, 18(12), 1028–1035. Johnson, C. E., Mues, K. E., Mayne, S. L., & Kiblawi, A. N. (2008). Cervical cancer screening among immigrants and ethnic minorities: A systematic review using the Health Belief Model. Journal of Lower Genital Tract Diseases, 12(3), 232–241. McDonald, J. T., & Kennedy, S. (2007). Cervical cancer screening by immigrant and minority women in Canada. Journal of Immigrant and Minority Health, 9(4), 323–334. Pasick, R. J., & Burke, N. J. (2008). A critical review of theory in breast cancer screening promotion across cultures. Annual Review of Public Health, 29, 351–368. Raja Jones, H. (1999). Breast screening and ethnic minority women: A literature review. The British Journal of Nursing, 8(19), 1284–1288. Samuel, P. S., Pringle, J. P., James, N. W., Fielding, S. J., & Fairfield, K. M. (2009). Breast, cervical, and colorectal cancer screening rates amongst female Cambodian, Somali, and Vietnamese immigrants in the USA. International Journal of Equity Health, 14(8), 30. 361 Globally, cardiovascular disease is the number one cause of death, and in 2005, cardiovascular disease caused 30% of all deaths worldwide. Cardiovascular disease is a category that encompasses a myriad of disorders of the heart and blood vessels, including coronary artery disease, cerebrovascular disease, peripheral vascular disease, infectious diseases of the heart, and congenital heart disease. Coronary artery disease is an impairment in the coronary blood vessels that are responsible for supplying blood to the heart, and disruption in this circulation can in turn lead to heart attacks. Similarly, cerebrovascular disease causes an impairment of blood flow to the brain, resulting in strokes, and peripheral vascular disease causes disruption of blood to body organs and extremities, resulting in organ dysfunction and pain. There is a large body of evidence that supports the causal role of a number of risk factors in increasing the risk of cardiovascular disease related events, such as heart attacks and strokes. These cardiovascular disease risk factors are hypertension, diabetes, hyperlipidemia, tobacco use, and obesity. The global rise of cardiovascular disease can be largely attributed to the increase in prevalence of modifiable risk factors due to shifts in lifestyle such as immigration from smaller rural communities and villages to larger urban settings. With C 362 C Cardiovascular Disease these shifts comes an increased risk of tobacco use, diets high in sodium, saturated fats and carbohydrates, and sedentary lifestyles, in turn leading to an increase in rates of hypertension, diabetes, hyperlipidemia, tobacco use, and obesity. With this increased prevalence of risk factors comes an increase in heart attacks and strokes. Because of the large environmental component to cardiovascular disease, immigration plays a vital role in the global rise of cardiovascular disease. Immigration also plays a central role in the rates of congenital, metabolic, and infectious diseases of the heart. Maternal health and perinatal care are important determinants of cardiovascular morbidity and mortality in newborns. Maternal health and perinatal care are largely dependent on the social and economic conditions of different societies, and cultural norms and values and immigration status play an important role in the amount and type of pre- and postnatal care mothers receive. This in turn impacts the prevention and management of congenital heart disorders. Endocrine and metabolic disorders such as thyroid disease and vitamin deficiencies may also cause heart dysfunction. There are a number of infectious diseases that lead to heart dysfunction, including a parasitic disease such as Chagas disease and bacterial diseases of the heart valves such as endocarditis. The prevalence of infectious causes of heart disease differs widely based on geographical location, and immigration status plays a vital role in the development of these disorders. The Global Rise of Cardiovascular Disease Cardiovascular diseases are responsible for more deaths worldwide than any other cause. An estimated 17.1 million individuals died from cardiovascular illnesses in 2004. This accounted for 29% of all global deaths. By 2030, approximately 23.6 million people will die from cardiovascular diseases each year, maintaining cardiovascular disease as the number one cause of death in the world. It is estimated that the largest percentage increases in death will occur in the Eastern Mediterranean region, and the largest number increases in death will occur in Southeast Asia. Income levels play a large role in both the prevalence of cardiovascular disease and the mortality rate of cardiovascular illnesses. Eighty-two percent of cardiovascular disease deaths occur in low- and middle-income countries. In the United States, 31% of the population has cardiovascular disease, and 34.3% of annual deaths are due to cardiovascular causes. In Canada, in the year 2000, 34% of male deaths and 36% of female deaths were due to cardiovascular diseases, and cardiovascular diseases cost the Canadian economy approximately $18.4 billion annually. In the United Kingdom in 2003, there were 233,000 deaths due to cardiovascular disease and 38% of all deaths were from cardiovascular diseases. Death rates from cardiovascular disease are generally decreasing in developed nations – in the United States, from 1996 to 2006, death rates from cardiovascular disease declined by 29.2%. Over 80% of global deaths from cardiovascular disease occur in low- and middle-income countries. The number of years of productive life lost to cardiovascular disease will increase by 20% in 2030 as compared to 2000. The rate of increase in cardiovascular illness is much higher in developing nations as compared to more economically developed nations. In Portugal, this 30-year rate of increase is 30% – in South Africa it is 28% and in Brazil it is 64%. The 30year increase in risk of cardiovascular-related mortality in China is 57% and in India, it is 95%. In India, currently 10–12% of the population has cardiovascular disease. It is estimated that India bears 60% of the world’s coronary heart disease burden. The rate of heart attacks in South Asians in the United States is double that of the American average. There are more individuals with cardiovascular diseases in India and China than in all economically developed nations of the world combined. In Europe, each year cardiovascular disease causes over 4.3 million deaths, which is 48% of the total number of deaths in Europe. Cardiovascular disease is the main cause of death in women in all European countries, and is the main cause of death in men in all countries except France, the Netherlands, and Spain. Each year, cardiovascular disease costs the European Union approximately €192 billion. There are likely multiple reasons why cardiovascular disease prevalence and death rates are higher in lowand middle-income countries as compared to higher income countries. Individuals in low- and middleincome nations have more exposure to cardiovascular disease risk factors and have less access to preventive methods as compared to higher income populations. Cardiovascular Disease Preventive measures to detect risk factors and provide early interventions that in turn prevent morbidity and mortality related to cardiovascular disease are much scarcer in economically disadvantaged regions. In general, people in lower income nations die younger from cardiovascular diseases when compared to people in higher income nations. These deaths of individuals in their most productive years in turn lead to increased poverty. Cardiovascular diseases are predicted to reduce GDP between 1% and 5% in lowand middle-income countries experiencing rapid economic growth. For instance, China is predicted to lose $558 billion due to loss of income in people with cardiovascular diseases. The sex distribution of cardiovascular disease is roughly equal at this time, but in many countries, women experience a disproportionately higher risk of dying from cardiovascular disease compared to men. The rates of cardiovascular disease death are increasing at higher rates in women as compared to men in many economically emerging countries, such as China and Brazil. Cardiovascular Disease in Immigrant Populations Numerous studies have been conducted to determine whether there is a relationship between immigration status and incidence of cardiovascular disease. These studies have consistently shown that first-generation immigrants have cardiovascular disease rates that reflect their countries of origin. After two to three generations, however, several studies have shown that cardiovascular disease rates in immigrant populations tend to match those of the adopted country. One study in 2008 in Sweden showed that Iranian immigrants had higher rates of cardiovascular disease than their native Iranian counterparts. Similarly, a study in 2006 showed that Chinese immigrants in New York City have a higher rate of cardiovascular disease than native Chinese from the same community. These results are consistent even after adjustments were made for income level and age. Similar studies in Indian, Pakistani, and West African populations have showed that both emigration from rural areas to more developed urban settings as well as emigration from developing to developed nations result in increased C rates of cardiovascular disease rates. This likely is the result of increased rates of risk factors such as obesity, tobacco use, Westernized diets, and sedentary lifestyles in urban populations. In the United States, individuals of South Asian descent have a fourfold higher rate of coronary artery disease as compared to the general American population. This is independent of the individual’s immigration status – first-, second-, and third-generation South Asian immigrants all have a consistently increased rate of cardiovascular disease prevalence and mortality. In South Asians, more than 30% of deaths from heart attacks occur in those younger than 65, a rate double that of the United States national average. This increased risk of cardiovascular disease has also been noted in South Asian immigrants in the United Kingdom. According to the British Heart Foundation, the death rate from coronary artery disease is 46% higher in South Asian men and 51% higher in South Asian women than in the UK population as a whole – this, again, is the case among both first- and secondgeneration South Asian immigrants. However, data from California have shown that South Asian women are the only ethnic group in California that has experienced an increase in mortality due to cardiovascular disease. Immigrants from Latin America to the United States have increased rates of cardiovascular disease when compared to native Latin populations. This could be at least partially due to health policies in Latin American countries. For example, Brazil has been cited as a model for effective cardiovascular disease prevention in Latin America. Brazil has been a world leader in promoting programs that reduce obesity, including national food and nutrition policies to promote healthy eating habits and lifestyles that lead to cardiovascular health. In the United States, there is a marked difference in cardiovascular disease rates across different ethnic groups and immigrant communities. Among Caucasians, 12.1% have heart disease, 6.5% have coronary heart disease, 23% have hypertension, and 2.7% have had a stroke. African American populations have lower rates of heart disease and coronary heart disease than their Caucasian counterparts but higher rates of hypertension and stroke. Ten percent of African Americans have heart disease, 5.6% have coronary heart disease, 363 C 364 C Cardiovascular Disease 31.8% have hypertension, and 3.6% have had a stroke in the past. In contrast, Latinos in the United States have lower rates of cardiovascular disease, and 8.1% of Latinos have heart disease, 5.7% have coronary heart disease, 21% have hypertension, and 2.6% have had a stroke. Native Americans and Alaska Natives have higher rates of cardiovascular disease, and 12.1% have heart disease, 6.6% have coronary heart disease, 25.3% have hypertension, and 3.9% have had a stroke in the past. South Asians in the United States have the largest rates of cardiovascular disease of any subgroup, with rates of developing coronary heart disease ranging from 18% to 25%. Cardiovascular Risk Factors in Immigrant Populations Hypertension Globally, high blood pressure, or “hypertension,” causes approximately 7.1 million deaths each year. Hypertension, if left untreated, is a risk factor for strokes and heart attacks. It is estimated that about 62% of strokes and 49% of heart attacks are caused by hypertension. It has been predicted that the prevalence of hypertension will increase to 1.56 billion people by the year 2025. Currently, about 15–37% of the global adult population has hypertension, and in the United States about 140 million people suffer from hypertension. Throughout the world, it is believed that a significant percentage of hypertension is undiagnosed. Of the diagnosed cases of hypertension, it is thought that more than half of all hypertensive patients do not receive adequate treatment. In India and China, there has been a rapid rise in the prevalence of hypertension over the past 20 years, and a concomitant increase in rates of stroke. These increases correlate with a shift from rural to urban lifestyles and mirror the increases in rates of hypertension in Chinese and Indian immigrants in the United States and the United Kingdom. In contrast, studies have shown that rates of hypertension are higher in native Mexicans than in first-generation Mexican immigrants to the United States. Despite the lack of consistent health care coverage in Mexican immigrants, rates of diagnosis and treatment of hypertension appear to be better in Mexicans living in the United States as compared to native Mexicans. In Africa, the prevalence of hypertension is estimated at approximately 20 million people. The hypertension-related stroke rate is higher in Africa than in other regions of the world, and victims of hypertension-related stroke in Africa are relatively young. There is a lower rate of hypertension in Africans and firstgeneration African immigrants to the United States when compared to African Americans who have lived in the United States for several generations. This difference exists even when there are corrections for body mass index and age. There is a well-established relationship between increased salt intake and hypertension. Numerous studies have also shown that tobacco use, alcohol use, and sedentary lifestyle can lead to increases in blood pressure. It is likely that development of hypertension is multifactorial and that inherent ethnic differences, varied patterns of exercise, diverse dietary habits, and differences in alcohol and tobacco use all contribute to increased rates of hypertension. Because immigrants often bring with them dietary and social habits from their native cultures, there is a complex interplay between genetic and lifestyle factors that determine rates of hypertension in immigrant populations. Hyperlipidemia High blood cholesterol or “hyperlipidemia” is another important risk factor for cardiovascular disease. Three components of cholesterol are measured to determine overall cardiovascular risk – LDL or low-density lipoprotein, increased levels of which lead to an increase in heart disease; HDL, or high-density lipoprotein, a component that can actually protect individuals from cardiovascular disease if high enough; and triglycerides, a component that is also linked to cardiovascular disease. Hyperlipidemia is estimated to cause about 4.4 million deaths every year, and is directly responsible for 18% of strokes and 56% of coronary heart disease globally. Diverse studies of immigrants have shown that there is a strong environmental component to hyperlipidemia, and rates of hyperlipidemia rapidly change as patients emigrate to another country and dietary patterns change. A study in Israel published in 1960 showed that immigrants from areas where typical diets are high in fruits and vegetables and low in animal fat have much lower rates of hyperlipidemia. This study also showed how, as immigrants’ diets Cardiovascular Disease change to match local patterns and include increases in consumption of foods high in saturated fat, cholesterol levels also increase. Another study in 1985 showed that Japanese immigrants to Brazil had lower levels of HDL, the component of cholesterol that is protective against cardiovascular disease, when compared to native Japanese. Another study in Costa Rica in 2002 showed that as Chinese immigrants increased their consumption of animal protein, rates of hyperlipidemia increased. As with hypertension, there appears to be both inherent ethnic differences in rates of hyperlipidemia and a strong contributing lifestyle component. Obesity Obesity, defined as an unhealthy weight that adversely affects an individual’s health and well-being, has a strong and well-established relationship with cardiovascular disease. There is a direct correlation between increases in body mass index, a common measure of weight, and cardiovascular illnesses. As BMI levels and abdominal circumferences increase, the prevalence of hypertension, high blood glucose levels, hyperlipidemia, and low HDL cholesterol levels increase. The rates of overweight and obesity are rising dramatically throughout the world. This is thought to be due to increasingly sedentary lifestyles as well as dietary factors. In immigrant communities in the United States, studies have shown a direct correlation between the number of years of residence in the United States and increases in rates of overweight and obesity. A study in 2004 showed that after adjusting for age, socioeconomic and lifestyle factors, living in the United States for 10 years or more is associated with significant increases in the levels of overweight and obesity. Immigrants in the United States were also noted to be less likely than US-born individuals to discuss diet and exercise with clinicians. The study showed that only 8% of immigrants who had lived in the United States for less than a year were obese, but that 19% of individuals who had lived in the United States for at least 15 years were obese. Another study in September 2009 looked at immigrants in the United States, and noted that the sons of immigrants had higher rates of overweight and obesity than their American-born counterparts. It was found that 34% of kindergarten-age immigrant boys were obese or overweight compared with 25% of the sons C of native-born Americans. By age 13, 49% of sons of immigrants are overweight or obese as opposed to 33% of natives. This difference was independent of socioeconomic status and was more pronounced in children whose parents did not speak English. It is thought that a combination of easily available and inexpensive highcalorie, low-nutrient foods and beverages and the fact that often new immigrants are not aware of the risks of unhealthy lifestyle choices likely contributed to this effect. One of the most important causes of overweight and obesity in immigrants is lack of education about the adverse effects of obesity and the contribution of diet and exercise to moderating weight. Another small study in 2009 showed a direct correlation between education and rates of obesity in immigrants – immigrants with advanced degrees were less likely to become obese, while immigrants without advanced degrees were more likely to become obese after 5 years in the United States. The other factors influencing rates of obesity in immigrants are perceived health status and body image. In many resource-poor cultures, overweight and obesity are associated with economic success, and physical activity is associated with blue-collar jobs and poverty. Other cultures associate overweight and obesity with good health and in some cultures individuals who are overweight or obese are considered more “marriageable.” One study of Latina immigrant women in 2006 showed that the majority of women in the study associated overweight and obesity with attractiveness and were reluctant to lose weight because of perceived unattractiveness to men. Diabetes Mellitus Currently, it is estimated that there are approximately 150 million people worldwide with type II diabetes, and this figure is expected to double by 2025. About 58% of global diabetes mellitus is attributable to overweight or obesity. Rates of death from diabetes mellitus are also increasing. In general, immigrants from the developing world to more economically developed regions have higher rates of diabetes than native populations. One study in 2006 in Sweden showed that immigrants from nonEuropean countries had higher rates of diabetes than native Swedish populations or immigrants from European countries. Another Dutch study showed that immigrants from Suriname, India, Turkey, and 365 C 366 C Cardiovascular Disease Morocco to the Netherlands had higher rates of diabetes than their native counterparts. This tendency is independent of rates of overweight and obesity. A study of Ethiopian immigrants in Israel in 2005 showed a growing prevalence of type II diabetes. In Canada, individuals of aboriginal, Latino, Asian, South Asian, or African descent have been noted to be more vulnerable to diabetes. It is very well documented that South Asian immigrants have a much higher rate of diabetes mellitus than the general nonimmigrant population in developed nations. In the United Kingdom, studies have shown that the Bangladeshi and Pakistani communities have a disproportionately high level of diabetes when compared to Caucasians. In the United States, South Asian immigrants are seven times more likely to have type II diabetes than the general population, and in New York City, Indian immigrants are at a greater risk of hospitalization from diabetes than other immigrant groups. Studies in New York City have also shown that South Asian immigrants have a rate of diabetes that is almost three times higher than the rate for other Asian American immigrants in New York City. Another study in 2009 showed that 28% of Bangladeshis living in New York City have diabetes. South Asian immigrant women in New York City have the highest prevalence and highest increase in prevalence of gestational diabetes mellitus. There is also evidence that immigrants with diabetes have poorer glycemic control than their native counterparts. A study in 2008 in Ireland showed that non-White immigrants to Ireland had poorer glucose control than native Irish individuals with diabetes mellitus. Factors that are thought to play a role in higher rates of hyperglycemia in immigrant diabetic patients include lack of education about the consequences of untreated diabetes and the importance of medication compliance, and lack of information about appropriate food and diet choices. Studies have shown that a strong family support system and targeted culture-specific education can have a significant impact on rates of cardiovascular disease. Finally, immigrants who arrive in the United States at younger ages are more likely to become overweight with increasing time in the United States as compared to immigrants who come to the United States at older ages. Tobacco Use and Immigrants Currently, there are about 1.3 billion smokers in the world, and this number is projected to rise to 1.7 billion by 2025. Smokers in general have death rates two to three times higher than nonsmokers. A joint study by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) showed that smoking causes a 100% increase in the risk of stroke and coronary heart disease, a 300% increase in the risk of death from undiagnosed coronary heart disease, greater than a 300% increase in the risk of peripheral arterial disease, and a 400% increase in the risk of aortic aneurysm. In the United States, the rates of tobacco use in 2000 were 13.7% among Asian and Pacific Islanders, 19.1% among Latinos, 25% among non-Hispanic Whites, 24.7% among African Americans, and 40% among Native Americans and Alaskan natives. Various studies have looked at tobacco use rates among different immigrant populations in the United States. One study of Chinese Americans in Texas showed that while smoking rates were significantly lower in Chinese Americans as compared to the general Texas population, the smoking rate among recent immigrant men was higher. Twenty-eight percent of immigrant Chinese men smoked, as compared to 20.6% of the local population. In contrast, US born Chinese American smoking rates are comparable to those of the local American population. In Latino populations, studies have shown that adolescents are particularly vulnerable to tobacco use, and that there is a strong connection between poverty, unemployment, high school dropout rates and tobacco use. One study in California in 1993 showed that disadvantaged Latino youths were three times more likely to use tobacco than non-Latino youths. South Asian individuals in the United States have lower rates of smoking than other Asian groups. The tobacco epidemic is affecting an increasing number of children and adolescents. Tobacco use in children and adolescents is highest in the Americas and Europe, where it is approximately 20%. Cigarette smoking is higher among young people in the Americas and Europe, while use of other tobacco products is higher in South East Asia and the Eastern Mediterranean. Everywhere, tobacco use is significantly higher in boys than in girls. Cardiovascular Disease Infectious Diseases of the Heart in Immigrant Populations Infectious diseases that affect the heart are an important cause of morbidity and mortality in immigrants. In particular, two infectious conditions – Chagas disease and rheumatic fever – are commonly responsible for cardiovascular disease in immigrant populations. Chagas disease is transmitted by the protozoan parasite Trypanasoma cruzi. Infected insects take blood meals from humans and their domestic animals and deposit parasite-laden feces. The parasites are then transmitted to humans through breaks in the skin, mucosal surfaces, or conjunctiva. Transmission also occurs congenitally or through blood transfusion or organ transplantation. Once an individual is infected with T. cruzi, there is no way to eradicate the infection. Longstanding T. cruzi infection can lead to the serious cardiac disease of Chagas disease. Ten to 30% of individuals with chronic Chagas disease develop clinical manifestations of the disease. The most serious cardiac complication is an inflammatory cardiomyopathy that results from the presence of parasites in the heart. This cardiomyopathy results in congestive heart failure, causing symptoms of severe shortness of breath, decreased exercise tolerance, and swelling in the lower extremities. Cardiac rhythm disturbances can also occur. While the rates of cardiac disease due to Chagas disease are low in the native population of the United States, there has been a notable increase in the number of people with complications of Chagas disease in the last few decades due to immigration of people from endemic countries. It is estimated that now approximately 13 million people from endemic countries live in the United States and 80,000–120,000 of these people have chronic T. cruzi infection. Approximately two thirds of these individuals are from Mexico. Acute rheumatic fever is another infectious cardiac disease that is common in immigrant populations. Streptococcal throat infections are sometimes followed by rheumatic fever, typically beginning about 2–3 weeks after the initial streptococcal infection. In about half of patients with acute rheumatic fever, inflammation of the heart called carditis can follow, and carditis leads to heart failure in some patients. Rheumatic fever can also damage heart valves. In the United States, rheumatic fever is most common in recent immigrants from developing countries in which there is poor access to antibiotics. C 367 Conclusions Immigration status plays a large role in the development of cardiovascular disease. Shifts from rural to urban lifestyles and changing patterns of diet and exercise are largely responsible for the development of cardiovascular risk factors that in turn lead to coronary heart disease. Perinatal, metabolic, and endocrine causes of heart disease also are affected profoundly affected by immigration status. Immigrants without appropriate access to regular medical care are more likely to experience the sequelae of various cardiovascular illnesses. Cardiovascular disease rates are determined by a complex set of cultural, biological, and social factors, and immigration status is intimately tied to these factors. In order to adequately identify and treat cardiovascular illness in diverse populations, it is vital that this cultural milieu is recognized and considered. This will become even more imperative as increased immigration and globalization lead to increasingly heterogeneous populations throughout the world. Related Topics ▶ Body mass index ▶ Cardiovascular risk factors ▶ Chronic disease ▶ Diabetes mellitus ▶ Hypertension ▶ Obesity ▶ Stroke ▶ Tobacco use Suggested Readings Anderson, G. F., & Chu, E. (2007). Expanding priorities – confronting chronic disease in countries with low income. Baltimore: Johns Hopkins Bloomberg School of Public Health. Hossain, P., Kawar, B., & El Nahas, M. (2007). Obesity and diabetes in the developing world – a growing challenge. The New England Journal of Medicine, 356(9), 973. Howson, C. P., Reddy, K. S., Committee on Research, Development, and Institutional Strengthening for Control of Cardiovascular Diseases in Developing Countries, Institute of Medicine, et al. (1998). Control of cardiovascular diseases in developing countries: Research, development, and institutional strengthening. Washington, DC: National Academies Press. Leeder, S., Raymond, S., Greenberg, H., et al. (2004). A race against time. The challenge of cardiovascular disease in developing economies. New York: Columbia University. Levy, D., & Kannel, W. (2000). Searching for answers to ethnic disparities in cardiovascular risk. Lancet, 356(9226), 266–267. C 368 C Cardiovascular Risk Factors World Health Organization. (2008). Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva: World Health Organization. World Health Organization. (2005). Preventing chronic diseases: A vital investment. World Health Organization global report, 2005. Geneva: World Health Organization. Suggested Resources Institute of Medicine. (2010). Promoting cardiovascular health in the developing world: A critical challenge to achieve global health, report. http://www.iom.edu/Reports/2010/PromotingCardiovascular-Health-in-the-Developing-World-A-CriticalChallenge-to-Achieve-Global-Health.aspx Kaiser Family Foundation. Race, ethnicity, and health care: The Basics: Key data. http://www.kaiseredu.org/topics_reflib.asp?id= 329&rID=1&parentid=67 World Health Organization. Cardiovascular disease. http://www. who.int/cardiovascular_diseases/en/ Cardiovascular Risk Factors HOMER VENTERS Division of General Internal Medicine, New York University School of Medicine, New York, NY, USA Cardiovascular (CV) disease remains the single greatest cause of mortality in developed nations and is fast rising as a major cause of mortality elsewhere. While many developed nations have begun to address CV disease and the associated population risk factors, few resources are dedicated to identification and modification of CV disease risk factors elsewhere. Immigrants face multiple challenges addressing CV disease risk factors; many developing nations may fail to identify CV risks within immigrant populations and when these risks are identified, access to care, beliefs systems inconsistent with the Western medical model, and competing (non-health related) priorities may interact to make CV risk factor identification and modification difficult. Additionally, the CV risk profile that immigrants arrive with will change over time, often to include a more sedentary and stressful lifestyle and less healthy diet. Two important questions regarding immigrants and CV risk are whether one’s status as an immigrant confers inherent CV risk and whether ethnic or geographic variation changes the relative importance of various CV risk factors. These questions touch on the basic conundrum of medical providers, public health workers, and policy makers. How are immigrants different than other patients and how specialized do health care services need to be in order to address their unique health issues without recreating services that already exist elsewhere and for which specialization is not beneficial? Immigration clearly imparts stressors that may contribute to CV risk. The psychological stress associated with migration has been linked to increased CV risk and for immigrants leaving their country of origin after traumatic events, either natural or man-made, this stress translates to heightened CV risk. In addition to the psychological stress associated with immigration, the transition to a new country almost certainly interrupts normal diet and activity level. Some ethnic and regional groups of immigrants have been reported to possess inherently increased CV risk profiles. For example, multiple reports have identified increased rates of insulin resistance, diabetes, and other CV risks among Asian and Pacific Islander immigrants to the United States, Brazil, and other nations. Other groups of immigrants that have been identified as having particularly high CV risk profiles include It is likely that the most significant cardiovascular risk factors among immigrants stem from variables that are unrelated to immigrant status. One of the single largest studies to examine cardiovascular disease predictors among multiple national and ethnic groups was the INTERHEART study. This case-control study was conducted in 52 countries and identified 9 easily measured risk factors that account for over 90% of the risk of acute myocardial infarction (AMI) among patients presenting with their first AMI at 262 participating centers. These risk factors (smoking, lipids, diabetes, hypertension, obesity, diet, physical activity, alcohol consumption, and psychosocial factors) were analyzed for approximately 12,000 cases and 9,000 controls. Conventional wisdom has held that these traditional risk factors might account for only 50% of AMI risk and that these risk factors might vary widely in their predictive power across geographic regions. Surprisingly, these nine risk factors proved remarkably consistent in their predictive powers of AMI in both men and women as well as across the 52 nations of Africa, Asia, Australia, Europe, the Middle East, and North and Cardiovascular Risk Factors South America where subjects participated. One geographic dichotomy that INTERNEART reported was the much earlier presentations of AMI among men (8–10 years versus women) and in the regions of Africa, the Middle East, and South Asia (10 years versus all other regions). While most studies compare the CV risks of immigrant to a native-born cohort, a key consideration is whether the immigrants’ CV risks are truly acquired or not. For example, smoking among immigrant populations appears to mirror rates from the country/ region of origin. Immigrants moving from low to higher smoking prevalence nations (such as Africans living in Europe) appear to conserve their low prevalence status while immigrants making the opposite transition appear to similarly continue their high rates of smoking. Given projections that global smoking rates will continue to rise and soon account for 10% of all deaths, these observations may not hold and immigrants from less developed nations may arrive with additional CV risks. Unlike smoking, rates of diet and physical activity appear to change relatively quickly with immigration. Multiple studies have examined the role of new dietary habits among immigrants as well as the changes in physical activity and mental health. Immigrants from Africa to Europe may have lower rates of smoking but higher rates of physical inactivity and higher BMI than their native-born cohort. These changes in risk profile likely result in physiological consequences such as increased atherosclerosis changes over time. Additional information may be gained from knowledge of migration within nations that replicates external migration. For example, an analysis of CV risk factors among Tanzanian men and women who migrated from rural to urban setting revealed increased weight and decreased physical activity but mixed changes in cholesterol and diet (more red meat but also more fresh fruit and vegetables). In some cases, such as that of emigration from the former Soviet Union to the United States, the dietary and activity changes may actually improve CV risk from baseline. For policy makers, public health professionals, and medical providers, a central challenge is how to communicate CV health knowledge to immigrant patients and work to promote healthy living. Multiple studies have documented that immigrants acquire CV risk factors C associated with the diet and level of activity, but to date, the evidence concerning targeted interventions is mixed. Since most of these interventions are small community-based programs, rigorously evaluating their effectiveness is often a challenge. One challenge to these interventions is difficulty in targeting the intervention to a particular immigrant community. Some immigrant groups are wellacquainted with the Western medical model and long-term health risks and disease progression may be widely accepted concepts. Such groups may include immigrants moving between developed nations or those migrating from nations with established primary care systems. For many immigrants, however, the notion of CV risks and decade-long developments of CV disease is quite foreign. Many immigrants from developing nations are familiar with medical care, providers, and medication as interventions for urgent or emergent problems such as trauma, seizure, and complicated childbirth. For these immigrants, traditional beliefs and practices are often very intact when they arrive in a new home country. These traditional concepts of disease, and the traditional healers that offer services in the new country, must be integrated into any efforts to educate or otherwise engage immigrants about CV risk. Such an undertaking may be too great a challenge for primary care providers and concerted community and public health campaigns are often needed. Traditionally, public health interventions with immigrants in developed countries have focused on infectious disease, such as screening for tuberculosis, HIV, and parasitic infection. While these diseases remain important, similar efforts must be made to communicate abut CV risks and disease in immigrant communities. Another challenge that may impair CV risk reduction strategies among immigrants is the presence of more pressing needs. In developed nations, newly arrived immigrants face a dizzying array of social services and regulations that they must navigate in order to secure basic food, shelter, and employment. For immigrants arriving or staying in a new country without proper immigration status, the need to avoid detection (and detention/deportation) by immigration officials may supersede almost all other needs. For immigrants who do seek to engage with medical care, it is most often on behalf of their children, who may 369 C 370 C Caregiving and Caregiver Burden require certain medical documentation for school registration, and for whom medical care may be more accessible. Communities that have successfully engaged with immigrants concerning CV risks have done so by providing care in a convenient manner (i.e., in a mosque or taxi garage or school) and without any threat of immigration or police presence. CV risks among immigrants are essentially like those of nonimmigrants, an aggregation of dietary, lifestyle, and genetic components as reported in the INTERHEART and other studies. The unique concerns for promoting CV health among immigrants are how to identify changing CV risk profiles and engage immigrant communities on these risks and their modification. Several levels of intervention are required for meeting this goal. First, leaders in immigrant communities must be enlisted as advocates for promotion of CV health. Next, public health institutions must target their CV risk reduction campaigns toward the immigrant groups in their communities with programs that are rooted in familiar language and concepts. Simple, protective interventions such as smoking cessation, increased daily intake of fruits and vegetables, and moderate physical activity can be incorporated into most belief systems and concepts of health. Finally, primary medical care must be available to immigrants so that their physicians can perform adequate CV risk assessment and discuss CV risk modification. Related Topics ▶ Blood pressure ▶ Body mass index ▶ Diabetes mellitus ▶ Dietary patterns ▶ Disease prevention ▶ Obesity ▶ Percent body fat ▶ Stroke Glenday, K., Kumar, B. N., Tverdal, A., & Meyer, H. E. (2006). Cardiovascular disease risk factors among five major ethnic groups in Oslo, Norway: The Oslo Immigrant Health Study. BMC Public Health, 6, 102. Koochek, A., Mirmiran, P., Azizi, T., Padyab, M., Johansson, S. E., Karlström, B., Azizi, F., & Sundquist, J. (2008). Is migration to Sweden associated with increased prevalence of risk factors for cardiovascular disease? European Journal of Cardiovascular Prevention and Rehabilitation, 15(1), 78–82. Lear, S. A., Humphries, K. H., Hage-Moussa, S., Chockalingam, A., & Mancini, G. B. (2009). Immigration presents a potential increased risk for atherosclerosis. Atherosclerosis, 205(2), 584–589. Lepoutre-Lussey, C., Plouin, P. F., & Steichen, O. (2010). Cardiovascular risk factors in hypertensive patients born in Northern Africa and living in France. Blood Pressure, 19(2), 75–80. Misra, R., Patel, T., Kotha, P., Raji, A., Ganda, O., Banerji, M., Shah, V., Vijay, K., Mudaliar, S., Iyer, D., & Balasubramanyam, A. (2010). Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: Results from a national study. Journal of Diabetes and its Complications, 24(3), 145–153. Regidor, E., Astasio, P., Calle, M. E., Martı́nez, D., Ortega, P., & Domı́nguez, V. (2009). The association between birthplace in different regions of the world and cardiovascular mortality among residents of Spain. European Journal of Epidemiology, 24(9), 503–512. Renzaho, A. M., Mellor, D., Boulton, K., & Swinburn, B. (2010). Effectiveness of prevention programmes for obesity and chronic diseases among immigrants to developed countries – a systematic review. Public Health Nutrition, 13(3), 438–450. Epub 2009 Sep 2. Review. Yusuf, S., Hawken, S., Ounpuu, S., Dans, T., Avezum, A., Lanas, F., McQueen, M., Budaj, A., Pais, P., Varigos, J., Lisheng, L., & INTERHEART Study Investigators. (2004). Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet, 364(9438), 937–952. Caregiving and Caregiver Burden Suggested Readings BRANDY L. JOHNSON Rynearson, Suess, Schnurbusch & Champion, L.L.C., St. Louis, MO, USA Edelman, D., Christian, A., & Mosca, L. (2009). Association of acculturation status with beliefs, barriers, and perceptions related to cardiovascular disease prevention among racial and ethnic minorities. Journal of Transcultural Nursing, 20(3), 278–285. Gadd, M., Johansson, S. E., Sundquist, J., & Wändell, P. (2005). The trend of cardiovascular disease in immigrants in Sweden. European Journal of Epidemiology, 20(9), 755–760. Caregivers or, as they are known in some countries, careers, are people who are responsible for looking after, tending to, or aiding others who suffer from illness or disability. While there are numerous formal Caregiving and Caregiver Burden sources of care, such as nursing homes, assisted living communities, rehabilitation hospitals, and home health care, most caregiving occurs informally and at home. Likewise, although there are professional caregivers who get paid for their services, caregivers are more often unpaid family members or friends of the individual requiring care. Parents, spouses, siblings, and adult children are often informal caregivers. The care recipients can be of any age and are often ill, injured, physically disabled, mentally ill, mentally disabled, or elderly. Family members and friends commonly step into the role of caregiver out of love, respect, commitment, and/or a sense of duty or responsibility for the care recipient. With advances in medical science, the populations of many countries have seen an increase in longevity for the elderly, ill, and disabled. This has created an increased need for caregiving. In 2004, it was estimated there were 44.4 million caregivers in the USA The UK reported six million caregivers in 2001. In the same year, there were 481,579 caregivers in Scotland. As caregiving is very personalized, the amount of care provided, as well as the type of care provided, varies with each care recipient. The care recipient may need full-time care, requiring the caregiver to be present for forty or more hours a week. Other care recipients may need as little as a few hours a week. Depending upon the care recipient’s needs, the caregiver may have a full or part time job in addition to aiding the care recipient. In recent years, employers have begun to work with caregivers by offering more flexible hours, job sharing, the ability to work from remote locations, and leaves of absence. Most caregivers are women. A study performed by the National Alliance of Care Giving and American Association for Retired Persons (AARP), released in 2004, showed 61% of caregivers in the study were women. Male caregivers are more likely to provide care to other men. Female caregivers also tend to provide a greater number of hours of care and a higher level of care. Caregiving is extremely individualized. It can be relatively undemanding, highly demanding, or anywhere in-between these extremes. The care may be as minimal as grocery shopping, paying bills, driving to an appointment, and/or housekeeping. However, the care could be comprehensive and require assistance C with cooking, feeding, dressing, bathing, wound care, transferring/lifting, and management of medical equipment like catheters, wheelchairs, respirators, or oxygen tanks. As well as assisting in activities of daily living, caregivers often play other roles. Caregivers are usually advocates for the medical management of the care recipient. The provision of care requires that caregivers understand the care recipient’s illness, disability, or medical condition and participate in the treatment or management of it. Caregivers often dispense medication and provide both reassurance and emotional support to the care recipient. They may also be in charge of, or assist with, the care recipient’s finances and upkeep of the household. Informal caregiving may be coupled with formal caregiving, depending on the needs and resources of the care recipient. For example, the recipient may attend adult day care or have a home health nurse who only performs specific tasks related to the care recipient’s medical needs. The care recipient may have a housekeeper, driver, or the ability to utilize community transportation services to attend appointments. When this occurs, informal caregivers are required to coordinate the sources of care to ensure all the care recipient’s needs are met. An individual’s need for care can occur quickly, such as when there is an accident, or may develop over time. A care recipient’s need may also change as a disease progresses. Individuals who suffer from Alzheimer’s or dementia may be able to function relatively well in the beginning, requiring little to no care, and progress slowly toward a need for around the clock care. Caregivers must adjust to meet the needs of the care recipient and, when necessary, consider whether more formal care is required. When the needs of the care recipient become greater than the abilities and/or resources of the caregiver or caregivers, a decision must be made regarding whether to turn to institutionalization of the care recipient. Caregiving can be a rewarding experience. Although caregiving can be complicated and demanding of time and resources, many caregivers find a sense of purpose stems from the act. In fact, a 2007 nationwide survey by Caring Today magazine revealed, in the USA, nearly 80% of family caregivers found the experience to be emotionally rewarding. Caregivers also 371 C 372 C Caregiving and Caregiver Burden often find their bond with the care recipient strengthened through the caregiving experience. The caregiver may also develop increased self-esteem through the provision of care. These positive findings can be characterized as caregiver gain. While some find caregiving to be a positive experience, others find the opposite. Caregiving, especially if the care recipient’s needs are highly demanding, can be extremely stressful. The stress (physically, emotionally, and financially) experienced by those who provide care to the ill, disabled, and elderly can be characterized as caregiver burden. Caregiver burden is also known as caregiver syndrome, caregiver stress, caregiver distress, and caregiver strain. Caregiver burden is the result of more than the need to provide care. The way the caregiver approaches the task can affect how he or she feels about the role. Many times the role as caregiver is unexpected, unfamiliar, and unwanted. If the caregiver feels he or she had no choice in assuming the role, it is more likely there will be anxiety and a negative attitude on the part of the caregiver. There may be feelings of resentment toward both the role as caregiver and the care recipient. Additionally, the nature of the relationship between the caregiver and care recipient before the need for care arises can affect how the caregiver feels about his or her role. When the caregiver and care recipient have a good relationship before the need for care arises, the caregiver may feel more positive about his or her role. Conversely, when the participants have a bad or shaky relationship before the need for care arises, the caregiver may experience a greater amount of anxiety, bitterness, or resentment. The effect of caregiving on the caregiver’s relationships with others can add to caregiver burden. The majority of caregivers have a spouse and children. Caregiving can cause strain on marriage and relationships with children, friends, and coworkers. When the care recipient is also a member of the caregiver’s family, caregivers may find their relationships with other family members are also strained. The caregiver may feel other family members are not providing the additional aid they should. Disagreements may arise between family members, especially siblings, concerning the type of care being provided, the manner in which the care is provided, use of the recipient’s resources, or whether the recipient should be institutionalized. In addition to the strain on relationships, it is not uncommon for the caregiver’s social activities to diminish. Social isolation leads to feelings of loneliness, guilt, and resentment. The caregiver may feel anger over losing time with others, the ability to engage in hobbies or favorite past times, and free time. Such isolation, and the resulting feelings, can lead to depression and/or anxiety. Studies have shown caregivers suffer from a higher incidence of depression than control groups. If the caregiver has few coping skills, the burden felt can be magnified. Caregivers often neglect their own mental and physical health while caring for another. Caregivers are twice as likely to report a physical or mental health condition. Caregivers have been found to have a reduced immune function and slower healing of wounds. Viral illnesses tend to last longer in caregivers than non-caregivers. Studies have also found higher mortality and morbidity levels in caregivers who perceive greater stress in the provision of care. One study found elderly spouse caregivers who experienced caregiver burden had a 63% higher mortality risk than the control subjects. The amount of caregiver burden that is experienced by caregivers can be affected by the culture from which they belong. In some cultures, the caregiver does not differentiate this role from their other daily activities. Instead, it is perceived as a part of life. The Chinese culture, for example, views caregiving as just another part of family life. Caring for family is considered part of filial piety, or respect and love for one’s parents and ancestors. The Hispanic or Latino culture is very similar. The concept of familia dictates family members are morally responsible to help each other. Thus, members of this culture are raised to expect the need to aid family members when problems arise with their health, finances, or other life issues. The African-American culture has been found to have comparable values. Caregiver burden can have an effect on both the caregiver and the care recipient. As the caregiver declines, the quality of care to the recipient may also decrease. The care recipient may be exposed to the caregiver’s negative attitude and resentment. This can lead to guilt and resentment on the care recipient’s CAT behalf. Moreover, the possibility of abuse, verbally or physically, increases when the caregiver is under, or perceives, a larger amount of stress and anxiety. When considering caregiver burden, consideration must be given to what is occurring financially, socially, physically, and psychologically for both the caregiver and the care recipient. Once all of this is considered, steps can be taken to reduce the burden on the caregiver. Respite can provide the caregiver with a break from the provision of care. The caregiver can use the time to relax, take care of his or her own needs, spend time with friends or family, and engage in hobbies or favorite past times. Aid from other family members, support groups, and the utilization of community support programs can also help reduce the caregiver’s burden. The stress experienced by caregivers can be reduced further by having legal documents that outline the care recipient’s wishes. Discussion of the care recipient’s wishes coupled with legal documents like advanced directives, wills, powers of attorney, and Do Not Resuscitate (DNR) orders helps alleviate the stress that accompanies a caregiver having to make financial, health care, and end-of-life decisions for the care recipient. It can also prevent conflict among family members who have different ideas concerning the care recipient’s finances, treatment, and end-of-life decisions. Open and frank communication between the caregiver, the care recipient, and other members of the family about the conditions under which the recipient would be institutionalized can also serve to reduce the burden experienced by the caregiver. Unlike in the past, individuals today have an increased longevity. Technology and medical advancements permit many people who once would have been institutionalized to live at home. These factors, along with the rising cost of health care, have increased the need for family and friends to provide care for the ill, elderly, and disabled. Along with the increased need for caregivers is an increase in the burden they may experience. While caregiving can be stressful and demanding, it can also be a rewarding and fulfilling experience. However, caregivers should know their limits, develop additional coping skills, and be aware of the resources available to them financially, emotionally, and in the community. Caregivers must also learn to balance their C roles as a skilled caregiver, friend, spouse, parent, employee, and family member. Caregivers that are successful in doing this are more likely to view caregiving experience in a positive light and provide a higher quality of care. Related Topics ▶ Depression ▶ Disability Suggested Readings American Medical Association. (2001). American Medical Association guide to home caregiving. New York: Wiley. Brown, L. J., Potter, J. F., & Foster, B. G. (1990). Caregiver burden should be evaluated during geriatric assessment. Journal of the American Geriatrics Society, 38, 455–460. Bumagin, V. E., & Hirn, K. F. (2001). Caregiving: A guide for those who give care and those who receive it. New York: Springer. Meyer, M., & Derr, P. (2007). The comfort of home: A complete guide for caregivers (3rd ed.). Portland: CareTrust Publications, L.L.C. Mui, A., Choi, N., & Monk, A. (1998). Long-term care and ethnicity. Westport: Auburn House. Olshevski, J., Katz, A., & Knight, B. (1999). Stress reduction for caregivers. Philadelphia: Taylor & Francis. Parks, S., & Novilli, K. (2000). A practical guide for caring for caregivers. American Family Physician, 62, 2613–2622. Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality. The caregiver health effects study. Journal of the American Medical Association, 282, 2215–2219. Szinovacz, M., & Davey, A. (2007). Caregiving contexts: Cultural, familial and societal implications. New York: Springer. Suggested Resources Buchbinder, J. Cultural traditions & respect for elders. Retrieved March 7, 2010, from, Strength for Caring website. http://www. strengthforcaring.com/manual/about-you-celebrating-cultures/ cultural-traditions-and-respect-for-elders/ Caring Today. (2007). National survey: Caregivers find unexpected emotional rewards in tending for family members. Retrieved April 29, 2011, from http://www.caringtoday.com/pressreleases/national-survey-of-caregivers National Alliance for Caregiving and AAR. (2004). Caregiving in the U.S. Retrieved April 29, 2011, from http://www.caregiving.org/ data/04finalreport.pdf CAT ▶ Convention Against Torture 373 C 374 C Celiac Disease Celiac Disease MELANIE ATHEY Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, USA Celiac disease (also known as celiac sprue, nontropical sprue, and gluten sensitivity enteropathy) is an autoimmune disorder that damages the villi (small, fingerlike projections) in the small intestines and interferes with the absorption of nutrients from food. In individuals with celiac disease (CD), a negative reaction of the immune system is triggered by gluten, a protein primarily found in wheat, barley, and rye. When individuals with CD ingest gluten, their immune system responds by attacking and damaging the lining of the small intestine. This damage impairs the body’s ability to absorb important vitamins, minerals, and other nutrients properly, leading to malnutrition and other conditions. Developing CD requires a genetic predisposition, exposure to gluten through digestion, and a trigger to start this abnormal reaction from the immune system. Common triggers include stress, trauma, or possibly infection. CD is permanent and damage to the small intestine will occur every time gluten is consumed, regardless if symptoms are present or not. Left untreated, individuals with CD may develop further complications such as diabetes, infertility, neurological disorders, osteoporosis, thyroid disease, and cancer. Strict adherence to a gluten-free lifestyle is the only known treatment for CD. CD was once believed to only affect populations of European descent. Due to this belief, the majority of research for CD was focused on individuals of European origin until the late 1970s. Today, researchers consider CD to be a worldwide health problem with evidence of it affecting all ethnic populations, without exception. CD is common in developing countries where the major diet staple is wheat, posing a challenging health problem for individuals requiring a glutenfree diet. In addition to the misconception of CD only affecting Europeans, it was also thought of as a childhood disease presenting exclusively with GI (gastrointestinal) symptoms. It is now recognized that the disease is a multi-symptom, multisystem (organ) disease that can be triggered at any age. There are over 300 symptoms that may be associated with CD. The classic symptoms for CD include: chronic diarrhea/constipation, abdominal pain, bloating, and weight loss. More common but seemingly unrelated symptoms include joint pain, infertility, anemia, tingling/numbness, dermatitis, depression, irritability, and headaches. The symptoms of CD vary considerably from person to person, as does the severity of symptoms. To further frustrate patients and physicians, CD may present different symptoms at differing times within an individual’s lifetime. For example, at age 20, GI symptoms may be present, while years later, at age 35, the same individual may experience joint pain, fatigue, or anemia, without GI issues. Others with CD may not experience any symptoms at all. With such a wide variety of symptoms associated with CD, coupled with many symptoms mimicking numerous other health issues, an accurate diagnosis can be time consuming, frustrating, and difficult. On average, it takes 10 years from the onset of symptoms for an individual with CD to be appropriately diagnosed. Initial screening for CD is done through blood tests. The major tests that are available for CD screening include blood tests such as the IgA tissue transglutaminase antibody (also known as the TTG), the IgA anti-endomysial antibody, and the IgA antibody to deamidated gliadin. If these tests suggest CD, a small intestinal biopsy should be done, which is absolutely required to establish a definite diagnosis of CD. Individuals should not start a gluten-free diet prior to confirming the diagnosis of celiac disease by small intestinal biopsy. This is because the damage to the small intestine that is caused by gluten can heal when gluten is removed from the diet, therefore potentially causing a false-negative test result. CD is the most common genetic autoimmune disorder in the United States today. It is also the most underdiagnosed autoimmune disorder and considered a hidden epidemic by many celiac specialists. CD affects approximately 1% of average, healthy Americans. This means that more than three million people in the United States are living with CD and 97% of them are undiagnosed. Celiac disease predominately affects people of European descent (30% of Europeans currently carry Central America the gene for celiac disease), but recent studies show increased prevalence of CD worldwide. It is a global health concern that affects both developed and underdeveloped countries. No continent nor ethnicity has been spared of this disease. Information, awareness, and support are all necessary factors for every individuals managing CD. In Finland, England, and Australia, celiac disease awareness is more advanced than in the United States and other countries. For example, health policy makers in Finland set out to achieve high detection rate by training health personnel, and advocating blood tests for people known to be at risk for developing celiac disease. However, individuals with CD living in the United States have more food options than ever. Once only available through mail order or in health food stores, gluten-free foods are now mainstream, providing celiac suffers with more food options than ever before. Many restaurants offer gluten-free menus, making dining out a possible option for individuals with CD, an option that was not long ago unheard of for individuals with such dietary constraints. Sales of gluten-free foods increased 74% from 2004 to 2009 in the United States and the gluten-free market is expected to reach $2.6 million in sales by 2012. Many individuals experience several different emotions after being diagnosed with CD. Following a strict gluten-free diet for life can feel overwhelming. Individuals with CD must not only give up common foods such as bread, pasta, and pizza, but also have to be aware of items that may contain hidden gluten, such as lip balm, vitamins, and medicines. It is, however, a very a promising time for individuals with CD. New research results and information are becoming more accessible. Adhering to a gluten-free diet is challenging, although it is becoming easier as more and more gluten-free products come to market. The prognosis for CD is excellent in individuals that remain gluten-free. The small intestine will steadily heal and start absorbing the needed nutrients, and most individuals report an improvement with symptoms immediately after gluten has been removed from their diet. Related Topics ▶ Food ▶ Nutrition C 375 Suggested Readings Green, P., & Jones, R. (2006). Celiac disease: A hidden epidemic. New York: Harper Collins. Suggested Resources American Celiac Disease Alliance. www.americanceliac.org The Celiac Disease Foundation. www.celiac.org Celiac Sprue Research Foundation. www.celiacsprue.org National Foundation for Celiac Awareness. www.celiaccentral.org Central America AMY N. SHARPTON Department of Veterans Affairs, Louis Stokes DVA Medical Center Cleveland, Brecksville, OH, USA Location Central America is a region of the continent of South America. It is situated between the southern border of Mexico and the northwest border of Colombia. Most often Central America is understood to include the nations between Mexico and Colombia, including Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. There is some disagreement, however, as some geographers classify Central America as a large isthmus, in which case the boundaries include the portion of Mexico that lies east of the Isthmus of Tehuantepec, including: the Mexican states of Chiapas, Tabasco, Campeche, Yucatán, and Quintana Roo. Geography The region covers 524,000 km2. Its population was estimated at 41,739,000 as of 2009, with a population density of 77 people/km2. The land mass is recognized as the isthmus of southern North America, with boundaries that can be traced from southern Mexico’s Isthmus of Tehuantepec, running southeastward to the Isthmus of Panama, where it connects to the northwestern portion of South America at the Colombian Pacific Lowlands. The furthest reaches of Central America can be seen to the north at the Trans-Mexican Volcanic Belt and the Gulf of Mexico, to the southwest at the Pacific Ocean, and to the northeast at the Caribbean Sea. C 376 C Central America Central America is active geologically, with periodic volcanic eruptions and earthquakes. For example, in 1976, 23,000 persons were killed when Guatemala was devastated by an earthquake. Nicaragua’s capital city, Managua, was the site of two catastrophic earthquakes in 1931 and 1972. Approximately 5,000 perished in the latter quake. Volcanic eruptions are common. As a consequence, fertile soils from weathered volcanic lavas have made it possible to sustain dense populations in the agriculturally productive highland areas. Central America has many mountain ranges; the longest are the Sierra Madre de Chiapas, the Cordillera Isabelia, and the Cordillera de Talamanca. Fertile valleys lie between the mountain ranges and offer an attractive climate in which much of the population is concentrated. In fact, most of the population of Honduras, Costa Rica, and Guatemala live in valleys. Valleys are suitable also for the production of coffee, beans, and other crops. As part of the Mesoamerican Biodiversity hotspot, Central America holds greater than 7% of the world’s biodiversity, featuring many species from the Nearctic and the Neotropic ecozones. The most biodiversity is found in the southern countries of Costa Rica and Panama, followed by the northern countries of Guatemala and Belize. Recently, deforestation has been a concern for the region of Central America. The UN reports that despite efforts to arrest the decline, Central America had the highest rate of forest loss in Latin America for the decade 2000–2010. Over that same decade, the average annual rate of forest cover loss was 1.19% in Central America, compared to 0.13% globally, while Central America’s forested area shrank from 54 million acres in 2000 to 48 million acres in 2010. The chief cause of deforestation in the region is conversion of forest land due to urbanization and agriculture; reportedly 90% of the wood removed in the region is used for fuel. It is reported, however, that a variety of practices are being developed to avoid deforestation, such as emission reduction projects, forest fire control efforts, and improved stoves. History Due to the Spanish conquest in the sixteenth century, most of Central America had a similar history – the exception was British Honduras. To the English, the land was called British Honduras; to the Spaniards and Guatemalans, the land was called Belice. In 1973, independence from Great Britain was earned, and the name “Belize” was adopted. From the sixteenth century through 1821, Central America formed the Captaincy General of Guatemala, or the Kingdom of Guatemala – formed by the states of Chiapas (now part of Mexico), Guatemala (including present day Belize), El Salvador, Honduras, Nicaragua, and Costa Rica. Officially, the Captaincy was part of the Viceroyalty of New Spain; however, it was administered not by the viceroy or his deputies, but by an independently appointed Captain General headquartered first in Antigua, Guatemala, and later in Guatemala City. In 1821 a congress of Central American criollos, persons of Spanish heritage born in Latin America, declared their independence from Spain. Independence was short-lived; however, as on January 5, 1822, the leaders in Guatemala welcomed annexation by the First Mexican Empire of Agustı́n de Iturbide. When Mexico became a republic in 1823, it acknowledged Central America’s right to determine its own destiny. On July 1, 1823, the congress of Central America declared absolute independence from Spain, Mexico, and any other foreign nation, and a republican system of government was established and the nation of Central America was formed. The Constitution for the Federal Republic of Central America was signed in 1824; the nation was comprised of Guatemala, El Salvador, Honduras, Nicaragua, and Costa Rica, with an additional state – Los Altos – being added in the 1830s. Although Central American liberals hoped the new country would evolve into a modern, democratic nation, the Union dissolved in civil war, beginning when Honduras separated from the federation on November 5, 1838. The federation faced significant obstacles such as strong opposition by conservative factions allied with the Roman Catholic clergy, deficient transportation and communication routes between states, a broad lack of commitment toward the federation, and poverty and extreme political instability. Although various attempts have been made to reunite Central America, none has succeeded for any length of time. While reunification lacks popularity with the leaders of the individual countries, the concept arises occasionally. Today, all five nations fly Central America flags that have incorporated the old federal ornamentation of two outer blue bands bounding an inner white stripe. Demographics and Ethnicity The Central American population has grown rapidly over the last 60 years, with an estimated population in 2007 at over 40 million, up from 10 million in the early 1950s. On average, the population density is 77.3 inhabitants/km2, though the population is distributed very unevenly across the region. Spanish, the dominant language of the region, is the official language in six of the nations, while English is the official language of Belize and along much of the Caribbean Coast. Many of the native tribes speak only their native tongue, though some speak Spanish and others speak more than one native language. In some areas of Central America, many indigenous languages still exist; for example, there are 23 different Mayan dialects spoken in Guatemala. In other Central American countries, indigenous languages are now less prevalent. Central America is comprised of a large percentage, nearly 70%, of persons who are of mixed ancestry. It is estimated that approximately 60% of those with mixed ancestry are of mixed European and American Indian descent; they are called ladinos in Guatemala and mestizos elsewhere; with an additional 5% descended from European and African ancestors, referred to as mulattoes; and 1% descending from a mix of native and Black ancestors. The original indigenous population, Amerindian, comprise 20% of the population. Those of strictly European ancestry make up approximately 12%, with the remainder claiming descendency from Chinese and East Indian indentured servants. The population is distributed unevenly across the region, with one-third in Guatemala, one-sixth in El Salvador, onesixth in Honduras, one-eighth in Nicaragua, one-tenth in Costa Rica, and one-twelfth in Panama. A very small percentage, less than 1%, resides in Belize. The native populations were converted to Catholicism during the Colonial Period. Catholicism has remained the majority religion of the region, ranging across Central America from 80% to 90%. The Catholic faith was blended into the religious practices of the native peoples, and their original beliefs and rituals have become a part of the Catholic faith of the region. C 377 Culture Central America has a rich cultural heritage that includes influences from the Maya, Olmec, Teotihuacán, Toltec, Aztec, and other Mexican civilizations. From approximately 2000 BC, the Maya occupied the Yucatán and adjacent parts of Central America. Their greatest achievements included their elaborate calendar, writing, palaces and temple pyramids with vaulted rooms made of limestone, polychrome pottery, stone stelae, and stylized wall paintings and bas-reliefs. Maya architectural styles are found in three regions: the Petén district (Uaxactún and Tikal); the cities of the river valleys, such as Piedras Negras and Palenque; and the cities of central and North Yucatán (Uxmal). To the west, in the area of Veracruz and Tabasco, Mexico, the Olmec civilization developed in the Preclassic period. The finest Olmec art was produced between 800 and 400 BC. The Olmec are noted for the excellence of their stone carving; frequently, they used a motif combining human and jaguar features. Much to the west of the Olmec and Maya civilizations, dating from the first century AD to 700 AD, the Teotihuacán civilization formed – with the peak of its artistic expression occurring approximately between 300 and 700 AD. The Teotihuacán produced extraordinary architectural achievements including monumental pyramids, temples, and processional roads. The site of Teotihuacán was destroyed by invaders around 700 AD. The two centuries following the fall of Teotihuacán are characterized by the absence of a single dominant force, with a multitude of warring factions vying for power. Eventually one group, the Toltec, made their capital northwest of Teotihuacán at Tula and reigned approximately from 900 to 1,200. The Toltec dominated much of Mexico until they were defeated in the mid-1100s. During their reign they invaded Maya country, in particular Chichén Itzá. The Toltec’s cultural influences are revealed in the pyramids at Tula and Chichén Itzá, with their deep colonnades, their decorative bas-relief, and their many sculptured structural elements. Following a period of anarchy after the destruction of the Toltec’s, the Aztecs rose to power. By 1344, at the site of present-day Mexico City, they had founded Tenochtitlan, their grand capital, which became one C 378 C Central America of the architectural wonders of ancient America. Aztec art developed a unique character, drawing on the traditions of conquered areas, but under the influence of the harsh Aztec religion as well. The importance of human sacrifice in the cult of the war god, Huitzilopochtli, permeated life and art, and representations of skulls, hearts, hands, and sacrificial scenes were common. The Aztecs sculpted magnificent works made of stone; pieces were large and elaborate. One such example is the statue of the earth goddess Coatlicue, which features intertwined serpents and a necklace of human hearts and hands. Less ominous subjects, such as the plumed serpent, Quetzalcoatl, and various animals, were carved in a smooth, compact style. Feather work, jade carving, gold work, extraordinary ceremonial vases, and superb textiles were produced by the artisans of subjugated groups. Aztec power over Central Mexico extended until the arrival of Cortés in 1519. Modern Central America is undergoing considerable change – culturally, politically, and economically. With efforts toward cooperation, if not unification, communication between states has increased over recent decades. Four countries, Guatemala, El Salvador, Honduras, and Nicaragua, are undergoing a process of integration and have formed The Central America Four or CA-4, which has introduced common internal borders. The policy of common internal borders enables the citizens of the four signatory states to freely move across borders, without restrictions or checks. Foreign nationals who enter one of the signatory countries can travel to other signatory states also without having to obtain additional permits or to undergo checks at border checkpoints. The CA-4 Agreement is similar to the Schengen Agreement in Europe in that it establishes a harmonized visa regime for foreign nationals traveling to the area. Belize, Costa Rica, Panama, and Dominican Republic join the CA-4 only in matters of economic integration and regional friendship. Economy There is significant economic diversity within the Central American countries. Nicaragua is the least developed as reflected in rates of infant mortality, adult literacy, and GDP, common indicators of development. Panama and Costa Rica are more developed. Although Panama has the highest GDP per capita, Costa Rica is considered to be the most developed of the Central American countries due to its relatively high GDP per capita and has the best indicators of the Central American countries for life expectancy at birth, infant mortality rate, and adult literacy rate. Historically, Central American trade has been highly dependent on two exports – coffee and bananas. In fact, during much of the twentieth century, coffee was the single largest Central American export. The export of bananas has been critical to the economies of Honduras, Panama, and Costa Rica. The United States and Central America have strong trade agreements. The United States was the main importer of Central American products during the twentieth century. In recent decades, Central America has had success in diversifying its exports and is now less dependent on bananas and coffee. Furthermore, the region has sought to diversify its trading partners as well. At times the countries that comprise Central America have sought to promote mutual economic development. In 1960, with the chief goal of economic growth, Guatemala, Honduras, El Salvador, and Nicaragua created the Central American Common Market (CACM). However, CACM suffered from political disagreements, culminating in 1969 in a war between El Salvador and Honduras. The conflict resulted in slowed economic cooperation in all of Central America. In recent years, efforts have been made to increase economic integration among the Central American nations. Health As with many developing regions of the world, there are significant disparities in health equity across Central America. Public health campaigns were widely implemented first by the Pan American Sanitary Bureau and the ministers of health of Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. They were instrumental in the creation of the Institute of Nutrition in 1946, which was inaugurated formally in September 1949. The Institute orchestrated pioneering clinical and epidemiological studies and interventions. A primary goal was identifying and correcting dietary deficiencies in the region, and the Institute developed some of the first studies on the chemical composition of foods used by the population. Today, the Institute is known as the Instituto de Central America Nutritión de Centro América y Panamá (INCAP) and serves as a Pan American Health Organization (PAHO)/World Health Organization (WHO) Regional Center. Migration Central America has experienced high rates of migration for generations, including rural-to-urban and regional migration as well as emigration abroad, predominantly to the United States. Before the 1980s, a decade wrought with armed conflicts in the region, Central America drew little global or hemispheric attention in terms of migration. In this period, however, the region became a geographic bridge to North America as migrants from South America sought to enter the United States. Furthermore, Mexico has become the main transit country for Central Americans headed north. Emigration abroad has produced a range of profound changes within Central America, including economic dependency on remittances, an exponential increase in the volume of international phone calls, and – from fashion to governance – the importation of outside tastes. While Central America is a junction of numerous migratory flows, migration does not affect the region uniformly. The more conflictive zones and countries in the region, such as the civil strife in El Salvador, Nicaragua, and Guatemala for example, have experienced significantly higher rates of emigration than rates in the more stable countries of Panama and Costa Rica. Colonized by the Spaniards in the 1500s, Central America was chiefly a subsistence agricultural zone; that is, any agricultural economy in which the crops and/or animals are used nearly exclusively for local or family consumption. As such, the Kingdom of Guatemala provided far fewer riches than other Spanish colonies. Though independent as of 1821, the region’s livelihood did not change substantially until the late nineteenth century when coffee and other export crops were introduced. The reforms at that time privatized communal lands and displaced thousands of peasants. Equally important, however, is that the policies catalyzed a pattern that endures today – oligarchic control of the land and the armed forces, while much of the population fights to overcome perpetual poverty. This combination of agricultural labor needs with people C displaced from the land produced seasonal, rural-torural migration – a pattern that endured into the second half of the twentieth century. In the 1960s, several Central American countries attempted industrialization. However, the divided class structure persisted and became the impulsion for revolutionary and civil warfare in the region during the 1970s through the early 1990s. Warfare not only killed thousands and displaced millions, but also institutionalized a migration pattern to the north – a pattern that until this time had been very minor. Massive refugee flows moved through the isthmus into the United States and, to a lesser extent, Mexico, Costa Rica, Canada, and Belize. Until then, Central American emigration had consisted of small numbers of professionals, skilled laborers, and domestics. Internal labor migrations became increasingly dangerous as a result of the region’s conflicts. Thus, regional economies suffered, inciting combatants and noncombatants alike to flee. Figures derived largely from the 1990 US census suggest that more than a million Central Americans fled their homelands and sought asylum in the United States during the turbulent decade of the 1980s. Regional Migration In 1970, approximately half of all Central American emigrants relocated to other Central American countries, while half moved out of the region. By 1980, however, the proportions had altered dramatically, with 80% leaving the region. In fact, by 1990, 93% of all Central American migrants left the region. Information on extraregional migration flows is much more readily available, although there is some notable research on Nicaraguan migrants emigrating to Costa Rica and, to a lesser degree, migrations of Guatemalans and Salvadorans to Belize. Intraregional migration is an area that calls for further study. For example, there is growing evidence of migrations of Nicaraguans and Hondurans into El Salvador spurred by the late 1990s postwar economic recovery in that country – a rebound financed in large part by remittance dollars from Salvadorans living in the United States. Additionally, the Panamanian economy attracts a modest number of Central American migrants; the number of Central American foreign born rose 11% between 1990 and 2000. 379 C 380 C Cervical Cancer Related Topics ▶ Asylum ▶ Emigration ▶ Health care ▶ Health outcomes ▶ Immigration status ▶ Mexico ▶ Refugee Suggested Readings Menjivar, C. (2000). Fragmented ties: Salvadoran immigrant networks in America. Berkeley/Los Angeles: University of California Press. Orozco, M. (2005). Transnationalism and development: Trends and opportunities in Latin America. In S. M. Munzele & D. Ratha (Eds.), Remittances: Development impact and future prospects (pp. 307–329). Washington: The World Bank. United Nations Development Program (2005). Human development report for El Salvador, Migration Sections. Suggested Resources Migration Information Source. For information on Central America from the Migration Information Source. http://www.migration information.org/USFocus/display.cfm?ID=386 OECD. For information on Central America from the Organization for Economic Development and Cooperation. http://www. oecd.org Cervical Cancer STEVEN P. WALLACE1, GLORIA GIRALDO2 1 Center for Health Policy Research, School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA 2 School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA Cervical cancer is the seventh most common cancer worldwide and the third most common among women. In 2008, there were 529,000 new cases of cervical cancer and 275,000 deaths worldwide. Cervical cancer arises in the epithelium after persistent infection with one or more oncogenic types of human papilloma viruses (HPV). The resulting precancerous lesions can progress to invasive cervical cancer over a period of 10– 20 years if not identified and removed in a timely manner. The main risk factors are therefore HPV infection and a lack of screening with early treatment. The established identified cofactors that increase the risk of cervical cancer are long-term use of hormonal contraceptives, high parity, tobacco smoking, and coinfection with HIV. Common factors that contribute to most of these risks are low education and poverty. Epidemiology It is estimated that among women worldwide with normal cytology about 10.4% are positive for cervical HPV DNA. HPV and cervical cancer are unequally distributed globally with a high concentration in the Global South. The prevalence of HPV is higher in less developed countries (15.5%) than in more developed countries (10.0%). Women in Africa have the highest HPV prevalence (22.1%), followed by women in Central America (20.4%). In contrast, women in South America and North America have a lower prevalence (12.3% and 11.3%, respectively). While the geographic pattern of cervical cancer generally follows the HPV pattern, cervical cancer screening and treatment inequities modify the pattern somewhat. Approximately, 85% of the cervical cancer cases occur in low-income countries where cervical cancer accounts for 13% of all female cancers. In Africa, the agestandardized incidence rate (ASR) is 29.3 per 100,000 with an ASR of 42.7 in Eastern Africa. Central and South America have ASRs around 30 while the rate in Asia is 15.4 (26.6 in South Asia). In contrast, the cervical cancer ASRs in North America, Japan, Australia, Western Europe, and Northern Europe are all below 10. The slow conversion of an HPV infection to cervical cancer provides a long window for action. Early detection methods and curative treatments were introduced in the 1950s in developed countries, leading to falling cervical cancer rates in most parts of the world. The high incidence and mortality rates in low-income countries are mainly due to the lack of or ineffective screening programs, in addition to elevated disease burdens, a lack of basic health care services for women, and to general barriers to access and utilization of health care. Cervical Cancer in the Context of Migration The low international migration rates of residents of the poorest nations result in most migrant women Cervical Cancer coming from countries with middle incomes and an intermediate risk profile for HPV and cervical cancer. When they settle in high-income countries, those migrant women are often the focus of special efforts to screen, diagnose, and treat HPV and cervical cancer because their rates are noticeably higher than the average of their new homelands. Screening Data from high-income countries with large immigrant populations consistently show that screening rates are lower for immigrants than for the native born, and that Asian immigrants have particularly low rates. The majority of the 40 million immigrants in the USA come from Latin America (54.6%) and East and South Asia (17.6%). One study found that 18.6% of recent immigrant women (those who have lived less than 25% of their lives in the USA) and 9.9% of more established immigrants had never received a Pap test in their lifetimes, compared to 5.8% of US-born women. The highest rates of never being screened were for women born in India who had lived less than 25% of their lives in the USA (recent immigrants, 43.7% unscreened) and those who had lived more than 25% of their lives in the USA (established immigrants, 25.0% unscreened). The study similarly found high non-screening rates among immigrant women from Mexico, with 32% of recent immigrants and 16.6% of established immigrants reporting that they had never been screened for cervical cancer. There was a consistent trend among immigrant women of increasing “ever screened” rates as they lived a longer portion of their lives in the USA. When the rates were adjusted by socioeconomic factors, the adjusted prevalence of never receiving a Pap test was highest among women from Asia, Southeast Asia, and India (19.6%); followed by women from South America (12.7%), Mexico (11.2%), the Caribbean (11.0%), Europe (9.9%), and Central America (9.2%). Immigrants constitute 20.8% of Canada’s total population. While the largest number of foreign-born persons is from the United Kingdom (UK), the largest migrant groups since the 1990s have been from China, India, and other Asian nations. A study of immigrants in Canada found that White English-speaking foreignborn women have the best Pap smear screening rates C (only 3.8% never screened and 16.1% screened more than three years previously or not at all). These percentages were similar to the rates for White native women. In contrast, other groups of immigrant women reported high rates of never having been screened: 34.3% of South Asians, 30.1% of Arab/West Asians, 25.5% of Southeast Asians, and 17.5% of Hispanics. The authors concluded that Pap testing for Hispanic immigrant women and White women from continental Europe eventually reaches, and in some cases surpasses, that of Canadian born White women. Immigrant women from Asia, however, never reach the cancer screening rates of native-born women even after living many years in Canada. Immigrants in Australia constitute 26% of the total population and mostly come from the UK, New Zealand, China, and India. Several studies have shown that migrant women in Australia had significantly lower levels of screening compared with the nativeborn population, with only 39% of Thai women reporting regular Pap tests and Vietnamese women being at 10–12% points lower than the general population in cervical cancer screening rates. Similarly, the odds ratio of reporting ever having a Pap smear were significantly lower for migrants from Southern Europe, Southern Asia, the Middle East, and Southeast Asia compared to Australian-born women. While culturally based notions of modesty, embarrassment, and fatalism have been extensively studied as possible contributors to lower screening rates, it is important to note that most of these studies have not controlled for cohort and history effects. The Pap smear was introduced in 1949 and gradually became part of the routine care for women in developed countries. On the other hand, in low-income countries cervical cancer prevention programs compete with many health priorities in the midst of major financial constraints and have been plagued by ineffectiveness or limited to coverage in urban areas. Therefore, some cohorts of immigrant women lack familiarity with Pap testing, resulting in a lack of knowledge about the test and its purpose. However, increased education, the utilization of community health workers and interpreters, accessible transportation and child care, and most importantly, access to healthcare, have been shown to increase rates of Pap screening among immigrant women. 381 C 382 C Cervical Cancer Incidence Immigrants in high-income countries tend to exhibit cervical cancer rates that are between that of the country of origin and the receiving country. In the United States in 2007, the age-adjusted cervical cancer incidence was 7.9 for non-Latina White women, 10.7 for Latinas, and 7.0 for Asian American women. Just over half of Latina adults were immigrants and almost 80% of adult Asian American women were immigrants. The higher rate of cervical cancer for Latinas than Whites is the opposite of the pattern for most other cancer sites. In addition, Latinas living in heavily low-income Latino neighborhoods, which are also primarily immigrant communities, have higher odds that both cervical and breast cancer will be detected at a later stage compared to those living in neighborhoods with a lower proportion of Latinos. This suggests that barriers to screening, noted above, have a consequence on the severity of cervical cancer when it is identified. Immigrants to the USA from other low and middleincome countries also have high incidence rates. For example, in Miami, Florida the cervical cancer rate is highest among recent Haitian immigrants with an estimated incidence of 38 per 100,000. According to the Pan American Health Organization (PAHO), Haiti has the highest cervical cancer rate in Latin America and the Caribbean at 93.8 per 100,000 women. Laotian women have the highest rates among Asian American women with a cervical cancer incidence rate of 24.8; reliable data from Laos is not available. Cervical cancer rates in Canada among refugee women 45–64 years of age exceed rates among their Canadian counterparts. Refugee immigrants had an elevated incidence of cervical cancer with a standardized incidence ratio of 1.58 to native Canadians. Among non-refugee immigrant women of the same age, the rate was no higher than among native Canadian women. The majority of refugee immigrants originated from Southeast Asia and South and Central America, while non-refugees are from Northeast Asia, Middle East, North Africa, and Western Europe. In Sweden, there is an increased risk of cervical cancer among women who immigrated to Sweden at age 50 or higher and who were born in Asia, South America, Poland, Bosnia, Eastern, and Southern Europe; there was a decreased risk among women born in Turkey. The observed risk for women over 50 corresponds to the incidence rate of country of birth of the immigrants. These results also suggest that these women are not fully benefiting from screening programs due to differences in socioeconomic position. Survival and Mortality A comprehensive study of cervical cancer survivors in California found that a lack of English proficiency and Latin American origin were associated with lower levels of physical, social, and sexual well-being. Among cervical cancer survivors, the disease and its treatment appear to place additional demands on monolingual Spanish-speaking survivors and their families, including difficulty in accessing appropriate follow-up medical and psychosocial care that results in a poorer overall health-related quality of life. These outcomes underscore the greater disease-related burden of cervical cancer among immigrants and low-income survivors. Mortality rates in the USA for the period of 1985– 1996 showed that there was a marked difference in cervical cancer mortality rates between immigrant and native-born women, primarily among Latina and Asian and Pacific Islander women (AA/PI). The ratio of mortality rates between foreign born and US born was 4.11 for Latina women and 1.40 for AA/PI women. More recent data show that Latina women continue to have increased cancer mortality rates compared with non-Latina women. From 1998 to 2003, Latinas had increased cervical cancer mortality rates compared to non-Latina White women. A more concerning finding was that among Asian–Pacific Islanders and Latinas over the age of 50, the rates of invasive localized cervical cancer declined and regional and distal invasive cervical cancers increased, signifying a late presentation at diagnosis. There is a lack of studies on cervical cancer mortality among immigrants from other countries. Conclusion Most published studies have been conducted in developed nations where there are large numbers of immigrant populations. They reveal that immigrant women tend to lag behind in screening and have higher cervical cancer incidence rates than native-born populations. Cervical Cancer For most immigrant populations, high socioeconomic position, having health insurance (or access to healthcare), younger age, higher education, speaking the main language in the host country, having a usual source of health care, and spending more time in the host country are associated with increased cancer screening likelihood. Studies in California, where 27% of the total population is foreign born, show that near parity in cervical cancer screening has been reached among most groups of women. According to the 2007 California Health Interview Survey, 91% of US-born women between the ages of 21–64 received a Pap test in the past 3 years, compared with 92.3% of women born in Mexico and 80.3% of women born in Asia and the Pacific Islands. These results are to a large extent attributed to the successful implementation of a government sponsored cancer control program in the state that provides free screening and treatment to low-income women regardless of their immigration status. This success provides additional support to the many studies that conclude that the sociodemographic variable most strongly associated with screening and screening maintenance is healthcare coverage and access to care. Survival and mortality have been studied less often for immigrants, although some studies report higher mortality; there is less conclusive evidence about differentials in survival length and outcomes. When multivariate analyses were conducted that adjusted for socioeconomic differences and access to care, differences between immigrant and nonimmigrant populations in screening, incidence, and mortality usually disappeared, indicating that socioeconomic differences and differences in access to care are the most influential causes of variation in the cervical cancer care continuum for all women regardless of migration status. New technologies developed for cervical cancer prevention and control pose great opportunities and challenges in order to expand access to the new vaccines and detection technologies to the women who are most at risk. Newly developed vaccines for the most prevalent strains of the HPV virus may make prevention easier, especially in countries with less developed health care systems. But cost of a complete series of C vaccinations ($375) remains a barrier since it is more than the entire per person national health care expenditures of the poorest countries of the world and will compete with other priorities in middle-income countries. Cervical cancer prevention requires age appropriate interventions in order to be effective; women who are already affected by HPV need to be monitored while young women may be targeted for vaccination. Data show that many populations are receptive to vaccination of young girls. According to the 2007 California Health Interview Survey, 60% of US-born parents expressed interest in having their daughters vaccinated against HPV or had already had them vaccinated. Asian-born parents had the same level of interest (59%) and Mexican-born parents in the state had among the highest level of interest (70%). US immigration policy briefly (2008–2009) required that women aged 11–26 have the HPV vaccine to obtain permission to immigrate. The controversy over this requirement highlights the concerns over costs, coercion, and the portrayal of immigrants as vectors of disease in relationship to cervical cancer. Finally, although low-income immigrants tend to fare poorer in terms of cervical cancer screening, as well as higher incidence and higher mortality compared to their native-born counterparts in some countries, access to care, access to new vaccines, and novel testing methods have the potential to bring health equity to all women. Related Topics ▶ Access to care ▶ Asian Americans ▶ Australia ▶ Barriers to care ▶ Canada ▶ Cancer health disparities ▶ Cancer incidence ▶ Cancer mortality ▶ Cancer prevention ▶ Cancer screening ▶ Ethnic minority group ▶ Global health ▶ Health barriers ▶ Health care utilization 383 C 384 C Chain Migration ▶ Health disparities ▶ Health services utilization ▶ Healthy immigrant ▶ Hispanics ▶ Immunization ▶ Latinos ▶ Pap test ▶ Reproductive health ▶ Screening ▶ United States Suggested Readings Anikeeva, O., Bi, P., Hiller, J. E., et al. (2010). The health status of migrants in Australia: A review. Asia-Pacific Journal of Public Health, 22(2), 159–193. Ashing-Giwa, K. T., Tejero, J. S., Kim, J., et al. (2009). Cervical cancer survivorship in a population based sample. Gynecologic Oncology, 112(2), 358–364. Beiki, O., Allebeck, P., Nordqvist, T., et al. (2009). Cervical, endometrial and ovarian cancers among immigrants in Sweden: Importance of age at migration and duration of residence. European Journal of Cancer, 45(1), 107–118. Boyle, P., Levin, B., (Ed.) (2008). World cancer report 2008. World Health Organization; International Agency for Research on Cancer. Geneva: WHO Press. McDermott, S., Desmeules, M., Lewis, R., et al. (2011). Cancer incidence among Canadian immigrants, 1980–1998: Results from a national cohort study. Journal of Immigrant and Minority Health, 13, 15–26. Scarinci, I. C., Garcia, F. A., Kobetz, E., et al. (2010). Cervical cancer prevention: new tools and old barriers. Cancer, 116(11), 2531–2542. Tsui, J., Saraiya, M., Thompson, T., et al. (2007). Cervical cancer screening among foreign-born women by birthplace and duration in the United States. Journal of Women’s Health, 16(10), 1447–1457. Wallace, S. P., Gutiérrez, V. F., & Castañeda, X. (2008). Access to preventive services for adults of Mexican origin. Journal of Immigrant and Minority Health, 10(4), 363–371. Watson, M., Saraiya, M., Bernard, V., et al. (2008). Burden of cervical cancer in the United States, 1998–2003. Cancer, 113(10), 2855–2864. Suggested Resources Castellsague, X., De Sanjose, S., Aguado, T., et al. (Eds.). (2007). HPV and cervical cancer report. Vaccine, 25(Suppl. 3). http://www. who.int/hpvcentre/publications/HPVReport2007.pdf. Accessed June 30, 2010. United Nations Development Programme. (2009). Human development report: Overcoming barriers: Human mobility and development, New York. http://hdr.undp.org/en/reports/global/hdr2009/. Accessed June 30, 2010. Chain Migration BIN YU Rhode Island College, Providence, RI, USA Chain migration is a social process that is more complex than a simple mechanical process of people migrating. Sociological factors such as social networks are the key during the chain migration process. It is common for some scholars to refer to chain migration in the context of social network which usually operates within a social network that includes family, friends, community, etc. However, the term chain migration usually refers to the migration chain that operates within family members only. Most research on chain migration has focused on the operating mechanism of chain migration and its demographic and socioeconomic impact on the destination countries on a macro level. Some research has examined chain migration at local levels. During a typical chain migration process, the initial immigrants migrate to a destination country on their own, although they have no family ties there. These initial immigrants will migrate either driven by the socioeconomic factors (such as wages, employment potentials, etc., as validated by all of the economic and sociological immigration theories), or by nonsocioeconomic factors (wars, natural disasters, refugee and asylum policies, etc., as validated by all of the nonsocioeconomic theories). They are either voluntary or involuntary (or forced) migrants, depending on their situations. The key is that these initial immigrants make the move on their own; there is no family tie in the destination countries. Therefore, migration for them usually has a high price, both economically (in terms of financial cost) and noneconomically (in terms of the disruption of their family lives and the cultural shock associated with migration). Once they arrive at their destination countries, they will settle down and start bringing their family members over by sponsoring them. The potential cost of the future migration of their family members and relatives is substantially lower. With these initial immigrants anchoring at the destination countries, it is relatively easier for them to arrange for the migration of their family members Chain Migration and relatives. The growth and expansion of migration chains will reduce both the costs and the risks for future migrants, potentially making it virtually risk free and almost cost free, as they can diversify their household labor and earnings after their family members and relatives have joined them in their new countries. At the same time, the migration chains are also regulated by the emigration policies of the countries of origin and the immigration policies of the countries of destination – that is the non-socioeconomic aspect of the immigration process. For example, some European countries do not have family-unification-specific immigration laws similar to those in the USA. The differences among the immigration laws contribute to the differences in immigration patterns between US and European countries. Generalized Chain Migration Process The generalized chain migration process consists of three phases: the initiation phase, the family unification phase, and the family reproduction phase. The initiation phase of the chain migration process is the migration of the initial immigrants or principal immigrants, who are sponsored by nonfamily entities. The nonfamily entities include employers who sponsor immigrants as professional immigrants (or through investment as investment immigrants); the government that sponsors immigrants as refugees, asylumseekers, or diversity immigrants; and US-born citizens who sponsor immigrants as foreign-born spouses. Theoretically, undocumented immigrants could also be considered initial immigrants because they might obtain legal immigration status and someday sponsor family members. The family unification phase of the chain migration process is the cumulative migration of family members. During this phase, all prospective migrants immigrate under the sponsorship of previously migrated family members. Migration chains are usually established through the sponsorship of family members who were sponsored by other family members, and so on. It is important to understand that the original principal immigrants usually sponsor their immediate family members only, and they usually do not and cannot sponsor other relatives, such as nieces and nephews, of their family members. These relatives can, however, C be sponsored by the other family members who were sponsored by the principal immigrants. These relatives, once they arrive at the destination country, can also later sponsor their own immediate family members. Therefore, the chain migration process can progress to bringing more derived family members into a country. However, the principal immigrants are in fact truly responsible for all of the derived family members. This is the phase where the Immigration Unification Multiplier (IUM) is defined. IUM measures the multiplier effect of the chain migration during this immigration unification process. The family reproduction phase of the chain migration process is the settlement stage of the immigrant family, during which the immigrant second-generation will be born in the destination country. In this phase, immigrant fertility plays a significant role in affecting the size of the second-generation immigrant population. As immigrants arrive from different countries, their respective fertility patterns will have various chain migration multiplier effects that Immigration Reproduction Multiplier (IRM) can measure. Major Factors Affecting the Chain Migration Process During the chain migration process, the strength and length of the migration chains will be determined by several key factors, such as the total number of principal immigrants, the size and structure of immigrant families, and the immigrants’ fertility patterns. The total number of principal immigrants is the most important factor during the chain migration process because the number is actually the total number of migration chains to be initiated. Since each migration chain will have its own family network to sponsor future family immigrants during the complete chain migration process, larger numbers of migration chains will mean a larger number of family members could be potentially sponsored. Therefore, the greater the number of principal immigrants, the greater the number of migration chains that will be generated during the process and the greater the potential number of future family immigrants will be. Since each future family immigrant could be sponsored either directly by a principal immigrant or indirectly by other family immigrants (who were sponsored by the original principal immigrant), the size and 385 C 386 C Chain Migration structure of the immigrant family will determine the potential size of the eventual migration chain. Every such sponsorship is a chain migration event that will result in bringing an additional family member into the destination country. Since each newly sponsored family immigrant could later also initiate his or her own migration sub-chain (for a spouse, children, parents, siblings, and in-laws), these migration sub-chains, combined with the all other migration sub-chains originated from the same principal immigrant, are the basic elements of the large family migration network or the complete migration chain. The potential total number of family members to be sponsored is directly linked to the family sizes of these immigrants, which is determined by the culture of their countries of origin. The larger the immigrant family is (determined by the culture in their own countries), the larger the total number of family immigrants and the stronger and longer the migration chain will be. Immigrant fertility is another very important factor that will have major impact on the chain migration process after immigrants (both principal and family immigrants) settle down in the destination country. Immigrants with higher fertility rates will produce more children, while immigrants with lower fertility rates will produce fewer children. Since various cultures in the countries where the immigrants are from all play significant roles in shaping the immigrant fertility, immigrants from different regions/countries usually have quite different immigrant fertility patterns in producing immigrant children. Therefore, various immigrant fertility patterns decide the total number of second-generation immigrants in the destination country. The higher the immigrant fertility rate, the greater the immigrant second-generation population will be, if the immigrant population size is the same. At the same time, other socioeconomic and nonsocioeconomic factors also have major impacts on the process of chain migration, and the actual realization of the chain effects could differ greatly among various immigrant groups. Other possible determinants include: ● The attractiveness of the destination country The more attractive the destination country is relative to the country of origin, the more family members will want to be part of the chain. According to existing research on international migration, developed countries are highly attractive to immigrants from underdeveloped or developing countries. ● The openness of the immigration policy of the destination country The more open the immigration policy of the destination country is, the greater the potential for more chain effect during the chain immigration process. While most European countries are among the least open in terms of immigration policies, the USA is one of a few top countries with very open immigration policies. ● The culture factor of the immigrant home country Assimilation is one of the most discussed topics in international migration research. During the assimilation process, the greatest challenge for immigrants is usually the process of cultural adaptation and adjustment. The degree of successful cultural adaptation and adjustment of earlier immigrants will have major impact on the migration decisions of potential future immigrants within the chain migration process. Measuring the Migration Chain Measuring the impact of chain migration is very complicated. The current available indicators are the Immigration Unification Multiplier (IUM) and the Immigration Reproduction Multiplier (IRM). Both are the components of the Immigration Multiplier (IM). The Immigration Unification Multiplier (IUM) is the total number of first-generation immigrants each principal immigrant generates. The IUM reflects the total number of future immigrants who come to the host country through the family unification process as a result of the admission of one principal immigrant (who was not him or herself sponsored for a family reunification visa by any previous family immigrant). The IUM value is, therefore, the multiplier factor that measures the family reunification process in migration chains. Since principal immigrants are part of the firstgeneration immigrants, the value of the Immigration Unification Multiplier (IUM) will have to be 1 or greater. The extreme case of the IUM being 1 would Chain Migration mean that the principal immigrants migrate to the destination country all by themselves without sponsorship of any of his/her family members. In reality, however, immigrants will most likely sponsor some of their family members. Therefore, with the assumption that the additional family members will join the principal immigrants, we should always see a value greater than 1 for the IUM. Since the family reunification process is heavily influenced by the immigrants’ cultural backgrounds (such as family size, family values, etc.), it is easy to suggest that the larger the immigrant family is and the stronger its family values are, the higher the IUM value it will have, and the stronger the chain effect of the migration chain will be in the form of Immigration Unification Multiplier. The Immigration Reproduction Multiplier (IRM) is the combined total of the first- and the secondgeneration immigrants that each first-generation immigrant generates. The value of IRM is the multiplier for measuring the family reproduction component of the chain migration process. Since all first-generation immigrants are responsible for all of their immigrant children (i.e., the second-generation immigrants), the Immigration Reproduction Multiplier (IRM) will also have to be 1 or greater. If, in an extreme case, the IRM is equal to 1, it means that the principal immigrants (and their sponsored family members, if IUM is greater than 1) will not produce any children in the destination country after their migration. In reality, immigrants do usually have children in the destination country. Therefore, we can use this new indicator to measure the fertility component of the chain immigration process, because producing children in the destination country is the final phase of the migration chain. Usually, the higher the immigrant fertility rate, the higher the IRM value, and the stronger the chain effect of the migration chain in the form of the Immigration Reproduction Multiplier will be. As some research suggests, when children are born in the destination country, immigrants tend to stay there permanently. This fertility component in chain migration process is very important. The IM, therefore, indicates the total number of all future immigrants who are directly or indirectly sponsored by one principal immigrant, and the total number of all second-generation immigrants who C are born to all of these immigrants. For example, higher IUM indicates higher sponsorship rate, and thus stronger family unification multiplier effect of the chain migration; higher IRM indicates higher fertility rate, and thus stronger family reproduction multiplier effect of the chain migration. With clear multiplier effects from unification and from reproduction, we will have the overall IM and can assess the overall multiplier effect and its impact of the chain migration process. Related Topics ▶ Assimilation ▶ Citizenship ▶ Family reunification ▶ First generation immigrants ▶ Illegal immigration ▶ Labor migration ▶ Social networking Suggested Readings Goering, J. M. (1989). The explosiveness of chain migration – Research and policy issues: Introduction and overview. International Migration Review, 23(4), 797–812. Jasso, G., & Rosenzweig, M. R. (1986). Family reunification and the immigration multiplier: U.S. immigration law, origin-country conditions, and the reproduction of immigrants. Demography, 23(3), 291–311. Jasso, G., & Rosenzweig, M. R. (1989). Sponsors, sponsorship rates and the immigration multiplier. International Migration Review, 23(4), 856–888. Massey, D. S. (1990). The social and economic origins of immigration. In S. H. Preston (Ed.), World population: Approaching the year 2000 (Annals of the American Academy of Political and Social Science, Vol. 510, pp. 60–72). Newbury Park: Sage Periodicals Press. Massey, D. S. (1999). Why does immigration occur? A theoretical synthesis. In C. Hirschman, P. Kasinitz, & J. DeWind (Eds.), The handbook of international migration: The American experience. New York: Russell Sage Foundation. McDonald, J. S., & McDonald, L. D. (1964). Chain migration, ethnic neighborhood formation, and social networks. The Milbank Memorial Fund Quarterly, 42(1), 82–97. Price, C. A. (1963). Southern Europeans in Australia. Melbourne: Oxford University Press. Yu, B. (2005). Immigration multiplier: A new method of measuring the immigration process. Providence: Brown University. Yu, B. (2007). Chain migration explained: The power of the immigration multiplier. New York: LFB Scholarly Publishing LLC. 387 C 388 C Chaldean Americans Chaldean Americans ANDREA M. PRZYBYSZ Case Western Reserve University School of Law, Cleveland, OH, USA In the Detroit metropolitan area, an estimated 490,000 individuals refer to themselves as Chaldeans. While most people in the Detroit area are accustomed to the term, due to small populations elsewhere, few individuals outside the area have heard the term. Even fewer individuals know the full definition of what it means to be Chaldean or the history behind Chaldean Americans. Chaldeans are commonly thought of as Christian Middle Easterners, but this definition lacks precision. More specifically, Chaldeans are Roman Catholic individuals who have immigrated from the northern Tigris-Euphrates Valley, the area historically known as Mesopotamia, and presently known as Iraq. It should be acknowledged that while Chaldeans compose only about 10% of Iraq’s population, the vast majority of Iraqis living in America are Chaldean. As a result of the early promise of Detroit’s auto industry, the vast majority of Chaldeans living in America reside in Detroit, with small communities also appearing in Chicago, Illinois; El Cajon, San Jose, and Turlock, California; and Oaxaca, Mexico. Of the Chaldeans living in Detroit, nearly 95% of people can track their ancestry back to the Tigris-Euphrates town of Telkaif. At the same time that auto incentives drove the first Chaldeans to Detroit in the late 1800s, many Chaldeans left Telkaif for Mosul, Baghdad, Basra, and Beirut. But, by the time Chaldean Americans settled and found success in Detroit, many encouraged their families and friends to join them. This second coming started the process of chain migration, which continued with wavering intensity through the 1960s. While newly arriving Chaldeans viewed Detroit as a hospitable economic environment, the Detroit’s large Catholic population also drew Chaldeans in. Though the majority of Iraqis are practicing Muslims, Chaldeans are Roman Catholics, thought to have been converted by the missionary St. Thomas the Apostle in the early part of the first century. Until the arrival of St. Thomas in the Tigris-Euphrates Valley, the Chaldean people followed Nestorius, a patriarch of Constantinople who led the Church of the East and taught that Jesus was not simultaneously God. Aside from this division, Chaldean people followed the teachings of the Roman Catholic Church. In 1445, the Church under the leadership of Pope Eugenius IV and the Nestorians reconciled their differences: the Church agreed to permit a new Catholic rite, the rite to hold mass in Aramaic, and the Nestorians agreed to accept Jesus as God. Those Nestorians who refused to accept the Church’s terms continue to belong to the Church of the East. Unlike the majority of Iraqis who speak Arabic, the ancestral language of Chaldeans is Aramaic, commonly known as the language Jesus was thought to have spoken. Despite being better educated and from wealthier families than their Chaldean counterparts who immigrated in the early and mid-part of the twentieth century, most recent Chaldean immigrants do not speak Aramaic. The loss of the Aramaic language among modern Chaldean immigrants is considered a grave loss and can primarily be attributed to the fact that the Iraqi school system requires school to be taught in Arabic. Following the Gulf War in the 1990s, the USA has seen fewer Iraqis and Chaldeans immigrate. Because many Chaldean families had sons and nephews on both sides of the Gulf War, fighting for the USA on one hand, and Iraq on the other, many families suffered devastating psychological effects. The result of this so-called brother versus brother combat left many Chaldean families who identified first and foremost as Americans without a sense of home or belonging. The result of this impact can arguably be seen today where Chaldean and Arab Americans continue to be cautious of anti-Arab attitudes by limiting the extent to which they are willing to acculturate. Instead, many Chaldeans and Arabs elect to live in close proximity to one another. Due to continued stigma associated with mental disorders in Middle Eastern culture, less acculturated Chaldeans face major obstacles in admitting problems Chemical Exposure and seeking mental health services. In Chaldean culture, it is still believed that mental disorders cast shame upon the family. Unfortunately, these negative attitudes toward mental health greatly undermine the work many Middle Eastern refugees need. Many Middle Eastern refugees come to America after having witnessed serious atrocities, political unrest, and in some cases, even torture. More acculturated individuals similarly face problems due to the creation of a public identity to minimize ethnicity when desirable and a private identity to be used around family and friends. These negative attitudes pose further risks when considering that Chaldean Americans who seek out proper services do so in the context of there being little empirical research on the culturally relevant services needed. Related Topics ▶ Arab Americans ▶ Chain migration ▶ Iraq ▶ Labor migration Suggested Readings Abudabbeh, N., & Aseel, H. A. (1999). Transactional counseling and Arab Americans. In Transcultural Counseling (pp. 283–296). Alexandria, VA: American Counseling Association. Ahmed, S., & Akhter, K. (2006). Understanding and working with Muslim youth. Paper presented at the American Psychological Association, New Orleans, LA. Ahmed, S., & Ezzeddine, M. (2009). Challenges and opportunities facing American Muslim youth. Journal of Muslim Mental Health, 4(2), 159–174. doi:10.1080/15564900903245782. Ajrouch, K. J. (2000). Place, age, and culture: Community living and ethnic identity among Lebanese American adolescents. Small Group Research, 31(4), 447–469. doi:10.1177/104649640003100404. Haboush, K. L. (2007). Working with Arab American families: Culturally competent practice for school psychologists. Psychology in the Schools, 44, 183–198. Sengstock, M. C. (2005). Chaldeans in Michigan. Lansing, MI: Michigan State University Press. Suggested Resources Hakim-Larson, J., Kamoo, R., Nassar-McMillan, S. C., & Porcerelli, J. H. (2007). Counseling Arab and Chaldean Americans. Journal of Mental Health Counseling, 29(4), 301–321. Retrieved from http://findarticles.com/p/articles/mi_hb1416/is_4_29/ai_ n32372837/ C 389 Chemical Exposure DOUG BRUGGE Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA There are over 80,000 chemicals in use in the USA and it is safe to say even more if one were to do a global inventory. In addition, there are many more chemicals that people are exposed to that are generated by combustion and other reactions in the environment. Combustion products, smoke of various sorts, can by themselves be composed of thousands of chemicals. In contrast, only a small number of these chemicals have been thoroughly tested for their toxicity and an even smaller number are regulated in terms of human exposure or environmental release. Thus, it is almost impossible to comprehensively review chemical exposure in general, let alone for immigrants. However, some broad strokes of understanding are possible. Chemicals come in three basic forms: gases, liquids, and solids. The form that a chemical takes will influence how it might or might not get into the body. Gasses or very tiny suspended particles of liquid or solid can be breathed in. Inhalation is a critical entry path because the lungs provide an easy surface onto which chemicals can be deposited or be absorbed into the blood. Liquids and solids may be ingested. The gastrointestinal tract is more protective than the lungs in terms of penetration into the blood, but depending on the nature of the chemical, it may be absorbed to a greater or lesser extent. The skin is another route of entry and is most easily penetrated by fat-soluble substances such as organic solvents. Many potentially hazardous substances will not easily pass through the skin, although some, such as acids, can cause direct damage to the skin on contact. In addition, some chemical substances will cause harm if they penetrate the skin physically, such as depleted uranium shrapnel fragments that may remain lodged internally in combat veterans leaching uranium into the body. The chemical structure of a substance is highly deterministic of its toxicity and ability to enter the C 390 C Chemical Exposure body. As suggested above, a fat-soluble compound, such as benzene, which is found in the gasoline that we put into our cars, has numerous properties that contribute to its toxicity. It is a liquid, but evaporates easily to form vapors that can be breathed in. It is fat soluble and can pass through the skin on contact and enter the blood and travel through the body. Benzene is an acute toxin and can cause drowsiness, dizziness, rapid heart rate, headaches, tremors, confusion, unconsciousness, and even death in a short time at high doses. But it is also a well-established carcinogen and can cause a specific type of leukemia (acute myeloid leukemia) following years of low-grade exposure. The settings in which people are exposed to chemicals are also quite varied. Some people are exposed at work, others at home or during recreation. There may be exposures at school that are not present at home or vice versa. There may be chemicals in the food that we eat, pesticides for example, and in the water we drink, arsenic being one. Particularly in industry, mining, construction, and other manual jobs there can be toxic chemicals that are part of the job, such as silica dust or various solvents. In other settings, restaurants for example, there will be chemicals from the combustion associated with cooking and tobacco smoke (if it is not banned), even though we think of these as “safe” occupations. Some chemicals in the home are a legacy of the past, an example being interior lead paint, while others are introduced to address a problem, such as pesticides used to kill cockroach infestations. Because there are so many chemicals and they each have their own properties and toxicities it is impossible to remember all of them. Even an expert will need to seek documentation of what is known about a chemical that they have not already investigated. The first problem is to find out what the chemical is. This may not be easy; but many consumer products and substances used in the workplace have labels on the container that give the chemical names. Also, in the USA and many other countries workplaces are required to retain and provide to workers Material Safety Data Sheets that have information about chemicals. Other sources (listed at the end of this entry) include the Agency for Toxic Substances and Disease Registry’s Toxicological Profiles and the National Institute of Occupational Safety and Health’s Pocket Guide to Chemical Hazards. A couple of examples will provide a sense of how chemical exposure might be higher for some immigrant populations. Nail salon workers in the USA are staffed heavily by Vietnamese immigrants, perhaps making up a majority of these workers. While nail salons are not industrial and may not be considered hazardous occupations by many people, they use products that contain many toxic chemicals, including solvents, resins, acids, and plasticizers. While there is little question that Vietnamese immigrants in the USA will have higher exposures to these compounds, it is unclear to what extent this is affecting their health because of the paucity of studies on this occupation. The few studies to date have depended largely on surveys and observation and do not directly monitor exposures or measure biomarkers or long-term health outcomes. Southeast Asian immigrants to the USA often come from rural villages. Due to their experience and comfort with fishing and hunting, their low-income status, and the general acceptability of fishing in the USA, many will fish for food. However, in industrialized areas, fish may be contaminated with chemicals that bioaccumulate, such as methyl mercury or polychlorinated biphenyls (PCBs). Bioaccumulation is a process by which certain chemicals, often fat soluble, increase in concentration as they move up the food chain to higher order predators. If humans are at the top of the food chain, then they may be consuming and thus bring into their bodies these substances. Indeed a study by Schantz et al. found elevated levels of some of these pollutants in Southeast Asian immigrants who fish. A classic example of chemical exposure in immigrants is farm worker exposure to pesticides. Many farm workers are immigrants, documented or not, and many are migrant in that they move to follow the available work. Farm operations commonly use pesticides to control insects and other pests and herbicides to control weeds. While there are a large number of chemicals that are used for these purposes, the toxicity of some of them are well understood, raising concerns about occupational exposure. Numerous studies have confirmed what is clear simply from observation, that many farm workers are exposed to pesticides on a regular basis and that they receive little or no training or protective equipment. Chemical Exposure Farqhar et al. studied Oregon indigenous farm workers who mostly did not speak English or Spanish and found that 48% worked with pesticides (probably an underestimation) and that only 57% received any training. Arcury et al. reported findings in 2009 from a study that measured urinary concentrations of six metabolites of organophosphate pesticides. Frequency of detection of the pesticide metabolites ranged from about 8% at the low end to over 78% at the high end and reported that these metabolites increased during the farm work season. Studies have also associated pesticide exposure in farm workers with biological harms, including genetic damage. Our understanding of the mechanism of action of the organophosphate and N-methylcarbamate types of pesticides is highly developed. We know that these substances inhibit a specific enzyme in the body, cholinesterase, and that their immediate, acute/short-term, effects are primarily on the nervous system. Long-term associations include increased risk of developing cancer. Indeed, the leading edge of research on the biological effects of these pesticides is now investigating and showing that some genetic/biological traits interact with pesticide exposure to modify their impact on enzyme activity. In the USA, regulation of occupational exposure of farm workers to pesticides is through the Environmental Protection Agency rather than the Occupational Health and Safety Administration. This, combined with the exclusion of agricultural workers from many labor laws and the often undocumented status of these workers, places severe barriers on the ability of immigrant farm workers to be afforded basic protections from chemical exposures that are hazardous to their health. At the more local level of workplace practices aimed at reducing chemical exposure, a 2009 report by Pechter, Azaroff, Lopez, and Goldstein-Gelb addresses the use of hazardous cleaning products for Janitors in Massachusetts, USA. This project, engaged the workers, their union, and a local nonprofit called the Massachusetts Coalition for Occupational Safety and Health. Using a survey and having workers show and describe the substances they were using at work, it was possible to identify products that were the most hazardous, misused, or not needed. Supervisors responded to this effort with a number of changes C aimed at reducing exposures and addressing health complaints. While the examples given above only scratch the surface of chemical exposures to immigrants, many more of which are probably not even identified let alone studied, they illustrate that there are distinct aspects of chemical exposure for at least some groups of immigrants. There is a need for more research as well as increased education of immigrant populations about chemical exposures and health. Related Topics ▶ Air pollution ▶ Environmental exposure ▶ Environmental health ▶ Environmental tobacco smoke ▶ Migrant farmworkers ▶ Occupational and environmental health ▶ Occupational health ▶ Pesticides Suggested Readings Arcury, T. A., Grzywacz, J. G., Chen, H., Vallejos, Q. M., Galvan, L., Whalley, L. E., et al. (2009). Variation across the agricultural season in organophosphorous pesticide urinary metabolite levels for Latino farmworkers in Eastern North Carolina: Project design and descriptive results. American Journal of Industrial Medicine, 52, 539–550. Farquhar, S., Shadbeth, N., Samples, J., Ventura, S., & Goff, N. (2008). Occupational conditions and well-being of indigenous farmworkers. American Journal of Public Health, 98, 1956–1959. Flocks, J. (2009). Pesticide policy and farmworker health. Reviews on Environmental Health, 24, 327–332. Hofmann, J. N., Keifer, M. C., Furlong, C. E., De Roos, A. J., Farin, F. M., Fenske, R. A., et al. (2009). Serum cholinesterase inhibition in relation to paraoxonase-1 (PON1) status among organophosphate-exposed agricultural pesticide handlers. Environmental Health Perspectives, 117, 1402–1408. McCauley, L. A., Lasarev, M., Miniz, J., Stewart, V. N., & Kisby, G. (2008). Analysis of pesticide exposure and DNA damage in immigrant farmworkers. Journal of Agromedicine, 13, 237–246. Pechter, E., Azaroff, L. S., Lopez, I., & Goldstein-Gelb, M. (2009). Reducing hazardous cleaning product use: A collaborative effort. Public Health Reports, 124, 45–52. Quach, T., Nguyen, K.-D., Doan-Billings, P.-A., Okahara, L., Fan, C., & Reynolds, P. (2008). A preliminary survey of Vietnamese nail salon workers in Alameda County, California. Journal of Community Health, 33, 336–343. Roelofs, C., Azaroff, L. S., Holcroft, C., Nguyen, H., & Doan, T. (2008). Results of a community-based occupational health survey of Vietnamese-American nail salon workers. Journal of Immigrant and Minority Health, 10, 353–361. 391 C 392 C Chernobyl Sequelae Schantz, S. L., Gardiner, J. C., Aguiar, A., Tang, X., Gasiorb, D. M., Sweeney, A. M., et al. (2010). Contaminant profiles in Southeast Asian immigrants consuming fish from polluted waters in Northeastern Wisconsin. Environmental Research, 110, 33–39. Suggested Resources ATSDR Toxicological Profiles: http://www.atsdr.cdc.gov/toxprofiles/ tp3.html NIOSH Pocket Guide to Chemical Hazards: http://www.cdc.gov/ niosh/npg/ Chernobyl Sequelae ABDUSAMAD DUSTOV Department of Nuclear Medicine, Gastroenterology Institute of the Academy of Sciences of the Republic of Tajikistan, Dushanbe, Tajikistan Twenty-four years have passed since the time when the world was shaken by the damage at Chernobyl nuclear power station, the fatal consequences of which many thousands of people now feel. A tragic fate overtook 1,800 citizens of the Republic of Tajikistan who participated in the response to the disaster. The effect on the environment of the Chernobyl atomic catastrophe has been investigated many times, and from different points of view, since the accident. But investigations of the effects of different radiation doses on the human immune system have not been studied. In our Institute in Dushanbe, we examined approximately 750 people who had taken part in the liquidation of Chernobyl between 1994 and 2006. The psychological, digestive system, and immune responses of these people, who directly took part in the liquidation, were assessed. The investigation began eight or more years after the catastrophe. All of the patients were investigated and treated in our hospital, opened after the Chernobyl disaster. This work characterized the immune status of 350 individuals who participated in the 1986–1990 cleanup work of the Chernobyl nuclear power plant explosion. The level of immunoglobulin (IgA, IgG, and IgM), the numbers of peripheral blood leukocytes, lymphocytes, T-lymphocyte and their subpopulations (CD3+,CD4+, CD8+),B lymphocytes (CD19+), and natural killer cell (CD16) were determined in the peripheral blood. Most of our patients were sent by general physicians to us for psychiatric consultation about psychological and psychiatric problems. The doses received by our patients depended on the time at which they began their work in the contaminated area and its duration. The first signs of disorders appeared at the end of 1986 among 45% of our patients. It took 1.5–2 years or more for these disorders to appear. The average age of our patients was 30–45 years at the time. Most of them had similar multiple complaints: headache, dizziness, fatigue or chronic tiredness, poor concentration and lack of attention, memory loss, irritability, sometimes anger, mood swings, anxiety, exhaustion after physical and mental activities, high blood pressure, respiratory deregulation, feelings of hopelessness and worthlessness, and lack of libido. They also had a high sensitivity to loud noises, bright light, and high temperatures. The overall symptoms of these patients were so similar, that we call this syndrome: “Cerebrasthenic post Chernobyl Syndrome.” In some cases, the cerebrastenic syndrome developed into an encephalopathic syndrome. The pathological change in these cases included autoimmune, neuro-immune reactions and biochemical changes. At the same time, most of our patients suffered from various somatic diseases. The results of psychological examination of those patients indicated poor attention, lack of concentration and attention, memory loss, mental exhaustion, and reduction of mental ability. Eighty percent of the patients had a very high level of anxiety. Some patients could not even remember their phone numbers or what they just had read in the newspaper. Sometimes they did not remember where they were going. More than 85% had changes in their character, and 96% had low levels of self-esteem and selfevaluation. At our Institute, we saw many patients, and we realized that it was very difficult, and sometimes impossible, to sort out all these symptoms. Psychoorganic syndromes can evolve in three stages: – The first is mild, with asthenia or cerebrasthenia, reduced emotional ability, decreased physical working ability, changes in mood, poor attention, lack of concentration, and memory impairment. – The second stage is moderate, which includes all of the first stage, plus personality changes, irritability, Chernobyl Sequelae C 393 Chernobyl Sequelae. Table. 1 Parameters of immunity and biochemical parameters in blood of the liquidators Control group Liquidators P T-lymphocytes suppressors Immune complex IgA 2.0 + 0.08 1.88 + 0.12 2.65 + 0.2 1.37 + 0.07 3.35 + 0.25 1.86 + 0.2 P < 0.01 P < 0.05 P < 0.05 IgM IgG Protein Bilirubin 1.24 + 0.15 15.8 + 1.1 74.0 + 0.59 20.5 + 0.3 0.78 + 0.1 10.3 + 1.1 66.1 + 0.4 25.5 + 0.6 P < 0.01 P < 0.01 P < 0.01 P < 0.01 Cholesterol AsAT ALAT 4.11 + 0.4 125 + 11.9 280 + 12.3 3.86 + 0.5 156 + 11.8 380 + 13.1 P > 0.1 P < 001 P < 0.001 dysphasia, periods of anger and psychotic-like states. – The third stage is severe, with important aggravation of the symptoms of the first and second stage, plus instability. Clinical and psychological examinations allowed us to describe a specific “cerebrasthenic Syndrome” as the first stage of organic mental disorders. The diagnosis, the prevention, and the treatment of neuropsychiatric syndromes, especially those related to radiation and to acute radiation sickness, are of great interest and they need to be analyzed and studied further. In 350 liquidators from Chernobyl, we found a significantly decreased number of CD16+ cell (natural killer), of CD4+ and CD8+ T-lymphocytes. In Chernobyl cleanup workers there was variation in the number of T-lymphocytes. Levels of IgG and IgM were significantly decreased in persons who worked in Chernobyl in 1986 during the first month after the accident. For the T-lymphocytes suppressors, there is a similar situation: a decrease of the T-helpers which increases the defense mechanism against various infections, and an important increase of T-lymphocytes suppressors, which reduces these deference mechanisms. Our results clearly reflect an impaired immune system in the Chernobyl cleanup workers even 10–14 years after the nuclear accident (Table 1). The liquidators from Chernobyl had a reduced IgG (gamma-globulins), pointing to a reduced reaction of their immune system. They also have low doses of Cs 137 in their bodies. We also found an increase in the number of circulating autoantibodies in the blood of these liquidators: These are very complex, very pathogenic proteins, which induce several autoimmune disorders in various organs. In conclusion, the immune systems of liquidators from Chernobyl have been impaired. We find various disorders of the immune system in these people. Related Topics ▶ Disasters ▶ Displaced populations ▶ Environmental exposure ▶ Environmental health ▶ Nuclear trauma ▶ Occupational health Suggested Readings Foster, R. P., & Goldstein, M. F. (2007). Chernobyl disaster sequelae in recent immigrants to the United States from the former Soviet Union (FSU). Journal of Immigrant and Minority Health, 9(2), 115–124. Yablokov, A. V., Nesterenko, V. B., & Nesterenko, A. V. (2009). Consequences of the Chernobyl catastrophe for public health and the environment 23 years later. Annals of the New York Academy of Sciences, 1181, 318–326. Suggested Resources http://en.wikipedia.org/wiki/Chernobyl_disaster C 394 C Child Child MARJORIE NIGAR EDGUER Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA Child immigrants are children who immigrate, as distinguished from children of immigrants, who are the children of adult immigrants (and may be immigrants themselves, or may be born in the country to which the parents have migrated). A child who immigrates is born in one country and at some point following their birth migrates to another country to live. Child immigrants usually move to a new country (the “receiving country”) with their parents and/or other family members, but may migrate alone for a number of reasons (see Unaccompanied Minor entry). Child immigrants constitute a special population of immigrants because they have not reached the age of legal adult status in the receiving country, so they do not have the ability to make legally binding decisions for themselves but need to rely on adults to act for them. They are also a special population because of child development: they are experiencing many significant biological transformations physically, cognitively, and emotionally. They are a diverse group, representing many different sending and receiving countries, and having a multitude of reasons for migrating. Many aspects of the child immigrant experience are important: their status within the receiving country, especially regarding citizenship; their interactions with the child systems in the receiving country, especially education systems; and their roles within and the dynamics of their family systems. National policies of receiving countries vary widely regarding child immigrants. Policies regarding immigrant integration in the receiving country may relate to supportive services, educational services, or immigration status. National attitudes regarding immigrants also impact the experiences of child immigrants. Receiving countries tend to be European Union (EU) countries or North American countries (the United States and Canada). Policies regarding immigrant children vary widely from country to country. In the United States, the 14th Amendment to the Constitution states that anyone born or naturalized in the United States is considered a citizen; thus children of immigrants who are born in the United States are citizens of the United States. Because the United States recognizes dual citizenship in certain cases, children born in the United States to immigrant parents may be able to maintain a legal connection to both their parents’ sending country and the United States. In Germany, historically, citizenship was only granted through a blood relationship to a German citizen. Recently, the law has been amended so that some children born in Germany to immigrants are eligible for German citizenship. But dual citizenship is still not recognized in Germany, so youth with immigrant parents have to choose a citizenship as young adults. Immigrant children will find themselves with similar choices as other children of immigrants: policies in the receiving country may support maintaining their connection to their sending country, but more often the policies will encourage establishing themselves in the receiving country by cutting ties to their sending country. Child immigrants are often eligible for a multitude of services to ease the transition to the receiving country. Services to support the transition include language classes, educational support programs, preschool programs, vocational training programs, and translators. Immigrant children are eligible and expected to participate in the compulsory educational opportunities available to children of their age in the receiving country. Depending on their educational experiences in their sending country, they may or may not be prepared for the educational opportunities they find in the receiving country. They may need educational support to catch up with their peer group academically. Children may also be eligible for medical services, either short term or long term, depending on the receiving country. Children who immigrate may have families that are well educated, with many socioeconomic resources in both the sending and receiving country, or their families may have less education and fewer resources than the average family in either sending or receiving country. Immigrant children will be presented with different opportunities, based on these factors. But regardless of socioeconomic differences, immigrant families tend to value education, and immigrant children tend to Child Abuse internalize this value and work hard to succeed in the educational system of the receiving country. Recent research in the United States and Canada that has focused on child immigrants has found that in general immigrant children tend to do well, surpassing the academic achievements of native born children and overcoming risk factors related to neighborhood poverty and violence. Immigrant youth tend to be healthier physically, including reporting less obesity, asthma, or school absenteeism, and less risky behaviors (drug and alcohol use, sex, delinquency, or violence). While different ethnic groups report some differences in specific patterns, in general, immigration is a protective factor for children. Research in Europe has suggested less positive outcomes: immigrant children in Europe are less likely to be fluent in the language of the receiving country and less likely to experience success in the educational systems at the same rate as native born children. Some studies have shown that immigrant youth are more likely to be involved in violent behavior than native youth. It would be important to know more about the differences that have been reported regarding immigrant youth outcomes, so that the appropriate interventions can be implemented. Related Topics ▶ Adolescent health ▶ Child development ▶ Child health and mortality ▶ Child labor ▶ Family ▶ Intergenerational differences ▶ International adoption ▶ Refugee youth ▶ Trafficking ▶ Unaccompanied minor ▶ United Nations Convention on the Rights of the Child Suggested Resources Annie E. Casey Foundation/Kids Count. Retrieved February 21, 2011, from http://www.aecf.org/KnowledgeCenter/SpecialInterestAreas/ ImmigrantsRefugees.aspx Child Trends Databank. Retrieved February 21, 2011, from http:// www.childtrendsdatabank.org/?q=node/333 UNICEF Innocenti Research Centre. Retrieved February 21, 2011, from http://www.unicef-irc.org C 395 Child Abuse SUSAN HATTERS FRIEDMAN1, JOSHUA FRIEDMAN2 1 Departments of Psychiatry and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA 2 Department of Pediatrics, Te Puaruruhau Child Protection Unit, Starship Children’s Hospital, Auckland, New Zealand Child maltreatment includes several distinct but sometimes co-occuring acts: physical abuse, emotional abuse, sexual abuse, and child neglect. Child physical abuse consists of intentional or reckless injury including cuts, bruises, fractures, thermal burns, at times with violent forces such as hitting, kicking, slapping, throwing a victim. For infants, shaking and/or impacting the head has been recognized as shaken baby syndrome, non-accidental head injury and abusive head trauma. Among and within various cultures, corporal punishment is considered distinct from physical abuse, as intentional infliction of physical pain as part of discipline with the goal of changing behavior (e.g., smacking and spanking). Child sexual abuse involves sexual activity of a child with an older child or adult— and can include indecent exposure/viewing genitalia, viewing pornography, producing child pornography, intentional sexual activity in view of a child, inappropriate touching, sexual contact, requesting or coercing such contact, as well as encouraging masturbation or prostitution. Child neglect is generally conceptualized as the parents or guardians not providing for the child’s physical necessities, including food, shelter, or clothing; their needs for medical treatment; their emotional needs for nurturing; or their educational needs. Neglect also includes any failure to act or omission which presents the child with an imminent risk of serious harm. Child abandonment, when done illegally (rather than through Safe Haven type programs), may be considered child neglect. Emotional abuse, more difficult to define, co-exists with other forms of child abuse but on its own may include intentional or reckless devaluation of a child’s human worth and/or violation of individual rights by terror, exploitation, threat, isolation, insult, humiliation, rejection, or failing to care or give C 396 C Child Abuse affection. Overall, the bulk of substantiated cases of child abuse are child neglect, followed by physical abuse and sexual abuse, but there is concern of under reporting and lack of detection. The occurrence of child abuse is multifactorial. Some of the risk factors for perpetration of child abuse include being a single-parent, being in an abusive relationship, substance abuse, and severe socioeconomic stress. Prior abusive or neglectful behavior increases risk, as does parenting skill problems. Special needs children are more likely to be victims. Younger children are at highest risk of fatality. In the vast majority of cases, parents or persons in loco parentis are the perpetrators and the abuse most frequently takes place in the home. However, extended family and even community members such as teachers or religious leaders are perpetrators in some cases. Child abuse was not recognized as a public health concern until the 1800s. Many societies had protection for the safety of animals prior to protection of children. There has been ambiguity across cultures and nations, and even across generations, regarding what is considered to be abuse and what is considered to be within the range of normal or acceptable parenting practices. In the 1920s a Declaration of the Rights of the Child was drafted. The United Nations Convention on Rights of the Child, borne out of decades of revisions of the aforementioned Declaration was opened for ratification by the United Nations in 1989. It was signed by the US Secretary of State in 1995, but unlike 194 countries of the world, the US has as yet failed to ratify. The Articles lay out the social, political, cultural, economic, and civil rights of children. Several countries have made various forms of corporal punishment illegal, yet others view this parental right preferentially. As an example, Sweden, over a decade ago passed a law that children must not be physically punished or humiliated. As of 2007, over 20% of American children had parents who immigrated. Immigrants and their children potentially face many stressors such as lack of family, financial and/or social support, and these may elevate the risk of maltreatment. Several American studies have considered child maltreatment reports from immigrant families in Los Angeles County (California). A study of 221 Chinese immigrant families found that the most common type of maltreatment was physical abuse of children. Another study considered rates of abuse among 170 Korean immigrant families. They found that Koreans were similarly more likely to be accused of physical abuse. This most frequently occurred in situations in which corporal punishment gone wrong. When psychological abuse occurred, it was often in the context of witnessing domestic violence. Still another LA study considered 243 case files of Cambodian refugee families. They found that compared to other Asian and Pacific Islander ethnic groups, Cambodian cases were more frequently reported. Parents often suffered substance abuse (more common in the fathers) or mental illness (more common in the mothers). The Cambodian refugees were more likely to be reported for neglect (compared to other Asian and Pacific Islander groups). Overall, however, it has been noted that the reported rates of child maltreatment among Asian Americans is low; this may be due to protective factors, or may be related to lack of disclosure of abuse. Community support may help decrease risk of child maltreatment. Parenting education with specific knowledge of the culture has been recommended as a prevention effort. Medical problems after the abuse or neglect will vary depending on the sort of abuse or neglect specifically suffered. Shaken baby syndrome is a form of inflicted traumatic brain injury based on shaking trauma to the infant’s brain. Other children may suffer broken bones or organ damage. In addition, whether due to direct medical causes or psychological reasons, some may suffer chronic pain as adults. Among child victims of abuse, there may be psychological consequences in addition to medical complications. Anxiety, depression, and posttraumatic stress disorder are psychiatric disorders, which may occur among victimized children. In addition, decreased self-esteem, disorganized attachment styles, and acting out behaviors may be seen. They may experience difficulty trusting others. Childhood victims of sexual abuse are at elevated risk for the development of borderline personality disorder. Emotional scars as well as physical scars need considered. Child Abuse For some, in later life, a pattern of abuse is carried on through the generations. There is an age-old pattern that women often become perpetual victims in later relationships and that men often become the abusers, perpetuating the cycle of violence. Early diagnosis and treatment may help prevent furthering this cycle. Thus, medical treatment and psychological treatment are often both indicated for victims. Medical treatment may occur in a hospital or as an outpatient, depending on both safety and the severity of the injury. Children may participate in psychotherapy, play therapy, or group therapy, depending on what is recommended for their individual situation and developmental level. Teachers, medical professionals, police officers, legal professionals, and other professionals are often required to report cases suspicious for abuse to the appropriate agencies, often called “Child Protective Services” (CPS) or a “Children and Family Services.” Other concerned members of society may also report. CPS will determine whether investigation is warranted, and if so, a case worker will be assigned. Though parents have rights, the State or Nation generally has the authority to intervene in cases in which parents fail to protect their children’s safety or well-being. Recently, social services have the imperative to learn to improve practices in a culturally competent manner with immigrant and minority families. Specific concerns identified within immigrant communities related to whether to report child abuse have included, among others, fear of government intervention or deportation, differing cultural norms of acceptable parenting behavior, and lack of social support. For example, immigrants to New Zealand may be surprised to learn that only children over age 14 may be left home alone. They may be considered to have neglected their children though their behavior was consistent with what they considered normal in their community of origin. Immigrants may have diverse customs and approaches to child discipline, child monitoring, and cultural practices in illness (e.g., cupping). When there is concern of abuse or neglect, CPS and associated services make a safety plan, and C determine whether remaining in the home is appropriate. If not, the child may be cared for by safe relatives or within the foster care or group home system. Immigrants who are lacking the social support network and kin from home may find their child removed to the foster care system, whereas their native counterparts see the child cared for by a grandparent. Other potential complications with involvement of CPS related to immigrant status include lack of knowledge of immigration law/transnational issues, religion, culture, lack of appropriate resources, and bias. There has been a lack of sufficient research in this area, and CPS workers may find themselves unprepared for complicated cultural issues. Better practices include consideration of cultural competency, consular relations, potential for transnational placement with relatives, and provision of interpretation services. Foster care systems may suffer some racial or ethnic disparities in delivery of care. The aforementioned study in Los Angeles also found that the Chinese children of immigrants were less likely to be removed from their home than non-Chinese children. Criminal and civil court cases may be initiated. Many cases go through the court system, and children may be removed from the parent’s care temporarily or in some cases, permanently. Parents, in collaboration with CPS, are often prescribed a “case plan” which they must complete for custody or reunification with the child to occur. Case plans may include such directives as attending drug treatment, psychiatric treatment, and parenting classes. If the child has been put in out-of-home placement, initial visits with the child may be supervised by CPS or other professionals. In sum, in the late nineteenth century, Western civilization acknowledged child abuse and neglect as unacceptable, and by the late twentieth century recognized its manifestations and clearly codified social responsibility toward children, the criminality of the acts, and the imperative to further improve detection and service. Meanwhile, anthropological exploration of the process of raising children within many of the world’s cultures overturned conventional wisdom of an extant universal standard of 397 C 398 C Child Development child maltreatment. Indeed, the rights of children vis-à-vis the rights of the group vary by society, and change over time; cultural rationalizations for acceptable treatment of children heed the perceived conditions for survival. As cultural idiosyncrasies ranging from tolerant and permissive to authoritarian and restrictive have been revealed across the world’s cultures, there has been concomitant effort globally to root decisions regarding child protection in the child’s “best interests” and to innervate culturally competent child advocacy. However, raising children by weaving diverse cultural norms into a novel social fabric burdens immigrant families and the social institutions of destination states in consideration of child abuse and neglect. Suggested Resources Bridging Refugee Youth and Children’s Services (BRYCS). (2005, April). Determining child abuse & neglect across cultures. Washington, DC: Spotlight. Available in PDF from the BRYCS Clearinghouse. http://www.brycs.org/brycs_spotapr2005.htm Child Development MARJORIE NIGAR EDGUER, MAUREEN RILEY-BEHRINGER Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA Introduction Related Topics ▶ Cultural humility ▶ Domestic violence ▶ Gender-based violence ▶ Homicide ▶ Intimate partner violence ▶ Trafficking ▶ United Nations Convention on the Rights of the Child Suggested Readings Banton, R. (2004). Child abuse. In Wyse Dominc (Ed.), Childhood studies: An introduction. Oxford: Blackwell. Chang, J., Rhee, S., & Berthold, S. M. (2008). Child abuse and neglect in Cambodian refugee families. Child Welfare, 87, 141–160. Chang, J., Rhee, S., & Weaver, D. (2006). Characteristics of child abuse in immigrant Korean families and correlates of placement decisions. Child Abuse & Neglect, 30, 881–891. Fontes, L. A., & Conte, J. R. (2008). Child abuse and culture: Working with diverse families. New York: The Guilford Press. Khamis, V. (2000). Child psychological maltreatment in Palestinian families. Child Abuse & Neglect, 24, 1047–1059. Korbin, J. E. (Ed.). (1981). Child abuse and neglect: Cross-cultural perspectives. Berkeley: University of California Press. Rhee, S., Chang, J., Weaver, D., & Wong, D. (2008). Child maltreatment among immigrant Chinese families. Child Maltreatment, 13(3), 269–279. U.S. Department of Health and Human Services, Administration for Children and Family. Federal Child Abuse Prevention and Treatment Act (CAPTA), as amended by the Keeping Children and Families Safe Act of 2003. Zhai, F., & Gao, Q. (2009). Child maltreatment among Asian Americans: characteristics and explanatory framework. Child Maltreatment, 14, 207–224. Child development and immigration have a multifaceted relationship. It is important to understand this relationship to grasp the experience of child immigrants and develop appropriate supports/interventions. Key aspects of immigration that affect child development include the following: sending country characteristics, family, receiving country characteristics, and cultural expectations of both the sending and receiving countries. Sending country characteristics are the resources, health, safety, and education of the country of origin. Family includes kinship dynamics, resources, and separation(s). Receiving country characteristics include resources, health, safety, and education of the new country. Cultural expectations focus on attitudes, behavior, and beliefs regarding biopsychosocial development, social stratification, developmental milestones, and the interaction of these with other influences. Due to these influences, child immigrants will progress in unique, individual ways that need to be assessed and understood in order to support their optimal development. The concept of an “individualized child development trajectory” refers to the projected developmental pathway given those influences that impede/enhance that child’s overall growth; while there may be many generalizations regarding developmental expectations, it is important to consider which of these are relevant for this particular child (Fig. 1). This concept is important for all children, but particularly relevant for immigrant children, as a multitude of influences surround the immigration experience. Child Development One in five children in the USA is an immigrant, resembling rates in most high-resource, developed nations. Immigration usually occurs from low- to high-resource nations. Children/adolescents constitute a special subgroup of immigrants because they are still developing physically, cognitively, socially, and emotionally, and lack adult rights. For example, children/ adolescents are dependent upon the adults around them to meet basic needs (e.g., shelter, food, clothing, and safety). Dependence on adults varies by both the age of the child and their cultural context. Based on this dependency, children/adolescents may immigrate because of a decision by their parents. They may also immigrate after becoming refugees in their sending country. Children and adolescents’ experiences are impacted developmentally: their understanding, insights, ability to act, and motivations will vary at different developmental stages. Additionally, children and adolescents have particular vulnerability because their physiological and psychological development may be changed by trauma, and incorporating new influences may change their previous sense of identity. Immigration poses a significant transitional event, regardless of the dynamics preceding it. Children and adolescents are learning how their world works, and what is valued by their world. Immigration means that there have to be shifts in this knowledge and Culture C understanding. Their ability to make these shifts, and learn how their new world works, will be instrumental in their ability to successfully transition to a new country. Immigrant children’s ability to successfully transition will have long-term impacts for them, their families, and their new countries. Intervention with child and adolescent immigrants has to be grounded in both developmental processes and have awareness of the impacts of immigrant children’s experiences on overall growth and well-being (see Fig. 1). Much of the research regarding child and adolescent immigrants has found conflicting results, possibly because it fails to integrate the multiple dynamics that impact the process. Some research has found that child and adolescent immigrants are more at risk for problems. Other research has found that immigration is a protective factor for children and adolescents. The reality is that there are multiple aspects that influence the experience of immigrant children and adolescents: biological and psychological child/adolescent development, immigrant status, ethnicity or culture of origin, culture of migration/host society, and individual family culture. Research often uses single measures for complex concepts, like preferred language as a measure for acculturation. Acculturation is defined in a myriad of ways, and has been conceptualized very differently depending on the theoretical model. Simplistic Standardized Lenses for Interpreting Developmental Trajectory (WHO, IPA, etc) Sending Country Resources Child Receiving Country Resources Individual Developmental Trajectory Family Influences Supports and Interventions Child Development. Fig. 1 Individualized developmental trajectory model 399 C 400 C Child Development definitions and models fail to give an accurate picture because they only look at one aspect of the experience. Many immigrant children experience stress and are also doing well on many measures (e.g., academic grades, graduation rates, delinquency, or risky behaviors). Each of these reinforces the importance of considering the child’s individualized developmental trajectory. Potential Influences: Sending Countries Resources Sending countries tend to be limited-resource nations. The literature links children failing to meet their developmental potential in limited-resource countries to factors of poverty, health-related issues, and barriers to education. An estimated 200 million children under the age of 5 are failing to grow healthily and meet their developmental potential, leading to devastating shortand long-term implications for the value of human capital. An interdependent relationship exists among domains of child developmental growth and family preservation, all of which are affected by aspects of living in poverty (i.e., joblessness, migration), experiences of health-related issues (i.e., malnutrition, infectious diseases), and encounters with barriers to education (i.e., school access, child labor). Lack of these resources can be the primary reason families immigrate from limited- to higher-resource countries. Although the developmental effects experienced may follow that child to a new country. Economics Raising children in limited-resource countries can present many barriers to accessing resources to meet needs of the developing child. A parent’s/provider’s competence in supporting his or her family is vested in his or her ability to meet primary needs. Some countries in transition face a restructuring labor market, lack available jobs, or experience a shortage of workers with adequate skills to fill available positions, which may influence a family’s decision to immigrate. Unemployment often prompts temporary (i.e., migration, child labor) or permanent family separations (child relinquishment related to death of parent(s), abandonment, or inability to meet children’s primary needs). Youth may feel some pressure to work to promote preservation of their families. In Central Asian culture, there has been an increase in individuals between ages 15 and 19 being employed. Reportedly, youth in this age group feel financial pressures to support their families financially and question the value of higher education. Millions in Asian cultures have also gone outside of their countries’ borders in order to find jobs and decrease family poverty. Employment migration, in some cultures, serves the purpose of raising families out of poverty, aiding them in remaining preserved long term. It is typical to live in a multigenerational family home where kinship care supports children in their parents’ absence. For immigrant families, there may have been a history of temporary migration and separation prior to immigration. This will impact relationships following reunification and immigration. Health/Safety Health-related issues in low-resource countries can be detrimental to children reaching their developmental potential. Common issues are malnutrition, infectious diseases, lack of access to health care, growth stunting, impaired cognitive functioning at work/ school, and costly use of healthcare services. Intrauterine growth restrictions are most common in low-resource countries, primarily from malnutrition and infections. Research links this to low birth weight at delivery, lower cognitive scores, decreased problemsolving abilities, and other growth restrictions having impacts as late as adolescence/adulthood. Processes during brain growth have consequences for later cognitive functioning (e.g., school readiness, later academic performance). Children with stunted growth reportedly have a less positive affect, decreased playfulness, and increased likelihood for insecure attachment versus non-stunted children. Ongoing hunger and malnutrition is another threat to children’s developmental potential, reportedly perpetuating poverty by leading to a poor physical condition, impaired cognition/school performance, and more need for healthcare services. Although children may have access to nutrition and health care following immigration, the long-term consequences of the earlier deprivation often follow immigrant families to their new countries. Child Development Limited-resource sending countries have greater exposure to infectious diseases (e.g., malaria, HIV/ AIDS). Inadequate general healthcare services compound long-term detriments of infection on children’s development, often accompanying them beyond their immigration. The literature notes that children who survive severe malaria have been found to have varying degrees of neurological impairments, deficits in hearing, memory, attention, neurological effects (fine/gross motor), speech and language, and nonverbal developmental domains. Globally, over two million children under the age of 15 and more than ten million people between 15 and 24 years are HIV positive. Many children are orphaned and vulnerable (OVC) following parental death from HIV/AIDS. Nations’ infrastructures have been severely impacted by the epidemic, resulting in the loss of a generation usually at their peak for economic and societal production. Armed conflicts affect the safety of over one billion children globally. There are many impacts of war such as injury, death, orphanhood, maiming, abduction, rape, children used as soldiers, posttraumatic stress, denial of humanitarian access, and geographic displacement. Even when children and their families immigrate to a peaceful receiving country, they can suffer many long-term physical and emotional ramifications from the effects of war. Education Children from limited-resource countries often experience disadvantages or losses related to their education prior to immigrating. Receiving a basic education is many times beyond reach for millions of children due to families’ inabilities to afford school fees (i.e., uniforms, school supplies, and books), lack of access to facilities in remote areas, few educational facilities being equipped with water/sanitation systems, and fear for children’s safety due to civil conflicts/natural disasters. Discrimination against indigenous populations/minorities, children with disabilities, and students touched by the AIDS crisis often exclude some children from receiving an education in limitedresource countries. Teacher mortality rates in subSaharan Africa are particularly high due to the AIDS epidemic. Schools often have to share available educators who travel from community to community to meet children’s needs on a part-time basis. Many of C these children struggle with language and math, receiving fewer than 800 hours of instruction a year, learning in crowded classrooms, in inadequate learning environments. Immigrant children coming from limited-resource countries are also often deprived of the right to an education in their sending countries due to gender inequalities. It is common for families to remove them from school to help support the family through child labor. Poorer families have greater difficulty in managing risk (i.e., by having savings/eligibility to borrow) related to downturns that can threaten family preservation. Girls often bear the brunt of education loss due to family poverty, with it being the norm for parents to send their male children to school if a choice must be made. This lack of prior education or substandard education by the receiving country’s expectations may place an immigrant child at a disadvantage following immigration. This disadvantage may be very difficult to overcome. Potential Influences: Family Dynamics Kinship Dynamics Most limited-resource countries remain preindustrial economies, lacking financial surplus to provide structured social welfare systems to care for the needs of their countries’ vulnerable populations. In preindustrial societies, family dynamics encompass the larger, extended kinship network. These networks provide for the primary physical, emotional, and financial needs of the collective. The ideology of patriarchy also plays a role in gender power differentiation within the family network. Resources/Separations When a nuclear family leaves its country of origin through immigration, it often separates from the extended kinship group that once served as its social welfare-based system of safety nets. Once in receiving countries, immigrant families reportedly feel a sense of uncomfortable physical, emotional, and financial exposure without the safety net that they once were accustomed to having. Many times, parents of children will immigrate in advance for financial purposes, while children remain in their country of origin in kinship care with the extended family. Parents travel for 401 C 402 C Child Development employment purposes to raise money to bring the rest of the family with them or simply to send funds back to the larger kinship network for a better life. Millions of parents in Asian cultures leave their homes, with or without their children, to find better-paying jobs than in their countries of origin. Potential Influences: Cultural Expectations Cultural expectations have a major influence on how child development is viewed. Different cultures have different expectations regarding dependency, independence, passivity, aggression, assertiveness, language acquisition, and motor skills. These expectations may also vary depending on the age of the child and on cultural values and beliefs. Childhood can be conceptualized as a position in a social structure, which will vary depending on the social structure. Different cultures have different social structures and thus view childhood and adolescence differently. Different countries assign or legislate different expectations for children and parents. Nations decide what the rights of children and parents are, what responsibilities each has, limit or regulate their power, and decide on the age that children can legally engage in work for pay. Nations also decide on resource allocation for children (education, health, etc.). Many of these assignments are based on cultural beliefs and expectations. When children immigrate, they are likely to move from one set of cultural expectations to a different set of cultural expectations. A child and his or her family may attempt to maintain the cultural expectations of their sending country, leading to conflicts with different systems in the receiving country. An example of this would include situations in which immigrant families do not enroll adolescents in school, expecting them to care for younger children or to bring in a wage. If a family has different developmental expectations regarding independence and interdependence than the larger surrounding culture, institutions (and representatives of the institutions) may judge the child to not be meeting developmental norms. While every culture will have some specific differences in the expectations of children and adolescents, there are some general patterns regarding sending countries and receiving countries. Receiving countries are more likely to use “Western” concepts about the role of children as innocent and needing protection, whose place is one of safety: with family and in some kind of educational setting. In most receiving countries, child populations are declining except among immigrant groups. Sending countries may have similar expectations; or they may see children as having more freedom and not needing to meet the more rigid expectations for different genders that will exist after puberty in that culture; or they may see children as economic resources to be used for the benefit of adults. Sending countries are more likely to have poverty, forced migration, or war, which have a large effect on children because of their vulnerability. Receiving countries and sending countries often have different developmental expectations based on sex or gender. Sending countries tend to be more agrarian, and have more traditional division of labor and very different role expectations for males and females. Most sending countries value having many children, and value male children more highly than female children because both of these increase the economic options and standing of the family. Sending countries usually do not have policies that support gender equality. Receiving countries tend to have similar role expectations for male and female children, and usually have policies that regulate gender equality. Culture has a strong influence on parenting practices, including the value that parents place on education, how parents discipline their children, what is seen as appropriate behavior for a child, the role of extended family, expression of emotion, sleep patterns, social skills, and coping styles. Cultural expectations can influence even a habit like nail biting, and how parents understand and respond to the habit. A child or adolescent who had different expectations in their sending culture may resent the new expectations of their receiving country. The difference in cultural expectations can also lead to conflicts between the child and family, if one or the other adopts the expectations of the receiving country while the other seeks to maintain the expectations of their country of origin. The different expectations between sending and receiving countries may cause confusion, conflict, or stress for immigrant youth and families. It is important to be able to understand the different cultural expectations and how they are influencing a particular child and family. Child Development Potential Influences: Resources in Receiving Country Resources Resources in receiving countries impact child development through a variety of ways, including what resources actually exist, what mechanisms are used to distribute resources, the families’ skills and abilities to access resources, and belief systems (both the immigrants’ and the receiving countries’) regarding resources. Resources in this context are not limited to those that are natural or raw, which may be in abundance in both receiving and sending countries. “Resources” reflects the amount of goods and services produced, which tend to be highest in wealthy nations, which also tend to have an abundance of welldeveloped systems for their distribution. Those resources in receiving countries with the most impact on child development include employment and social supports, health care, and housing and education systems. Economics The economies of receiving countries with their highresource status do not usually mirror those of sending countries; immigrants may not be well prepared for the differences they encounter. Economic systems include employment and social supports, health care, and housing. Employment supports refer to job availability, job training, and having a living wage, as well as supports that effect parents’ ability to both work and parent. These supports may be difficult for immigrant families to understand and access, which effects the family’s economic status and further opportunities. Immigrant families are more likely to have a lower socioeconomic status, and to live in neighborhoods with more violence and other problems. While immigrant families tend to have protective factors regarding the effects of poverty and neighborhoods, they are still disadvantaged. Health care includes the quality of medical care, prevention and intervention, as well as its accessibility. Housing refers to the quality, safety, and affordability of available living accommodations. Social supports include unemployment benefits, family allowances, disability and sickness benefits, housing benefits, and other forms of social assistance. Each of these supports may be differentially accessible to C immigrants. The institutionalized systems may be difficult for immigrant families to understand, impacting their use of support systems in the receiving country. In turn, these can all impact immigrant child development. Education Education systems affect child development by their ability to teach skills that children need to meet the demands of their environment and prepare them for adult life. For most receiving countries, this includes literacy, job skills, and cultural norms. Children may have not been in a formal education setting prior to immigration, or the education system of the receiving country may be different in its structure and expectations from those of the sending country. The education system in the receiving country may have difficulty assessing and educating the immigrant child due to language differences. The need to function in a nonnative language will lead to stress. There may also be tension for immigrant youth related to minority status. There may be disparities between educational domains for the immigrant child (e.g., high math and low reading scores) that can impact the child’s sense of self-efficacy, and their developmental trajectory. Lenses for Interpretation Impacts of earlier discussed detriments to child development are typically evaluated over a growth continuum that ranges from infancy through adulthood in which milestones are measured by physical, emotional, and social markers. When markers go unmet, a child’s full developmental potential may not be reached, leading to short- and long-term consequences. Primary, generalized tools used to measure whether children are reaching their developmental potential are the World Health Organization’s (WHO) Growth Standards and the International Growth and Development Criteria (IDGC). Both sets of criteria are endorsed strongly by the International Pediatric Association (IPA). Child development theories that are often used to conceptualize psychosocial growth of children include Erikson’s psychosocial stages of development, Piaget’s cognitive stages of development, and Vygotsky’s sociocultural perspectives on cognitive 403 C 404 C Child Development development. Theories relating to acculturation and independence/interdependence are also helpful in understanding the development of immigrant children. WHO and IGDC These growth standards serve as a framework for healthy, physical child growth and development to guide parents and pediatric professionals. The WHO Growth Standards are endorsed by the International Pediatrics Association (IPA), which encompasses several guiding pediatric organizations in the world. The International Growth and Development Criteria (IGDC) differ from WHO Standards as they standardize physical, emotional, and cognitive domains for a given chronological age. Both are based on long-term studies of infants/children and are multiculturally/ socioeconomically applicable. These milestoneaccomplishing approaches base standards on families’ having ideal access to resources, a nurturing primary caregiver, and an environment in which children are most likely to reach their developmental potential. The WHO tool is gender specific, detects undernutrition and obesity, good healthcare practices (i.e., immunizations), and appropriate growth criteria for children aged 0–60 months. It offers percentile and z-score curves for length/height-for-age, weight-for-age, weight-for-length, weight-for-height, and body mass index (BMI)-for-age (see “Further Resources” to access these standards). Child Development Theories Theories of child development are used to assess psychosocial–emotional growth in children and tend to be based on the cultural expectations of high-resource nations. Three examples of commonly used theories are as follows: Erikson’s psychosocial stages of development, Piaget’s cognitive stages of development, and Vygotsky’s sociocultural theory of development. Professionals in education, government, and mental health settings use such theories as lenses to view individual children and their development. A brief summary of both Erikson’s and Piaget’s models of development can be found at http://psychology.about.com/od/ developmentalpsychology/a/childdevtheory.htm. Erikson’s and Piaget’s models are very structured, noting a sequential nature to each developmental stage. While they are important lenses by which to view child development, the impacts of immigration must also be factored into children’s psychosocial and emotional growth trajectories. This is especially true when the culture, values, and experiences of the sending country differ from those of the receiving country. Vygotsky’s sociocultural theory of development proposed that children’s cognition and learning form through the continuous interplay of social interactions and culture. Vygotsky stressed the importance of language as an expression of culture and values. Differing from other developmental theorists, Vygotsky did not use formal stages in his model, but spoke of “zones of proximal development,” that is, skills that children are capable of achieving, but cannot do without adult guidance. This emphasizes the role that culture plays in child development, and the range of behavior that children present, based on their culture. His concept of “scaffolding” children’s behavior, teaching them the skills that they need in a society, is also important for professionals working with immigrant children to keep in mind. Theories of acculturation inform professional understanding of immigrant child development. Originally, acculturation theories focused on the adaptation of the immigrant to a new cultural context. Current models of acculturation have evolved from more simplistic origins, proposing categories that include integration, marginalization, assimilation, separation, fusion, and other strategies. They also highlight varying degrees of resiliency in immigrant children where some may/may not experience adjustment problems regardless of category. Cultural tenets regarding independence and interdependence also play a role in the immigrant child’s developmental processes. These concepts serve as a framework for immigrant child development by providing a context within which development takes place. Most sending countries value interdependence. Receiving countries typically emphasize independence, which is evident in both Erikson’s and Piaget’s developmental stages. Valuing either independence or interdependence affects the behaviors, relations, boundaries, and skills that children learn. The developmental progress of immigrant children is often judged on the basis of the receiving country’s expectations of independence. Clearly, the Child Health and Mortality integration of developmental concepts from both sending and receiving cultures is important for professionals working with immigrant children to use in assessing development. Conclusion A myriad of influences impact the healthy growth of immigrant children making it imperative that those medical, mental health, and education professionals working with them understand their complex set of developmental needs. Devising an individualized child developmental trajectory that encompasses sending country characteristics, influences of the family, receiving country characteristics, and cultural expectations of both the sending and receiving countries will support immigrant children in reaching their full developmental potential. Related Topics ▶ Acculturation ▶ Adolescent health ▶ Assimilation ▶ Child ▶ Child abuse ▶ Child health and mortality ▶ Child labor ▶ Child rearing ▶ Family ▶ Family reunification ▶ Family violence ▶ Gender ▶ Hague Convention on Child Abduction ▶ Infant mortality ▶ International adoption ▶ Intergenerational differences ▶ Refugee ▶ Unaccompanied minors ▶ War-affected children ▶ Youth ▶ Youth antisocial behavior Suggested Readings Carter, J. A., Mung’ala-Odera, V., Neville, B. G. R., Murira, G., Mturi, N., Musumba, C., et al. (2005). Persistent neurocognitive impairments associated with severe falciparum malaria in Kenyan children. Journal of Neurological Neurosurgical Psychiatry, 76, 476–481. C Kagtçbas, Ç. (2007). Family, self, and human development across cultures. Mahwah: Lawrence Ehrlbaum. Kaushik, B. (2003). Child labor: Its economics, sociology, and politics. Scientific American, 289(4). Suárez-Orozco, C., & Qin, D. B. (2006). Gendered perspectives in psychology: Immigrant origin youth. International Migration Review, 40(1), 165–198. UNESCO. (2008). Education for all by 2015. Will we make it? Oxford: Oxford University Press. World Food Programme & UNICEF. (2006). HIV/AIDS & children: Bringing hope to a generation. Food aid to help orphans and other vulnerable children. Rome: World Food Programme. World Health Organization (WHO). (2006). WHO growth standards. Length/height-for-age, weight-for-age, weight-for-length, weightfor-height and body mass index-for-age: Methods and development. Geneva: WHO Press. Suggested Resources Central Intelligence Agency. (2008). World Fact Book. Field listingunemployment rate. Retrieved January 8, 2009, from https:// www.cia.gov/library/publications/the-world-factbook/fields/ 2129.html Child Development in Context Research Project at Brown University. Retrieved from http://www.brown.edu/Departments/Education/ research/cgc/research/cidc.php Immigration Studies at NYU. Retrieved from http://steinhardt.nyu. edu/immigration/ UNICEF Innocenti Research Centre. Retrieved from http://www. unicef-irc.org/ World Health Organization Growth Charts. Retrieved from http:// www.who.int/childgrowth/en/ Child Health and Mortality MARY LOU DE LEON SIANTZ Office of Diversity and Cultural Affairs, University of Pennsylvania School of Nursing, Philadelphia, PA, USA Demographics Nearly 3% of the world’s population migrates, with one out of three persons around the globe undergoing migration. Children of immigrants are the fastest growing group in the US population under 18 years of age, with one in five children the child of an immigrant. While immigrants are 11% of the US population, children of immigrants make up 22% of the 23.4 million children under 6 years of age. As of 2005, nearly one-fourth (23%) of children lived in an immigrant 405 C 406 C Child Health and Mortality family. This explosive growth, combined with the large numbers (40%) originating from Mexico, and additional areas that include 10–11% each from the Caribbean, East Asia, or Europe combined with Canada and Australia; as well as 5–7% each from Central America, South America, Indochina (Cambodia, Laos, Thailand, Vietnam, or West Asia); and 2–3% from Russia and Africa. As a group, immigrant children are changing the racial and ethnic composition of US children for the present and adults in the future. These children are also among the poorest segment of the population, with one in four immigrant children living in poverty. Their families are among the poorest, least insured, or educated with limited, or no access to health care. Poverty is a social determinant that negatively impacts health across the lifespan. Immigrant Children’s General Health Children of immigrants are likelier to be in “fair” or “poor” health than children of natives, with their health declining more rapidly as they age. Seven percent of immigrant children under 11 have been reported to be in fair or poor health which rises to 13% among 12–17year-olds. Poor health status increases with poverty. While 12% of poor immigrant children 5 years or younger have been reported in fair or poor health, poor health status increases to 19% among adolescents, 12–17 years. Immigrant Infant Health The rate of low birth weight and infant mortality are two common indicators of infant health. Findings based on linked birth/infant death data sets for a number of immigrant subgroups that include Mexican, Cuban, Central/South American, Chinese, Filipino, and Japanese have documented that children born in the USA to immigrant mothers are less likely to have low birth weight and to die during the first year of life than children born to native-born mothers from the same ethnic group. While other factors may be involved, cigarette smoking, alcohol consumption, and weight gain during pregnancy are critical determinants of difference between immigrant and native-born women and their infant’s low birth weight and mortality. Since the 1980s, research has supported the “immigrant paradox” that despite risk factors that include higher poverty rates, lower education, and less access to health care, some immigrants have better birth outcomes than the native born. The immigrant paradox is most consistent with Hispanic immigrants; however, some of the largest differences in low birth weight and infant mortality rates have occurred between foreign and US-born non-Hispanic Blacks. Congenital Anomalies Asian American children have a lower prevalence of congenital diseases and chronic conditions in general. Among Hispanics, the incidence of congenital anomalies is no greater than in the general non-Hispanic White population. About 2% of newborns have a major malformation, with an additional 3% having such conditions discovered in later childhood. According to the American Academy of Pediatrics, immigrant children may not be screened at birth for diseases such as congenital syphilis, hemoglobinopathies, and inborn errors of metabolism. Immigrant Preschool Health Untreated health and developmental conditions that occur during infancy may continue during the preschool period of 2–5 year of age. The child’s living environment is critical to his or her cognitive and social-emotional development not only during infancy, but also during the preschool period. Exposure to toxins such as lead can lead to developmental problems if left untreated. Unintentional injuries from accidents will also negatively impact a child’s overall growth and development and especially effect children living in poverty. Consequently, screening and follow-up for developmental problems is recommended. Asthma Asthma is the leading pediatric chronic condition of the USA. A growing body of evidence documents a disproportionally higher lifetime asthma prevalence among children born in the USA compared to those born elsewhere. While a relatively low prevalence of asthma exists among Hispanic children as a group, Puerto Rican children have been found to have the highest prevalence compared with children in all other racial and ethnic groups. Among Asian immigrant subgroups, a wide variation can be found in the prevalence of asthma, with Filipino children born in the USA having similar rates of asthma compared with children of Black, American Indian, or Alaskan Native Child Health and Mortality heritage. Asian Indian children born in the USA have a much lower asthma rate. Interactions among genetic, environmental, and social factors have been associated with differences in the prevalence of asthma among immigrant children. Children from immigrant families with asthma often experience additional factors that exacerbate their condition. These may include pollen-sensitive forms of asthma, with migration from tropical to a temperate climate with higher and more seasonably varying pollen rates which can worsen the condition. Exposure to viral pathogens to children not previously exposed can precipitate asthma. Cultural beliefs may also affect the etiology and treatment among immigrant families. C Infectious Disease While children of immigrants in general have better health outcomes compared to children born of US parents, it is unclear whether the immigrant paradox applies to children with chronic conditions. For example, compared to asthmatic children of US-born parents, asthmatic children of immigrant parents are more likely to be uninsured, lack a usual source of health care, report a delay in medical care, report no visit to a physician, or no emergency room visit for asthma in the past year. Asian Indian children have the lowest percentage of chronic conditions. Infectious diseases commonly found among immigrant children and adolescents are often easily treated and rarely pose a public health threat to the school community. Children with latent TB infections may attend school, pending evaluation and treatment with skin testing recommended for students coming from endemic countries. High rates of intestinal parasites, such as giardia, are found in some immigrant populations. Children with symptoms that suggest a parasitic infection or those in situations that pose a high risk of infection or transmission in institutional care settings may warrant screening and treatment or even empiric treatment with antiparasitic medication. A less common infection includes hepatitis B among children from endemic countries. Skin infections such as fungal infections, scabies, and lice are seen in newly arrived immigrants. Children of migrant farm workers are at increased risk for respiratory and ear infections, bacterial and viral gastroenteritis, intestinal parasites, skin infections, lead and pesticide exposure, tuberculosis, poor nutrition, anemia, undiagnosed congenital anomalies, developmental delay, intentional and unintentional injuries, as well as occupational injuries and substance abuse. Immigrant School-Age Health Dental Health School health issues for immigrant children range from childhood nutritional challenges that include nutrient deficiencies, obesity, diabetes, as well as infectious diseases like tuberculosis, and dental caries. Health issues of school-age children from 5 to 11 years of age are a continuation of those that were identified during the infant and preschool period with untreated chronic medical conditions such as asthma negatively affecting a child’s overall educational potential and development. Immigrant children whose parents lack health insurance are especially vulnerable since this limits their access to health care, needed medication, equipment, and monitoring of the condition. While lowincome immigrant children 6–11 years of age are less likely to have more behavioral problems than native children, advantages have been found to worsen with time, with no differences found among low-income children 12–17 years of age. Tooth decay is not only the most common chronic illness among children, affecting five times as many children as asthma but the most unmet health need among children. Decayed teeth retain bacteria that can be spread throughout the body and increase a child’s susceptibility to other problems which include ear and sinus infections. Oral disease can affect children’s growth, speech development, nutrition, learning, and overall quality of life. The American Academy of Dentistry recommends that all children have a dental care visit within 6 months of the eruption of their first tooth. Dental problems are common among immigrant children. Elementary school–aged immigrant children have been found to have twice as many dental caries in their primary teeth as their US counterparts. Immigrant children have been found to be twice as likely as native children to receive no preventive dental care. Chronic Health Conditions 407 C 408 C Child Health and Mortality Nutritional Deficiencies Immigrant Adolescent Health Anemia and micronutrient deficiencies, especially of iron, zinc, and vitamin A, are common health problems among refugee and immigrant communities. Iron deficiency anemia has been found among highrisk age groups such as toddlers/preschoolers and early adolescents from developing countries. Anemia and iron deficiency may be compounded by lead poisoning. Adolescence in the twenty-first century is defined as the period from puberty onset to societal independence and includes the development of sexual and psychosocial maturity during that stage. Adolescence not only harbors immense health risks but also vast opportunities for sustained well-being through health education and prevention. In order to provide a comprehensive view of adolescence, health and physical development cannot be overlooked. These two factors drive the developmental changes that are experienced during this vibrant period and the sustained consequences over time of health choices. The mental health, nutrition, and risky behaviors are special challenges among immigrant adolescents. Obesity and Diabetes Among school-age children, obesity has emerged as a significant problem affecting long-term health. Mexican-American and Puerto Rican children are significantly more obese than non-Latino White children. Both of these Latino subgroups demonstrate increased fat deposits in the trunk which has been associated with higher cardiovascular disease in adults. This higher prevalence has been found to start as early as 6– 7 years of age and continues through adolescence and adulthood. This high rate of obesity is of concern with its increased risk for cardiovascular disease and association with Type 2 diabetes. Mexican Americans are at particular risk for Type 2 diabetes. Type 2 Diabetes As a consequence of the high rates of obesity, many US adolescents are beginning to suffer from diseases that have traditionally been diagnosed in adulthood. The average age of onset of Type 2 diabetes is currently 13, and minorities with the disease suffer greater rates of complications and early death than their non-Hispanic White peers. Type 2 diabetes occurs when the body does not make enough insulin or does not adequately utilize the insulin that is produced (this is called insulin resistance). Type 2 diabetes increases the adolescents’ risk for serious complications including, heart disease (cardiovascular disease), blindness (retinopathy), nerve damage (neuropathy), and kidney damage (nephropathy). Nonetheless, the risk of Type 2 diabetes can be cut by 58% simply by decreasing dietary saturated fat and engaging in at least 30 min of moderate to vigorous physical activity every day. Parents, educators, and public health officials need to find new ways to engage immigrant youth in healthy lifestyles within their own cultural context. Mental Health Immigration imposes unique stresses on children and families resulting in depression, grief, and anxiety. Current research on depression in immigrant adolescents is inconclusive, with some studies showing higher rates of depression in this population, and others showing lower rates. Hispanic immigrants, especially of Mexican origin, have the highest prevalence of depression. Research in Texas has documented that 31% of Mexican adolescent girls experienced depressive symptoms, compared to 16% of non-Hispanic White girls. Data from the National Center for Health Statistics in 2000 found an increased risk for suicide in this population, with 20% of Hispanic adolescent girls attempting suicide compared to 9% of non-Hispanic White girls. The rates of death from suicide are much higher for boys (83%) than girls (17%), but girls are more likely to report attempting suicide than boys in data from the Centers for Disease Control and Prevention. Regardless, depression is a serious health risk among adolescent immigrants. Among Hispanics, foreign-born youth (first generation in the USA) have been found to experience lower self-esteem and higher levels of suicide thoughts, while those born in the USA of immigrant parents show more serious health risk behaviors and conduct problems. It is worth noting that depression increases the risk for serious depression later in life, and is associated with poor health outcomes, such as risky sexual practices, pregnancy, violent behavior, and suicide. Recognizing depression in Child Health and Mortality the adolescent could prevent further, more severe depression later in life, and other serious negative outcomes. Nutrition Overall, the nutritional status of foreign-born children upon entering the USA is associated with their socioeconomic circumstances in their country of origin. Limited data exist on nutritional status in general. More is known about Hispanic and Asian children than about children from Eastern Europe, Russia, Africa, and the Middle East. While foreign-born Hispanic adolescents have lower rates than their US-born counterparts of risk of overweight, the rates for foreignborn youth are very high. The most recent data report that nearly half of adolescents aged 12–19 are at risk for overweight, while more than one-fourth of Mexicanorigin boys of all ages and one fifth of girls are overweight. Data concerning the nutritional status of Asian children in immigrant families are limited and complicated by the diversity of Asian countries that send children to the USA. Understanding the economic, nutrition, and health conditions of their country of origin is critical to evaluating their nutritional status. Available data document the initial consumption by Asian children in immigrant families of traditional foods as part of the dietary intake with a transition to an American diet occurring over time. Among Southeast Asians, high levels of anemia have been found with limited intake of iron-rich food and possible gastrointestinal bleeding due to active parasitic infection. factors for sexual risk taking behavior are early exposure to sexual pressure, depression, and low social support. Violence as a source of injury and death among immigrant adolescents cannot be overlooked. It has become a major public health problem among adolescents in the USA. Poor urban young men of color, especially Latinos and African Americans, are especially at risk for violence. Mortality among Hispanic adolescents is associated with homicide and unintended injuries. According to the National Center for Health Statistics, Latino adolescents have a rate of death from homicide that is higher than for non-Hispanic Whites. Some of the violence is due to gang activity with the developmental needs of adolescents for peer acceptance and social support, especially among marginalized immigrant youth. Gangs provide feelings of community acceptance and belonging. More research is needed to address violence prevention that is culturally tailored and developmentally appropriate to the immigrant adolescent subgroups of the USA. Substance abuse increases with acculturation. Hispanic adolescents who are more highly acculturated to American culture report increased substance abuse with some variation by country of origin. In general, high-risk behaviors have been found to increase for each generation for adolescents with origins from Mexico, Cuba, Central and South America, China, the Philippines, and Canada with findings inconclusive. More research is needed to examine the association between acculturation and high-risk behaviors of adolescents including the identification of cultural factors that could protect immigrant teens from such behaviors over time. High-Risk Behavior Research has documented high rates of tobacco use, alcohol consumption, and substance abuse among Hispanic adolescents. Other studies have documented an association between high risk behaviors and acculturation. With increased acculturation, Hispanic girls engage in sexual activity at earlier ages and are more likely to give birth outside of marriage and to drop out of school. Increased risk for HIV/AIDS cannot be overlooked among immigrant adolescents as they acculturate and engage in substance abuse and sexual activity over time. The most frequently cited risk C Related Topics ▶ Adolescent health ▶ Asthma ▶ Childhood injuries ▶ Depression ▶ Diabetes mellitus ▶ Health disparities ▶ Healthy immigrant ▶ Hispanics ▶ Lead poisoning ▶ Nutrition 409 C 410 C Child Health Care Access ▶ Obesity ▶ Oral health ▶ Pediatrics Suggested Readings Alberti, G., Zimmet, P., Shaw, J., Bloomgarden, Z., Kaufman, F., & Silink, M. (2003). Type 2 diabetes in the young: The evolving epidemic. Diabetes Care, 27(7), 1798–1811. Arif, A. A., Delclos, G. I., Lee, E. S., & Tortolero, S. R. (2003). Prevalence and risk factors of asthma and wheezing among U.S. adults: An analysis of the NHANES III data. The European Respiratory Journal, 21, 827. Carter-Pokras, O., Pirkle, J., Chavez, G., & Gunter, E. (1990). Blood lead levels of 4–11 year old Mexican-American, Puerto Rican, and Cuban-American children. Public Health Reports, 105(4), 388–393. Davis, A. M., Kretuzer, R., Lipsett, M., King, G., & Sheikh, N. (2006). Asthma prevalence in Hispanic and Asian American ethnic subgroups: Results from the California health kids survey. Pediatrics, 118, 363–371. Doi, Y., Roberts, R. E., Taekuchi, K., & Suzuki, S. (2001). Multiethnic comparison of adolescent major depression based on the DSMIV criteria in a U.S. Japan study. Journal of the American Academy of Child and Adolescent Psychiatry, 40(1), 1308–1315. Emslie, G. J., Weinberg, W. A., Rush, A. J., Adams, R. M., & Rintleman, J. W. (1990). Depressive symptoms of a self-report in adolescence: Phase I of the development of a questionnaire for depression by self-report. Journal of Child Neurology, 5(2), 114–121. Fuller, B., Bridges, M., Bein, E., Jang, H., Jung, S., Rabe-Hesketh, S., Halfon, N., & Kuo, A. (2009). The health and cognitive growth of Latino toddlers: At risk or immigrant paradox? Maternal and Child Health Journal, 13, 755–768. Harris, M. I. (1998). Diabetes in America: Epidemiology and scope of the problem. Diabetes Care, 21(Suppl 3), C11–C14. Hernandez, D. J., Denton, N. A., & Macartney, S. E. (2008). Children in immigrant families: Looking to America’s future. Social Policy Report, Society for Research in Child Development, 22(3), 3–23. Holguin, F., Mannino, D. M., Anto, J., et al. (2005). Country of birth as a risk factor for asthma among Mexican Americans. American Journal of Respiratory and Critical Care Medicine, 171(2), 103–108. Javier, J. R., Wise, P. H., & Mendoza, F. S. (2007). The relationship of immigrant status with access, utilization, and health status for children with asthma. Ambulatory Pediatrics, 7(6), 421–430. Kandula, N. R., Kersey, M., & Lurie, N. (2004). Assuring the health of immigrants: What the leading health indicators tell us. Annual Review of Public Health, 25, 357–376. Lopez, M. (2009). Latinos and education: Explaining the attainment gap. Washington, DC: Pew Research Center. Saluja, G., Iachan, R., Scheidt, P., Overpeck, M., Sun, W., & Giedd, J. (2004). Prevalence of and risk factors for depressive symptoms among young adolescents. Archives of Pediatrics & Adolescent Medicine, 158, 760–765. Suggested Resources Anderson, J. R., Capps, R. & Fix, M. (2002). The health and well being of children in immigrant families. New federalism: National survey of America’s families, No. B-52 from the Urban Institute website. http//www.urban.org/publications. Child Health Care Access SHALINI G. FORBIS Division of General & Community Pediatrics, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA Access to health care remains a critical issue for underserved children, particularly for children from immigrant families. The causes of decreased access to health care differ for immigrant children. Recent studies indicate that one in five children in the United States live in immigrant families. The immigration status of these children varies widely. Some of these children are immigrants themselves and were born abroad and others are US citizens themselves (the majority). Immigration status factors play a role in their access to health care. In addition, immigrant children have differing demographic profiles from other minority children. For instance, they are more likely to come from settings with married parents and more likely to live in a multigenerational family. Because of differing immigration status of children from immigrant families, their barriers to access to health care vary. The specific areas within access to health care include health insurance coverage and then ability to access that care, particularly primary care, dental care, and vaccinations. Insurance coverage remains a critical issue for immigrant children in the United States. There have been gains in coverage in the past two decades with rates of un-insurance dropping from 19% to 15% by the mid-2000s. One third of all uninsured children in the United States are from immigrant families. This phenomenon has been seen both for children in families where all members are citizens as well as for children who are citizens with noncitizen parents. However, for children who are immigrants themselves Child Health Care Access and live in immigrant families the gap is widening, with levels of uninsured children rising from 44% to 48%. Under federal law, the Personal Responsibility and Work Opportunity Act of 1996, all legal immigrants (including children) are barred from Medicaid or SCHIP coverage during their first 5 years in the country. As of 2007, 22 states cover legal immigrants during this 5-year period utilizing state funds. However, there is significant variability as to what benefits are available from state to state. In addition to access to insurance coverage, immigrant children experience other issues related to access to health care. In one national study, >25% of noncitizen children did not have a usual source of health care as compared to 18% of citizen children in noncitizen families and 6% for US children in citizen families. This is well short of the Healthy People 2010 objective of 97% of all children having a usual source of care. Half of these noncitizen children had not seen a doctor or dentist in the past year. Despite the lack of primary care, these children are also less likely to be seen in the emergency department. However, there is a study that determined that when immigrant children are seen in the emergency department, they have higher medical expenditures. This may be due to families seeking medical care at later stages of illness due to lack of primary care access. Another access issue that is well documented in the medical literature is access to immunizations. Healthy People 2010 set goals of: (a) 90% up-to-date for individual vaccines and (b) children are 80% up-to-date with the series 4DTP/DTaP (diphtheria, tetanus, whooping cough/pertussis), 3 IPV (inactivated polio vaccine), 1 MMR (measles, mumps, and rubella), 3 Hib (Hemophilus meningitis), 3 HBV (hepatitis b), 1 Prevnar (pneumococcal meningitis) (4:3:1:3:3:1) by 36 months of age. However, noncitizen children are less likely to be adequately immunized and have demonstrated decreased rates of vaccination for hepatitis B and Haemophilus influenzae type b. This decreased immunization rates may be a consequence of a lack of primary care and can lead to increased risk of developing serious illnesses including meningitis hepatitis B. Another significant barrier for many immigrant families is related to communication. Immigrant children with insurance coverage are still less likely to C receive medical care than their insured nonimmigrant counterparts. Language barriers may play a significant role in this, particularly for recent immigrant families. Studies of Latino families demonstrate that language barriers play a significant role in creating a barrier to accessing care for their children. These families face many barriers when encountering the health care system. These barriers start with the first encounter which typically involves (depending on their level of English proficiency) scheduling appointments. This will require an interaction with a receptionist to discuss the nature of the appointment and potential times. During a visit, a parent may have to fill out paperwork, sign consent-to-treat forms, provide medical information to multiple providers, receive health education and complete billing information. Depending on the setting and location, there may be bilingual staff; if not, there are a variety of methods for approaching families with limited English proficiency. For hospital-based settings, there may be availability of medical translators or of calling a translator service and utilizing a two head set phone with the health care provider, parent, and then a translator on the other end of the call. In community-based settings where translation services are not readily available and may be prohibitively expensive, providers will often utilize informal services of family members of the patient (sometimes older siblings) or staff who may have limited experience with the language. Lack of consistent reimbursement for translation services is a barrier for these families as well as for health care providers to utilize trained medical translators. In addition to the aforementioned barriers, immigrant families may perceive discrimination in the medical settings. This may be due to lack of language skills, or may be related to cultural differences. In addition, cultural differences may create misunderstandings. Finally, there may be concerns related to immigration status, particularly for undocumented families. These families may be concerned that their immigration status may be reported to immigration authorities and they may face such negative consequences as deportation. Despite these documented barriers to access to health care, there are data to suggest that these children may be healthier than nonimmigrant children of similar socioeconomic status. This is known in the 411 C 412 C Child Labor literature as the “health immigrant phenomenon or paradox”. This has been demonstrated most consistently among Hispanic immigrants. One example of this phenomenon is that the prevalence of low birth weight is less common among immigrant MexicanAmerican women when compared to that of mothers who are US-born Mexican Americans (8% versus 12%). Some of this disparity is due to factors such as alcohol and tobacco use. Similar results have been demonstrated for infant mortality rates within the Black community. Children born to African women have decreased infant mortality rates when compared to African American women (10.5 versus 12.9 per 1,000 births). Analysis has demonstrated a clear role for immigrant status in this circumstance. Unfortunately, there is less research supporting a similar effect continuing into later childhood due to the difficulty of this research. Research for other immigrant groups is limited. Children from immigrant families that may either be citizens or immigrant themselves face many barriers to accessing and receiving health care in the United States. These barriers may include lack of insurance coverage, access to needed and required immunizations, lack of primary care and dental care, and language barriers. Those who work with immigrant children should understand their individual state’s benefits for immigrant children and assist with accessing insurance coverage as well as primary care. In addition, health care providers should be sensitive to the many barriers these families have when accessing and utilizing the health care system. Related Topics ▶ Birth weight paradox ▶ Child health and mortality ▶ Health care utilization ▶ Healthy immigrant ▶ Immunization ▶ Pediatrics Suggested Readings Hernandez, D. J., & Charney, E. (chairs) (1998). From generation to generation: the health and well-being of children in immigrant families. Washington, DC: National Academies Press. Huang, J. H., Yu, S. M., & Ledsky, R. (2006). Health status and health service access and use among children in U.S. immigrant families. American Journal of Public Health, 96, 634–640. Ku, L. (2007). Improving health insurance and access to care for children in immigrant families. Ambulatory Pediatrics, 7, 412–420. Mendoza, F. S. (2009). Health disparities and children in immigrant families: A research agenda. Pediatrics, 124, S187–S195. Yu, S. M., Huang, Z. J., & Kogan, M. D. (2008). State-level health care access and use among children in U.S. immigrant families. American Journal of Public Health, 98, 1996–2003. Suggested Resources Capps, R., Fix, M. E., Ost, J., Reardon-Anderson, J., & Passel, J. S. (2005). The health and well-being of young children of immigrants. Retrieved July1, 2010, from http:www.urban.org/url.cfm? ID=311139 Hernandez, D. J., & Charney, E. (1998). From generation to generation: The health and well-being of children in immigrant families. Retrieved July 1, 2010, from http://www.nap.edu/catalog/6164. html Child Labor MARISA O. ENSOR Department of Anthropology, The University of Tennessee, Program on Disasters, Displacement and Human Rights, Center for the Study of Youth and Political Conflict, Knoxville, TN, USA Child labor remains a widespread and persistent socioeconomic reality for many young people around the world. United Nations Children’s Fund (UNICEF) estimates that 158 million children aged 5–14 are engaged in child labor – one in six children worldwide. Children are involved in many different forms of work, and work relations between children and adults can vary from complete subordination to relative autonomy. The single biggest sector of child labor is in agriculture – where children either work on family farms or work, often part-time, on other local farms. There are also many child laborers who do domestic work or who work in the service sector, factories, or in office environments. Some forms of child labor are exploitative and abusive, either because they are inherently so, or because of the young age and immaturity of the child workers involved. These “worst forms of labor,” as they have been termed by the International Labor Organization (ILO), include bonded labor; prostitution; child Child Labor soldiering; or other extremely hazardous, unhealthy, or personally dehumanizing forms of work. While not all kinds of child work are necessarily harmful or incompatible with access to good-quality education – as often articulated by children themselves – agerelated conditions may make children more susceptible than adults to certain work hazards and health and safety risks. Working Children in Cultural Context Work has traditionally been an integral feature of the lives of most of the world’s children. Historical and cross-cultural comparisons of children’s work show enormous variation in the nature and intensity of what children are expected to do, the contexts and relationships within which work is performed, and the social perception and valuation of children’s work. Policy standpoints on the employment of children and young people are based, implicitly or explicitly, on models or theories of childhood. In turn, conceptualizations of childhood, and of acceptable forms of work for children at different ages and genders, are mediated by cultural and socioeconomic factors. The idealized image of the emotionally priceless but economically useless child – the “sacred child syndrome” – of upper- and middle-class Western society rarely exemplifies the daily reality of children around the work. Even in the Global North, many children resent the prolonged dependence resulting from what they see as a questionable and unnecessary exclusion from socially relevant work. Children’s work contribution often constitutes an essential part of a household survival strategy. For children in especially difficult circumstances such as in the aftermath of disasters, conflict, displacement, or economic crises, the prospect of gaining some control over their own lives and having access to an independent source of income can be both household-sustaining and self-affirming. On the other hand, these situations also create an increased potential for children to be compelled to engage in hazardous labor in an effort to ensure their own survival and that of their families. Their mental and physical health and well-being may be compromised as a result. Health Issues of Child Labor Children and adolescents have particular anatomical, physiological, and psychological characteristics C associated with their stage of development that may make them more vulnerable to work-related hazards than adults. While scientific studies regarding young workers’ susceptibility to the wide range of potential risks to which they may be exposed in their work places are not yet common, some conclusive evidence of a link between age and vulnerability is already available. Some epidemiological studies suggest that children exhibit more severe lead toxicity at lower levels of exposure, and tend to absorb higher amounts of lead than adults do at the same level of exposure. They could also be more vulnerable to pesticide exposure (a particularly alarming finding, given that agriculture constitutes the single biggest sector of child labor), asbestos, and ionizing radiation. An endocrine system compromised before full adulthood may result in hormonal imbalances and cause negative effects on sexual maturation. Young children breathe faster and more deeply and have a higher metabolic rate and oxygen consumption than adults. Their greater intake of air per unit of body weight results in an increased absorption of fumes, gases, air pollutants, and other potentially harmful particles often found in certain work environments. Young workers are believed to be more susceptible than adults to hearing loss induced by exposure to high levels of noise pollution – as would be the case in work performed in certain industrial or other environments. Children also have lower heat tolerance and are thus subject to higher risk of heat stress at work. Other studies indicate higher rates of injury-related disability among young workers when compared to adults due to more frequent cases of musculoskeletal problems and accidents. Injuries to ligaments and growth plates are particularly dangerous in children and can result in a condition known as osteochondroses (localized bone tissue death), potentially leading to limbs of unequal length. Carpal tunnel syndrome, tendonitis, and long-term back strain are additional concerns. Particular attention needs to be paid to the socalled “worst forms of child labor” which, by their very nature, are especially harmful to children, and categorically condemned by international labor and human rights instruments. Their negative consequences for children are often psychological in addition to physiological. 413 C 414 C Child Labor Worst Forms of Child Labor The International Programme for the Elimination of Child Labour (IPEC) was created in 1992 to spearhead the International Labor Organization’s (ILO) efforts against child labor. The primary policy instruments related to these efforts include the ILO Convention 138, the UN Convention on the Rights of the Child, and the ILO Convention 182. The link between child labor and health issues is clearly established in these provisions. The ILO Convention 138, also known as the Minimum Age Convention, seeks to regulate the intensity of work (generally measured in hours) at various age thresholds. Article 1 of this Convention requires ratifying nations “to pursue a national policy designed to ensure the effective abolition of child labour and to raise progressively the minimum age for admission to employment or work to a level consistent with the fullest physical and mental development of young persons.” While the Convention provides that “[n]ational laws or regulations may permit the employment or work of persons 13–15 years of age on light work which is not likely to be harmful to their health or development; and not such as to prejudice their attendance at school” (Article 7[1a and b]), a higher minimum age of 18 years is established for “work which by its nature or the circumstances in which it is carried out is likely to jeopardize the health, safety or morals of young persons” (Article 3[1]). Taking a rights-based approach, the UN Convention on the Right of the Child (CRC) addresses child labor by recognizing “the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development” (Article 32[1]). The CRC further calls for children to be protected from a variety of exploitative activities including the use of children in trafficking of illicit drugs (Article 33); child sexual abuse and commercial sexual exploitation (Article 34); the abduction, sale, or trafficking of children (Article 35); and the use of children in armed conflicts (Article 38). The ILO Convention 182, adopted at the International Labor Conference in June 1999, commits ratifying nations to “take immediate and effective measures to secure the prohibition and elimination of the worst forms of child labour as a matter of urgency” (Article 1). This Convention categorically condemns certain forms of child labor, which have come to known as “unconditional worst forms of child labor.” These include the sale and trafficking of children; the use of children in forced and bonded labor; children in armed conflict; the commercial sexual exploitation of children in prostitution and pornography; and children in illicit activities such as drug trafficking. While the ILO has the lead responsibility for regulating child labor issues, other UN agencies engaged in poverty reduction, education, and children’s rights also have a key role to play in addressing the underlying factors that give rise to child labor. These include the United Nations Children’s Fund (UNICEF), the United Nations Educational, Scientific, and Cultural Organization (UNESCO), and the World Health Organization (WHO). Further, although child labor does not appear explicitly in the Millennium Development Goals (MDGs), strong linkages between addressing child labor and fulfilling other goals are evident. These include poverty reduction (MDG 1); education for all (MDG 2); gender equality (MDG 3); combating HIV/ AIDS (MDG 6); and a global partnership for development (MDG 8). The important role played by nongovernmental organizations, trade unions, and child-advocacy and other organizations involved in activities concerning working children must also be recognized. Lack of coordination and disagreements among these organizations over the most appropriate objectives and strategies to pursue can, however, undermine their effectiveness. The major challenge in the coming years will be to better integrate child labor issues into the relevant frameworks at international and domestic levels. Measures to promote the physical and psychological recovery of children who have fallen victim of harmful forms of child labor must be an integral component of these efforts. Conclusions Child labor is a complex and multifaceted phenomenon requiring systematic attention to the socio-economic, cultural, and physical environment in which children live and work. While the institutional, legal, and human rights frameworks regulating child labor issues have Child Rearing been increasingly strengthened in recent decades, and some progress is already evident, child labor remains a concern of immense social and economic proportions. Millions of children are forced by necessity or circumstances to work too much at too young an age, or under particularly exploitative circumstances. In 2006, IPEC estimated that about 126 million children were engaged in various types of hazardous work worldwide. While there are encouraging trends in a number of nations – Brazil, Mexico, Turkey, and Vietnam, among others – child labor rates remain persistently high in much of the work. Although not enough is yet known about the links between age-related vulnerabilities and specific work hazards, it is clear that special health risks should be taken into consideration when prioritizing definitions of work appropriate for children and adolescents, and in enforcement of minimum-age regulations. Related Topics ▶ Childhood injuries ▶ International Labour Organization ▶ Labor migration ▶ Occupational injury ▶ Trafficking ▶ United Nations Convention on the Rights of the Child Suggested Readings Arat, Z. F. (2002). Analyzing child labor as a human rights issue: Its causes, aggravating policies, and alternative proposals. Human Rights Quarterly, 24, 177–204. Forastieri, V. (2002). Children at work: Health and safety risks. Geneva: ILO/IPEC. Hindman, H. D. (Ed.). (2009). The world of child labor: A historical and regional survey. Armonk/London: M.E. Sharpe. Levine, S. (1999). Bittersweet harvest: Children work and the global March against child labor in the post-apartheid state. Critique of Anthropology, 19(2), 139–155. Liebel, M. (2004). A will of their own: Cross-cultural perspectives on working children. London: Zed Books. Nieuwenhuys, O. (2005). The wealth of children: Reconsidering the child labor debate. In J. Qvortrup (Ed.), Studies in modern childhood (pp. 167–183). Houndsmills: Palgrave Macmillan. Palley, T. I. (2002). The child labor problem and the need for international labor standards. Journal of Economic Issues, 36(3), 1–15. WHO Study Group. (1987). Children at work: Special health risks (WHO Technical Report Series, Vol. 756). Geneva: World Health Organization. C 415 Suggested Resources International Labour Organization. http://www.ilo.org/. Accessed March 24, 2010. The Child Labor Photo Project. http://www.childlaborphotoproject. org/. Accessed March 24, 2010. The International Programme for the Elimination of Child Labour. www.ilo.org/ipec. Accessed March 24, 2010. Child Obesity and Overweight ▶ Pediatrics Child Rearing SARAH LYTLE Department of Psychiatry, University Hospitals Case Medical Center, Cleveland, OH, USA Child-rearing practices vary widely based on cultural beliefs, education, and economics. Immigration and acculturation can affect child-rearing abilities and practices as immigrant parents face unique challenges. These include, but are not limited to, poverty, unemployment, access to public health services, limited transportation, isolation, and incomplete command of the native language. One of the goals of many immigrant families is to provide a better life for their children, but immigration is often stressful for immigrant families and children. Studies have shown that circumstances associated with being an immigrant can undermine the parenting role. Immigrant parents may want to preserve their cultural identity and traditions and their children’s awareness of their former country, but also want their children to assimilate into the new country. Child rearing in infancy begins as people in contact with the child, typically a mother or mother-figure and family, interact with the newborn. The transition from being a woman to being a mother may be an isolating experience for some immigrant women. New immigrant parents often find that they have limited social support when it comes to caring for their new child and for themselves. Even in the hospital after delivery, some C 416 C Child Rearing cultures ascribe to specialized diets after birth, which are generally not provided in western hospitals. The social isolation can be significantly different from what they would have experienced in their native country, as some cultures place an emphasis on the family and provide significant emotional and physical support to new mothers. Lack of this support and social isolation can lead to early struggles with anxiety and depression, which may have an adverse effect on parent–child interactions. Compounding this problem, lack of knowledge of resources as well as stigma associated with mental illness often inhibit people from seeking help. As children enter the school system, child-rearing practices can affect the child’s progress. Some cultures place a strong emphasis on education; however, the parent’s ability to communicate with both the child and the school can affect how well the child is able to take advantage of educational opportunities. Immigrant parents may have limited access to information about their child’s new environment and experiences. They may not understand the new educational system, may use their native countries education system as a model for the education of their children, or be unable to take full advantage of the new education system. The immigrant family may become more dependent on the school for the child’s academic performance due to the language barrier or lack of understanding of the system. Studies indicate that in the United States, there are generally low rates of enrollment in early education programs, especially among low income families and those families with less formal education and/or command of the language. Sometimes immigrant parents are undocumented and may be wary of institutions like public schools for fear of deportation. At the same time, there may be pressure for the child to fulfill the parent’s dreams which can place stress on the child. Child rearing can be affected by traditional values of the parents and the new values being introduced by outside factors, like school. This dichotomy can lead to intrafamilial and intergenerational conflict. Studies indicate that children typically adjust more rapidly than their parents to the new country. This is referred to as the acculturation gap and has been found to be more pronounced in families where the parents are less educated. When this occurs, there may be some level of role reversal as the child’s command of language surpasses that of the parent, and the child becomes responsible for communication with outside agencies like schools, banks, or grocery stores. While this role reversal can weaken boundaries and lead to children being less likely to listen to or obey their parents, it can also have a positive effect whereby the child feels that they are contributing to the family and helping out their parents. Different parenting styles have been described in the literature. These include authoritarian, permissive, and authoritative. An authoritarian parent stresses control and obedience and places little emphasis on child autonomy. A permissive parent allows children to make their own decisions and regulate their own behavior. Authoritative parents emphasize limit setting through reasoning, verbal give and take, clear instructions, and positive reinforcement. Studies indicate that parenting at either end of the spectrum (authoritarian or permissive) may adversely affect the parent–child relationship. However, some studies have shown that if the parenting style is congruent with the sociocultural environment, then there is no negative impact. This can become an issue when the parenting style of the immigrant no longer matches that of the new culture. For example, the Chinese parenting style is traditionally authoritarian. Upon immigration to a more liberal society, conflict may arise as the child sees other children having fewer limitations. Cultural differences related to corporal punishment can also affect child rearing in immigrants. Corporal punishment may be a normal child-rearing practice in some cultures and immigrant families may not consider this child maltreatment or abuse. Additionally, native law enforcement may not reinforce immigrant parent rules, thereby undermining the parent’s authority. One study showed that immigrant adolescents had higher levels of psychological disorders and lower connectedness to families, and another suggested that family cohesiveness decreased after immigration. Data indicate that immigrants tend to have a lower income than natives. Children of legal immigrants often have hardships in the areas of food acquisition, housing, and health care, and a greater percentage of immigrant children than native children live in poor families. Financial stress may require both parents instead of one to work, which can mean there is less Child Rearing often a parent home to be involved in child rearing. Often, immigrants are employed at levels below their education level and may suffer from hostility from the natives. Highly educated individuals often suffer financial and occupational difficulties, especially within the first few years of immigrating. Lack of employment or employment below the parent’s education level can affect parenting as the breadwinner suffers in his role as the primary provider. This can create a tense atmosphere in the home. Socioeconomic disadvantage may lead to marital dissatisfaction, conflict, and aggression, which can adversely affect children. Unemployment and poverty can lead to grief, guilt, isolation, increased alcohol intake, increased risk of mental health problems, and neglect or punishment of children. While immigration status can have many adverse effects when it comes to employment and finances, there are some positive outcomes. Immigrant women who must work or choose to work may become more independent, and these women may take advantage of a broader range of child care options and work opportunities than they may have had in their native country. Immigrant mothers may gain more decision making control and have multiple roles compared to their native country. Additionally, in one study, fathers reported immigration allowed them to spend more time with their children (because they were working less). In addition to education and financial issues, certain countries may require detention of asylum seekers that do not have visas. Parents and their children can be held for months to years and may not have access to adequate physical and mental health services, education, housing, and hygiene. In addition, they may be exposed to violence and/or abuse. Adult asylum seekers have been shown to have high levels of anxiety, depression (including suicidal thoughts/intent), and posttraumatic stress disorder (PTSD), and this may affect their ability to care for their children. The children of such parents have been found to suffer behavioral regression, depression, anxiety, and suicidal thoughts. Another event which may significantly affect child rearing in immigrant populations is raids on and/or deportation of illegal immigrants. One or both parents may be separated from their children for a period of C time. While there may be a heavy reliance on extended family networks, children may be left to fend for themselves or other small children. Removal of the breadwinner can lead to decreased income (less access to food, etc.) and a more unstable home environment. It can also mean that the remaining parent must work, thereby altering the family dynamics as children are left without a parent at home. The loss of a parent or both parents can be difficult to explain to children and require adaptation to single parent families and stress associated with separation and finances. While immigrant parents face many challenges, studies have shown that many immigrants and their families may stay away from public assistance and health services due to uncertainty. Some countries have implemented programs to aid immigrants with transition and parenting. Research indicates that programs like Strengthening of Intergenerational/ Intercultural Ties in Immigrant Chinese American Families (SITICAF) tested in California, USA, which are family-based mental health programs, can be effective in reestablishing family connectedness and understanding. Canada and other countries offer educational programs for immigrants and their families on parenting and child development (for example, the Calgary Immigrant Aid Society) as well as offering family literacy programs. There remains room to make improvements to address and improve social isolation, transportation, employment, child care, partnership equality, and shared responsibility with family, neighbors, friends, and community. Related Topics ▶ Acculturation ▶ Child ▶ Child development ▶ Family ▶ Refugee ▶ War-affected children Suggested Readings Beiser, M., Hou, F., Hyman, I., & Tousignant, M. (2002). Poverty, family process, and the mental health of immigrant children in Canada. American Journal of Public Health, 92(2), 220–227. Bhattacharya, G. (2000). The school adjustment of South Asian immigrant children in the United States. Adolescence, 35(137), 77–85. 417 C 418 C Childhood Injuries Buki, L., Tsung-Chieh, M. A., Strom, R., & Strom, S. (2003). Chinese immigrant mothers of adolescents: Self-perceptions of acculturation effects on parenting. Cultural Diversity & Ethnic Minority Psychology, 9(2), 127–140. Capps, R. (2001). Hardship among children of immigrants: Finding from the 1999 National Survey of American Families. (New Federalism: National Survey of America’s Families, Series B No. B-29). Washington, DC: The Urban Institute. Capps, R., Fix, M., Murray, J., Ost, J., Passel, J., & Herwantoro, S. (2005). The new democracy of America’s schools: Immigration and the No Child Left Behind Act. Washington, DC: The Urban Institute. Dwairy, M., & Dor, A. (2009). Parenting and psychological adjustment of adolescent immigrants in Israel. Journal of Family Psychology, 23(3), 416–425. Mares, S., Newman, L., Dudley, M., & Gale, F. (2002). Seeking refuge, losing hope: Parents and children in immigration detention. Australasian Psychiatry, 10(2), 91–96. Roer-Strier, S., Strier, R., Este, D., Shimonis, R., & Clark, D. (2005). Fatherhood and immigration: Challenging the deficit theory. Child and Family Social Work, 10, 315–329. Childhood Injuries ELIZABETH M. VALENCIA Radiology Department, St. Joseph’s Hospital & Medical Center, Phoenix, AZ, USA Nonintentional childhood injuries are the leading cause of death and disability in children worldwide, responsible for 950,000 deaths, and of these 90% are preventable. In the USA, for every child injury death there are 34 children hospitalized and 1,000 children treated in the emergency department. Moreover, the health care burden attributed to non-intentional childhood injuries is nearly $300 billion each year, accounting for 15% of total medical spending for children between ages 1 and 19 in the USA. Efforts to decrease the morbidity and mortality led to an unprecedented World Health Organization Summit for Child Injury Prevention in 2005, which urged prevention and increased public awareness. While fire-related burns, falls, and poisonings are frequent causes, road traffic injuries and drowning are the source of more than 50% of childhood injuries. A brief synopsis of the injuries comprising this global public health epidemic is provided. An estimated 720 children die daily, while ten million children are either disabled or suffer permanent disability due to child road traffic injuries each year. The main cause of death in children between the ages of 10 and 19 is road traffic injuries, which accounts for 22% of total unintentional childhood fatalities. Children are at increased risk because they share the roadway as pedestrians, bicyclists, and as passengers in cars. Immigrant children are at increased risk of pedestrian injuries in part due to cultural differences regarding roadway safety. Cross-walk improvements, bike path expansions, and neighborhood education on child roadway safety has helped reduce child pedestrian injuries. Other childhood injuries are due to inappropriate use of a car seat, or failure to wear a seatbelt or helmet. Improper installation of car seats results in high fatalities in children under the age of 8; however, appropriate car seat safety use can reduce fatalities by 71% in infants and 54% in toddlers. In addition, the overwhelming majority of bicycle fatalities involve non-helmeted riders, with nearly 47% of nonfatal hospitalized injuries resulting in traumatic brain injury. The use of helmets can reduce fatalities by 75% and head injuries by 85%. Also, globally, teenagers between the ages of 15 and 19 are at even greater risk for road traffic injuries because of increased propensity to speed, drive under the influence, failure to wear a seatbelt, and engage in other risky driving behavior. Every day 480 children die as a result of drowning and near-drowning injuries result in serious neurological damage worldwide. Drowning is the leading cause of death in children under the age of 5 and accounts for 17% of total non-intentional childhood fatalities. In addition, there is a higher incidence of drowning among immigrant children secondary to lower rates of swimming proficiency among children and adults. Drowning can occur quickly within a few minutes and in as little as a few centimeters of water with infants. Overall, children are vulnerable to these injuries because our daily environment involves direct contact with water sources for essentials such as drinking, bathing, cooling, and water recreational activities. Bathtubs, buckets, toilets, swimming pools, and open water sites are common locations for drowning or near drowning. The bathtub accounts for more than 50% of all infant drownings under the age of 1. Further in the USA, 30 infants drown each year in buckets containing Childhood Injuries water for household chores. Meanwhile, children over the age of 4 are more susceptible to swimming pools and open water sites, with 300 pool drownings in the USA annually. Fenced pool enclosures can reduce child drowning and near drownings by up to 50%. In comparison, teenagers often succumb to water-craft-related drowning, often due to failure to wear a personal floatation device, which can reduce child drowning by 85%. Prevention strategies shown to reduce child drowning fatalities and near-drowning injuries include: child supervision near or in water, drainage of all unnecessary water accumulations, four-sided fenced pool enclosures, and use of a personal flotation devices at all times with all water-craft activities. Similarly, 262 children die each day and 96,000 die yearly from unintentional burns worldwide. Each day in the USA there are 435 child burn injuries evaluated in the emergency department and there are two deaths. Further, the mortality associated with burns is 11 times greater in low- to mid-income countries compared to high-income countries. Daily interaction with heating, lightening, and cooking increases the likelihood of burns. For instance, the increased incidence of unintentional burns among immigrant children was often associated with food preparation. Burns are typically caused by scalding water or steam, electrical or chemical burns, and fires. Although scalds from tap water or steam constitute 75% of burns in young children, infants are at greatest risk of death due to smoke inhalation. Further, electrical burns from appliances or outlets cause 33% of burns in children under the age of 12 and residential fires cause the majority of child burn fatalities under the age of 9. Extensive rehabilitation and treatment are usually required for significant nonfatal burns. Prevention includes child supervision, child-proof lighters, antiscalding faucet heads, lowering residential water heaters to 120 , and installation of smoke detectors on each residential floor. Specifically, fatalities can be reduced up to 82% with appropriate installed smoke detectors. Child fall injuries are the fourth leading cause of death among children, with 130 deaths each day and 47,000 deaths per year worldwide. Moreover for every death, 690 children will miss school due to a fall injury. In the USA, on average there are 8,000 emergency room evaluations daily because of child fall injuries. Approximately 80% of fall injuries occur at home and 66% are falls from height. Meanwhile, among immigrant C children, fall injuries are increased in the agricultural setting. Overall, children are susceptible to falls due to unrefined motor skills, their general inquisitive nature, and increased level of physical activity. Infants sustain most injuries from nursery furniture and baby walkers, while playground and window falls account for the majority of older children’s injuries. In particular, playground falls result in 200,000 annual emergency room evaluations and 75% are due to head injuries. Prevention can reduce fall fatalities and injuries, with installation of window guards on multilevel floors, roof railings, safer play equipment with appropriate surface material, and other safe product modifications such as safety glass. Child poisoning injuries account for 123 deaths each day and 45,000 deaths each year worldwide. In the USA, child poisoning accounts for 374 emergency room evaluations and two fatalities each day. Additionally, millions of calls are made to the poison control center each year. Children are vulnerable to poisoning because their physiology is less well developed which increases risk of toxicity. Ninety percent of poisoning fatalities and injuries occur in a child’s residence due to household products and medications. The most common causes of poisoning are over the counter medications, prescription medications, household products, and pesticides. Meanwhile, 890,000 children suffer from lead poisoning, which delays growth and development, while carbon monoxide poisoning affects 3,500 children every year often due to improperly ventilated space heaters. Specifically, immigrant children are at increased risk of lead poisoning likely secondary to lead exposure from toys, pottery, jewelry, cosmetics, or herbal remedies from foreign countries. Prevention of child poisoning fatalities and injuries involves: storing medications out of the reach of children, having access to poison control center contact information, carbon monoxide detectors, undergoing health screenings for lead poisoning, and providing child education. In conclusion, childhood injury is a health epidemic that results in significant loss of life. The Report on Child Injury Prevention, by the World Health Organization provides a comprehensive approach on reduction of child road traffic injuries, drownings, burns, falls, and poisonings. Together, prevention and public education can save an estimated 1,000 children from childhood injury each day. 419 C 420 C Chinatown Related Topics ▶ Adolescent health ▶ Child ▶ Child health and mortality ▶ Child health care access Suggested Resources Center for Disease Control & Prevention- Safe Child Section. (2010). Retrieved from http://www.cdc.gov/safechild/. Accessed January 2011. Safe Kids USA. (2009). Retrieved from www.safekids.org/. Accessed January 2011. National Highway Traffic Safety Administration. (2011). Retrieved from http://www.nhtsa.gov/Safety/CPS. Accessed January 2011. Chinatown DOUG BRUGGE Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA Chinatowns exist in many cities throughout the world, including Asian countries outside of China. They are usually urban and densely developed. Chinatowns serve as a cultural and commercial center for Chinese populations who have immigrated into predominantly non-Chinese areas. There are Chinatowns in Nagasaki, Japan; Bangkok, Thailand; Honolulu, Hawaii, as well as in Australia and Europe. In North America, Chinatowns can be found in Victoria, British Columbia and Toronto, and in the USA in San Francisco, New York, Chicago, Houston, Boston, Philadelphia, and elsewhere. Because they serve as ethnic “hubs” that speak the language and provide food and goods that Chinese immigrants seek, the Chinatown community may be considered broader than simply the people who live there. It may also include the many Chinese (and others) who work and come to Chinatown to shop, eat, and visit. Thus, the community may be larger than the resident population. Also, the resident population in many Chinatowns has shifted over time. As the urban territory that they occupy may become prime real estate, pressures of gentrification and development may dislocate lower-income, working-class residents. The health issues associated with Chinatowns arise primarily from the living and working conditions of residents and workers and infectious diseases that are prevalent in Chinese populations. However, it is critical to note that there has been too little investigation to date on health of Chinatown community members and there is a risk of overlooking health problems simply because they have not been documented. A good example is asthma, which was largely not examined among Chinese immigrants to the USA until recently. When asthma was examined, Chinese children were found to have a substantial prevalence of asthma – above national averages. A specific event that may have affected respiratory health of Chinese immigrants was the 9/11 attack on the World Trade Center buildings in New York City. Hepatitis B is endemic in China and, therefore, also a common condition in Chinese immigrant populations, including those in Chinatowns. Hepatitis B is transmitted via blood and body fluids, but in the Chinese context much of transmission may be from mother to child during birth or between family members. Because it is widespread in the Chinese community, there have been efforts to educate members about the disease and encourage screening and vaccinations. A consequence of high hepatitis prevalence is high liver cancer rates. Another infectious disease of particular relevance to Chinatowns and Chinese immigrants is tuberculosis. Smoking prevalence is high among Chinese immigrant men, but very low among Chinese immigrant women. This is a pattern similar to many other Asian populations. Beyond the direct impact of smoking on the health of the smoker, who is at increased risk for cardiovascular disease, lung and other cancers, chronic obstructive pulmonary disease and other illnesses, second-hand smoke exposure poses a significant risk to wives (or other family members). Lung cancers among Chinese immigrant women are a notable outcome of this exposure. The environment and context of the Chinatown itself may also be important to consider. While there has been limited research in this area, there are some indications of health impacts arising out of the built environment. Many Chinatowns have heavily traveled Chinatown streets and some have adjacent highways. Thus, exposure to air pollution from motor vehicles is a potential concern that may merit further attention. Local “hot spots” of air pollution have been shown to exist near high traffic density locations. These pollutants are known to be associated with cardiovascular disease, lung cancer, and other illnesses. In addition to air pollution, traffic generates sound, perceived as noise by many, that is linked to a variety of adverse physiological outcomes, possibly through producing stress. Stress may be an important exposure in Chinatowns. Besides traffic noise, there are other urban sources of sound. In Chinatowns that experience major construction projects, for example, there is considerable noise and vibration associated with these projects (and air pollution releases as well). In addition, crime, walkability (including pedestrian safety), and onerous work schedules in low-paying and often unpleasant or hazardous jobs add to stress. This may be an area deserving greater attention in future research efforts. Traffic is also associated with motor vehicle–related injuries. A study conducted in Boston’s Chinatown found that both in-vehicle and pedestrian injuries were associated with times of days and days of the week and with particularly complex (confusing) intersections. While many victims were Chinese residents, the drivers were mostly from outside the community. Cross times at signals were too short for the large elderly population to cross on the green light. Crime, including violent crime and fear of crime, are common to many urban settings, but Chinatowns have been both subjected to stereotypes about being dangerous (mysterious) places and, because of their location in urban centers and near sources of crime, actually subjected to high crime rates. Again, crime produces stress that has health consequences, but crime also is directly harmful to health. For example, violent crime can lead to injuries, and drug use and prostitution spread infectious diseases. Housing is another critical issue in Chinatowns. Quality, quantity, and affordability are concerns. Overcrowding is, as it is with many low-income communities, immigrant or not, a significant factor. Overcrowding is, of course, driven by housing costs and ability to pay so low-income immigrants, including those in Chinatowns, are at risk. Overcrowding, C besides being stressful, also may increase the risk of transmitting communicable diseases and create conditions that attract pests. Pests and water damage, leading to mold growth, are also examples of deterioration of housing conditions that could put sensitive individuals, persons with specific allergies, for example, at risk of aggravation of underlying conditions such as asthma. Working conditions in Chinatowns are also likely contributors to adverse health outcomes. While there has been far too little attention to the risks faced by low-income Chinese immigrant workers, recently, studies have begun to probe into this area. It is clear that many of the jobs these workers do, restaurant and construction work, for example, carry high risks. And it is likely that working long and unconventional hours increases health risks in this population, as it does in others. Thus, Chinatowns have a mix of associated health concerns that are distinctive, but have not yet been fully elucidated. The lack of firm data creates a particular risk of misjudging the most salient health concerns in these communities. Many visitors are tourists looking for food or trinkets, who do not even realize that Chinatown is home to many people. There deserves to be more research to clarify which health concerns are most critical and how to address them. Related Topics ▶ Built environment ▶ Chinese ▶ Environmental tobacco smoke ▶ Ethnic enclaves ▶ Hepatitis ▶ Violence Suggested Readings Brugge, D., Lai, Z., Hill, C., & Rand, W. (2002). Traffic injury data, policy, and public health: Lessons from Boston Chinatown. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 79, 87–103. Brugge, D., Leong, A., & Law, A. (2003). Environmental health and safety in Boston Chinatown. In L. Zhan (Ed.), Asian voices: Vulnerable populations, model interventions, and clarifying agendas (pp. 43–67). Boston: Jones & Bartlett. Minkler, M., Lee, P. T., Tom, A., Chang, C., Morales, A., Liu, S. S., et al. (2010). Using community-based participatory research to design and initiate a study on immigrant worker health and 421 C 422 C Chinese safety in San Francisco’s Chinatown restaurants. American Journal of Industrial Medicine, 53(4), 361–371. Szema, A. M., Savary, K. W., Ying, B. L., & Lai, K. (2009). Post 9/11: High asthma rates among children in Chinatown, New York. Allergy and Asthma Proceedings, 30(6), 605–611. Epub September 18, 2009. Suggested Resources Wikipedia. Chinatown. http://en.wikipedia.org/wiki/Chinatown. Accessed April 29, 2011. Hepatitis B Initiative. http://www.hepbinitiative.org/. Accessed April 29, 2011. Chinatown San Francisco. http://www.sanfranciscochinatown.com/. Accessed April 29, 2011. Chinese ROWENA FONG, ALBERT YEUNG School of Social Work, The University of Texas at Austin, Austin, TX, USA Introduction About 15.2 million, or approximately 5%, of the population in the United States are of Asian descent, a number that is expected to grow to 20 million by the year 2020. Among the many diverse subgroups that make up the Asian American population, Chinese Americans represent the largest number (3.54 million), followed by Filipinos (3.05 million), Asian Indians (2.77 million), Vietnamese (1.64 million), Koreans (1.56 million), and Japanese (1.22 million). Chinese is also the second most widely spoken non-English language in the United States after Spanish. Eighty percent of the population of Chinese Americans are concentrated across five states – California, New York, Hawaii, Texas, and New Jersey – with California being the most populous, accounting for 40% alone. Within the Chinese American population, (non-native) immigrants make up 47%. It is also important to distinguish the various subgroups that make up the Chinese immigrant population. These subgroups are largely formed around cultural and language differences based on their country of origin or regional location. Chinese immigrants from mainland China speak Mandarin; individuals from Taiwan speak Taiwanese and identify themselves differently from Mandarin-speaking Chinese; and Cantonese-speaking Chinese from Hong Kong and southern China share a regional ethnic identification (Guangdong). Chinese immigrants coming from other Southeast Asian countries may distinguish themselves based on their country of origin (in many cases Vietnam). Health Status In terms of life expectancy, Asian Americans have the highest life expectancy (85.8 years) of any other ethnic group in the United States, with Chinese American women having the highest life expectancy (86.1 years) within the Asian subgroups. Although there is a paucity of specific health status data on Chinese Americans, the Office of Minority Health, as well as other research studies, indicates that Asian Americans as a whole have lower risks for death and disease compared to Whites and other non-Asian minorities. Elderly Asian Americans also have disproportionately lower mortality rates compared to their White counterparts. There is variability in health status within Asian subgroups with Chinese Americans ranking high in many categories compared to other Asian subgroups. Chinese were most likely to be within a healthy weight range; the least likely to be obese after Koreans; and 11% less likely than other minorities to be poor, although within Asian subgroups Chinese adults were more than twice as likely as Filipinos to be poor. Other health findings for Chinese Americans taken from the 2001 Health Care Quality Survey found that Chinese Americans were least likely among Asian subgroups to rate their health as fair or poor (11%) compared to 40% for Vietnamese and 29% for Koreans. Notwithstanding, there is also evidence of poorer health status in Chinese immigrants of lower socioeconomic status and those living in poverty. Trends in research data also indicate differences in disease incidence rates based on factors such as immigration status and acculturation. Findings show that foreign-born immigrants have better health status compared to their US-born counterparts; however, the differences in health status between groups diminish with increased years of residence, suggesting the influence of factors related to a Western lifestyle and environment. Chinese Health Risk Patterns While overall health statistics are generally higher among Asian Americans in general, the Office of Minority Health points out that the highest risks for Asian Americans are for heart disease, cancer, diabetes, stroke, and unintentional injuries (accidents). Cardiovascular Disease and Stroke Cardiovascular disease is the leading cause of death for Asian Americans as well as Chinese Americans in the United States, accounting for 28% of total deaths. However, there is a lack of studies specifically examining cardiovascular disease prevalence and risk among Chinese Americans. In China, the statistic is even more startling; mortality rates related to cardiovascular death accounts for over 40% of total mortality. In China, it has been found that the incidence of stokes were higher in China than in Western countries. Among Asian Americans, 6.9% have heart disease, 4.3% have coronary heart disease, 19.5% have hypertension, and 2.6% have had a stroke. With respect to hypertension, which is strongly related to coronary and cardiovascular health, data from the Multi-Ethnic Study of Atherosclerosis (MESA) found that, among Chinese participants, the prevalence of hypertension is higher than among their White counterparts after controlling for age, body mass index, smoking, and prevalence of diabetes mellitus. However, it has also been found that being born outside the United States, speaking a language other than English at home, and living fewer years in the United States were associated with a decreased prevalence of hypertension. Research also reports that Chinese (17%) or Korean (17%) adults are less likely than Filipino (27%) and Japanese (25%) adults to have ever been told that they had hypertension. Cancer Health research has shown that Asian Americans generally present the lowest incidence of cancer compared to non-Hispanic Whites. Research looking at ageadjusted cancer incidence and mortality rates of Asians residing in California from 1997 to 2001 showed that Chinese presented the lowest incidence rates for all types of cancers studied. Other research findings on cancer incidence and mortality rates among five Asian subgroups in California found that Chinese Americans C present the lowest rates of all cancers combined compared to Korean, Filipino, Vietnamese, and Japanese ethnicities. While some data shows that Chinese Americans have some of the lowest, age-adjusted incidence and mortality rates for all types of cancer as a whole, other studies show that Chinese Americans are at increased risk for cancers of the colon and lung, and have the greatest risk for cancers of the liver. Incidence patterns for liver cancer in Chinese Americans are associated with Hepatitis B, although liver cancers in Whites are associated with alcohol. Incidence rates for cancers of the colon, liver, and lung were high in Chinese Americans compared to the other Asian subgroups. In particular, Chinese women were found to have the highest lung cancer incidence and mortality rates of all the Asian ethnic subgroups in California; Chinese men had liver cancer incidence and mortality rates more than twice as high as in Japanese men. Also, Chinese men have the third highest incidence and mortality rate for colorectal cancer among the Asian ethnic subgroups. These findings are consistent with other reports investigating the incidence of prostate cancer in men across 15 countries; Chinese men have the lowest incidence rates which contrast with Black men in the United States who have mortality rates 12 times higher than Chinese men in Hong Kong. These findings offer additional support for research findings, which identify China as having the highest death rates for liver cancer compared to 50 other countries. China ranked high in death rates associated with cancers of the esophagus and stomach; conversely, death rates for prostate and breast cancers ranked the lowest among the 50 countries. Sharp differences exist in incidence and mortality rates for certain types of cancers for Chinese living in the United States compared to Chinese living in Asia. Cancers of the colon, breast, and prostate all show higher rates in Chinese American immigrants living in the United States compared to those living in China. Such contrasts in incidence rates imply possible risk factors associated with a Western lifestyle or environment. Diabetes Data based on Family Core and the Sample Adult Core components of the 2004–2006 National Health 423 C 424 C Chinese Interview Survey found a prevalence of diabetes among Chinese to be 6%. Worldwide incidence rates of insulin dependent diabetes mellitus (Type 1) show that China has the lowest rates of Type 1 diabetes compared to 100 other populations in both adults and children. However, despite the very low rates of diabetes in China, the World Health Organization predicts a two- to threefold increase in prevalence rates of diabetes within the next few decades. Tobacco Tobacco use behaviors from the National Center for Health Statistics indicate that most Asians report never having smoked; Chinese American adults are most likely to have reported not smoking (84%) compared to Korean adults (65%). Among Asian smokers, Korean adults (22%) were two to three times as likely to be current smokers as were Japanese (12%), Asian Indian (7%), or Chinese (7%) adults. Another study noted similar findings where Chinese Americans reported lower rates of current smoking behavior compared to Whites, as well as other Asian subgroups except Japanese. Among Asians generally and Chinese in particular, smoking is largely associated with males than females. However, smoking behavior also varies based on acculturation. Research looking at four Asian subgroups finds that more acculturated youth and less acculturated male adults have higher smoking rates. For females, the opposite is true – smoking behavior is more highly associated with greater acculturation. Also, smoking behavior was associated with low education, use of non-Western physician or clinic, lack of knowledge of cancer and health risks, and being foreign born rather than US born. Health-Seeking Behaviors Health-seeking behaviors of Chinese immigrants are a complex process that is influenced by demographic, financial, and cultural barriers. Generally speaking, health-seeking behaviors are heavily influenced by degree of acculturation. The more highly acculturated the Chinese immigrants are, the more positive attitudes they have toward healthcare services and higher levels of actual service utilization. Chinese immigrants also suffer disproportionately from a lack of knowledge of health issues and awareness that symptoms are signs of a health problem. For instance, research looking at cardiovascular health and disease awareness among Chinese immigrants finds low awareness of warning symptoms of heart attack and stroke and what to do in response in a hypothetical situation. The process of health seeking involves acknowledging that symptoms are severe enough to seek treatment. In terms of symptom severity, Chinese immigrants often delay accessing formal healthcare services in lieu of home remedies and traditional forms of medicine. When Chinese immigrants do access formal healthcare services, they often present with more severe symptoms when other more culturally acceptable forms of treatment have been exhausted. For most Chinese people, this pathway to accessing Western healthcare treatment is rooted in the desire to keep problems and issues secret within the family. Chinese cultural values and norms influence the perception and interpretation of physical symptoms as well. As opposed to interpreting physical symptoms as a health or mental health problem, individuals may perceive their problem as a spiritual condition or as a personal weakness or deficiency to be overcome. Moreover, Chinese culture imparts a tendency to minimize individual suffering and avoid dwelling on negative conditions; instead, willpower and personal determination are encouraged which may negatively impact their health-seeking behaviors. Healthcare Service Delivery Decades of research have reinforced common themes associated with healthcare service delivery for Asian minority populations. Persistent patterns of underutilization of healthcare service among Chinese immigrants are related to a lack of understanding in navigating the healthcare system, an inability to communicate effectively, and factors related to costs of healthcare and perceived benefits. Chinese families also have a tradition of utilizing family networks first to keep private concerns within the family. Underutilization of services by Chinese immigrants is strongly influenced by the stigma and shame associated with physical and mental illnesses. The association of illnesses with individual character flaws and personal weakness is still strong in immigrant Chinese communities, and the fear of shame and of “losing face” within the Chinese community keeps many families from seeking external social services. Chinese Another problem is the issue of racial discrimination and stereotypes of the Asian “model minority.” Perceptions of Chinese immigrants are shaped by the model minority myth which reinforces the notion that Asians as a whole have higher socioeconomic status, educational achievement, more stable families, and lower crime rates. This type of stereotyping ignores the heterogeneity within the various ethnic subgroups within the Asian population. It fails to recognize the bifurcation within the Asian population, polarized at the ends of the spectrum by those well educated, affluent, and upwardly mobile and by those uneducated, less acculturated, and of lower socioeconomic status. Thus, this misappropriated label applied to Asians serves to obfuscate the problems and needs that many Chinese immigrants and other Asian minorities face; and while population-level indicators may point to the overall success of Asians, it fails to call attention to the needs of many Asians living in the United States. In addition, research on the experiences of racial discrimination by Asian Americans found it to be associated with chronic health conditions such as heart disease, pain, and respiratory illness. Barriers to Healthcare Utilization The research evidence on the barriers to healthcare utilization among Chinese Americans is well established. Access to healthcare is influenced by the nature in which services are delivered. Often healthcare facilities are not located near areas populated by Chinese immigrants. Immigrants of lower socioeconomic status may also lack access to transportation to access services. Low awareness of health issues and inadequate availability of healthcare services persists in Chinese immigrant communities due to limited access to health information presented in their native languages. Cultural and social contexts also shape the way Chinese immigrants conceptualize their health, health problems, and utilization of healthcare services. An example of this can be seen by the manner in which many Chinese immigrants may conceptualize mental health problems as physical ailments caused by organic factors and describe their condition as such. This leads many individuals with mental health problems to present to healthcare providers in primary care settings. Also, the Chinese language does not have equivalent terms to describe some mental health terms like C depression, so patients may use Chinese idioms and metaphors to describe their physical condition. Thus, the somatization of mental health problems, compounded by a lack of common terms used to describe mental health conditions, often results in misdiagnoses and ineffective treatments. The role of language poses a major barrier in the overall quality of healthcare service delivery for Chinese immigrants. After English and Spanish, Chinese is the most common language spoken in homes in the United States. However, the absence of professional translators in healthcare settings exposes significant gaps in cultural competency with respect to the language barriers. This may cause Chinese patients to experience feelings of greater disconnect, suspicion of treatment and of their healthcare providers, and decreased levels of overall satisfaction with services. This is particularly true when there is also a practice of ad hoc use of translators and because there are different dialects of Chinese. Using the correct dialect is critical because speakers of one dialect usually will not understand another. Barriers to healthcare utilization among ChineseAmericans are also created by the cost of insurance and healthcare. While Chinese Americans have been shown to have better overall health compared to non-Asian ethnic groups, they are also less likely to have healthcare insurance compared to Whites. With the perceived high cost of individual health insurance plans, many Chinese immigrants who work in smaller, family owned business, such as restaurants, grocery stores, etc., who do not have access to more affordable, employee-sponsored insurance plans opt to go without health insurance coverage or utilize public insurance if they qualify. There needs to be more training and development of Chinese-speaking medical interpreters along with the promotion of greater diversity in healthcare staff. Ethnic matching and language matching in health treatments would facilitate trust building and might improve the utilization of services. Support for the development of community-based healthcare clinics to increase access would be helpful as well as the development of language-specific health promotion literature to be distributed among the Chinese populations in the United States to encourage them to get help for their health problems. 425 C 426 C Chinese Exclusion Act of 1882 (U.S.) Related Topics ▶ Cancer ▶ Cardiovascular risk factors ▶ Diabetes mellitus ▶ Ethnic minority group ▶ Health beliefs ▶ Health care utilization ▶ Health services utilization ▶ Language barriers ▶ Somatic symptoms ▶ Stroke Suggested Readings Barnes, P., Adams, P., & Powell-Griner, E. (2008). Health characteristics of the Asian adult population: United States, 2004–2006. Advance data from vital and health statistics (No. 394). Hyattsville: National Center for Health Statistics, Center for Disease Control and Prevention, Department of Health and Human Services. Collins, K., Hughes, D., Doty, M., Ives, B., Edwards, J., & Tenney, K. (2002). Diverse communities common concerns: Assessing the health quality for minority Americans. New York: The Commonwealth Fund. He, J., Gu, D., Wu, X., et al. (2005). Major causes of death among men and women in China. The New England Journal of Medicine, 353, 1124–1134. Hsing, A., Tsao, L., & Devesa, S. (2000). International trends and patterns of prostate cancer incidence and mortality. International Journal of Cancer, 85(1), 60–67. Jiang, B., Wang, W., Chen, H., Hong, Z., Yang, Q., Wu, S., Du, X., & Bao, Q. (2005). Incidence and trends of stroke and its subtypes in China. Stroke, 78(1), 1–8. Kramer, H., Han, C., Post, W., Goff, D., Diez-Roux, A., Cooper, R., Jinagouda, S., & Shea, S. (2004). Racial/ethnic differences in hypertension and hypertension treatment and control in the multi-ethnic study of atherosclerosis (MESA). American Journal of Hypertension, 17, 963–970. Kwong, S. L., Chen, M. S., Jr., Snipes, K. P., Bal, D. G., & Wright, W. E. (2005). Asian subgroups and cancer incidence and mortality rates in California. Cancer, 104(12), 2975–2981. Lauderdale, D., & Kestenbaum, B. (2002). Mortality rates of elderly Asian American populations based on Medicare and social security data. Demography, 39(3), 529–540. Lloyd-Jones, D., Adams, R., Carnethon, M., Di Simone, G., Ferguson, B., Flegal, K., et al. (2009). Heart disease and stroke statistics – 2009 update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 119(3), e21–e181. Ma, G., Tan, Y., Toubbeh, J., Su, X., Shive, S., & Lan, Y. (2004). Acculturation and smoking-behavior in Asian American populations. Health Education Research, 19(6), 615–625. McCracken, M., Olsen, M., Chen, M. S., Jr., Jemal, A., Thun, M., Cokkinides, V., Deapen, D., & Ward, E. (2007). Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA: A Cancer Journal for Clinicians, 57, 190–205. Moran, A., Roux, A. V., Jackson, S. A., Kramer, H., Manolio, T., Shrager, S., & Shea, S. (2007). Acculturation is associated with hypertension in a multiethnic sample. American Journal of Hypertension, 20, 354–363. Yang, Z., Wang, K., Li, T., Sun, W., Li, Y., Chang, Y.-F., Dorman, J. S., & LaPorte, R. E. (1998). Childhood diabetes in China. Enormous variation by place and ethnic group. Diabetes Care, 21(4), 525–529. Suggested Resources National Center for Health Statistics. (2006). US mortality public use data tape, 2003. Centers for Disease Control and Prevention, Office of Minority Health website. Retrieved May 3, 2010, from http://minorityhealth.hhs.gov/templates/content.aspx?ID=3005 U.S. Census Bureau. (2010). Asian facts. Retrieved May 3, 2010, from http://www.census.gov/newsroom/minority_links/asian.html U.S. Factfinder. (2010). American community survey. Retrieved May 3, 2010, from http://factfinder.census.gov U.S. Office of Minority Health. (2004). Retrieved May 3, 2010, from http://minorityhealth.hhs.gov/templates/browse.aspx? lvl=3&lvlid=29 Chinese Exclusion Act of 1882 (U.S.) ANDREW LEONG College of Public and Community Service, University of Massachusetts/Boston, Boston, MA, USA The Chinese Exclusion Act of 1882 (hereinafter “the Act”) is considered as the first and only federal piece of legislation that prohibited a specific race, nationality, and ethnicity from entering the USA. Signed by President Chester A. Arthur on May 8, 1882, the Act excluded Chinese unskilled and skilled laborers from entry into the USA. Originally lasting a 10-year period, the Act was extended by the Geary Act in 1892, and thereafter extended indefinitely. The Act served as a starting point for the exclusion of citizens of other Asian countries from immigrating to the USA. Through a combination of other Asian exclusionary acts such as the Gentlemen’s Agreement of 1907, Immigration Act of 1917, the National Origins Quota of 1924, and the Tydings-McDuffie Act of 1934, the legacy of the Chinese Exclusion Act of 1882 extended well Chinese Exclusion Act of 1882 (U.S.) beyond 1943, when the Act was finally repealed in a propaganda struggle against the Japanese during World War II. The impact of the passage of the Act was felt immediately as Chinese immigrants who were considered laborers were categorically excluded. There was also ongoing litigation as to the re-entry rights for immigrants who were residing in the USA but were out of the country at the time of the passage of the Act. The trickle of immigrants entering thereafter consisted of merchants and students. The ultimate impact of the Act and its legacy Acts was the halting of Asian immigration. No other racial group has been singled out in such a systematic and blatant way for immigration purposes in US history. Though repealed in 1943, the ban on Chinese immigration and restrictions on immigration from other Asian countries continued for all practical purposes because the annual allotted immigration quota was so small (e.g., China 105/year) in comparison with huge quota for European countries (e.g., Germany 25,814). Not until 1965 was the institutionally racist “national origins quota” formula abandoned in favor of an immigration quota system that allocated an equal number for countries in the eastern hemisphere. The 1965 Act did not, however, cure the decades of Asian exclusion. Therefore, shortly thereafter a huge backlog of immigration applications existed for those countries that had been racially excluded. This is why the Asian Pacific Islander population is such a low percentage in the overall US population. For those Chinese and other Asians fortunate to be in the country prior to the passage of the Act, they were not allowed to become naturalized US citizens since the 1790 Naturalization Act had limited naturalization only to “free white persons.” Even when people of African descent were allowed to become citizens of the USA through the passage of the 14th Amendment to the US Constitution in 1868, the ban continued against Asians. This ban was not lifted country by country until the 1940s and up to 1952, when the ban was removed finally for all Asian nationalities. Although not nearly as infamous, the passage of the Page Act of 1875 did more to negatively impact the healthy development of family life and social formation in the Chinese community than other legislation. The Page Act was a federal law that prohibited the entry of C Chinese, Japanese, and Mongolian contract laborers, and women for the purpose of prostitution, and felons. The section regulating the prohibition of prostitutes was applied against Asian women through a general assumption that Asian women were prostitutes attempting to enter the USA for immoral purposes unless they could prove otherwise. Whether it was cultural beliefs that women needed to stay behind in the home country to care for children and elders, or the enormous travel expenses, or the increasing anti-Asian hysteria, men were the primary immigrants in the nineteenth century. The many exorbitant fees levied upon each Chinese immigrant in the state of California alone became prohibitive to one working and living in the state, no less attempting to have a family life in the USA. With a huge disparity in the gender gap, these conditions became ripe for the prostitution industry. Such were the precursors to the passage of the Page Act. Health reasons were cited particularly for the regulation of Chinese brothels and eventually justifying passage of Asian exclusion Acts since Chinese prostitutes were looked upon as spreading venereal diseases and other germs amongst the White male population. The implementation of the Page Act greatly restricted the entry of Asian women into the USA. According to US Census data, the percentage of Chinese females in 1870 was 7.2% of the total Chinese population. By 1890 the figure dropped to 3.6%. The unavailability of Chinese women and thus potential mates served as a major impediment to the establishment of Chinese communities and a healthy family life. Many Chinese males working and living in the USA would travel back to China to get married, and possibly father a child but never or rarely have the occasion to see their family members due to restrictions on the exclusion Acts. Other Chinese males attempted to have family life in the USA but were forbidden from marrying White women due to various state anti-miscegenation laws as well as the federal Cable Act of 1922 (which had the effect of revoking the US citizenship status of any female who married an Asian man). The Chinese Exclusion Act should not be considered only as a single piece of legislation, but as a culmination of a national anti-Asian movement and “Yellow Peril” xenophobia that started in the West Coast through a series of California state legislation 427 C 428 C Christianity that attempted to prevent and discourage Chinese immigration and democratic participation in everyday life. In California, there were head taxes for disembarkation from ships, special taxes and fees for Chinese in certain industries, laws that prohibited Chinese from testifying for or against Whites in court, and a tax on the Chinese for just residing in the state. Infamous cases such as Ho Ah Kow v. Nunan (a pig tail “queve” cutting ordinance against Chinese prisoners that had violated the “Cubic Air Ordinance” that forbid overcrowding housing conditions in San Francisco in 1870) and Yick Wo v. Hopkins (a series of San Francisco ordinances in the 1880s that regulated the licensing of the laundry industry operating out of wooden buildings) were initiated by local San Francisco officials under the guise of addressing health and safety issues while the ultimate impact was discriminatory practices against the Chinese only. Similar laws modeled after the Chinese Exclusion Act were passed in Australia (the Immigration Restriction Act of 1901) and Canada (the Chinese Immigration Act of 1923). Related Topics ▶ Anti-Asian violence ▶ Chinese ▶ Discrimination ▶ Xenophobia Suggested Readings Chan, S. (1991). Entry denied: Exclusion and the Chinese community in America, 1882–1943. Philadelphia: Temple University Press. Hing, B. O. (1993). Making and remaking Asian America through immigration policy, 1850–1990. Stanford: Stanford University Press. Luibheid, E. (2002). Entry denied: Controlling sexuality at the border. Minneapolis: University of Minnesota Press. Tamayo, W. (1992). Asian Americans and present U.S. immigration policies: A legacy of Asian exclusion. In H.-c. Kim (Ed.), Asian Americans and the supreme court: A documentary history (pp. 1105–1130). New York: Greenwood Press. Suggested Resources Barde, R. (2004). An alleged wife: one immigrant in the Chinese exclusion era. Prologue: Quarterly of the National Archives and Records Administration, 36(1), 1–35. Retrieved June 14, 2011, from http://www.archives.gov/publications/prologue/ 2004/spring/alleged-wife-1.html Christianity CRISTINA GAVRILOVICI Department of Legal Medicine, Medical Deontology and Bioethics, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania General Issues Christianity originated in the geographical area that is now known as the Middle East. Christianity arose in Palestine during the first half of the first century among the followers of Jesus of Nazareth, who was called the Christ. Christ’s followers believed that He was the Messiah and the Son of God. Although Christ’s first followers were almost exclusively Jews, this new faith spread quickly throughout the Mediterranean basin and soon attracted many non-Jewish converts. During the first three centuries, it remained a minority religion. The practice of the faith was prohibited by the Roman imperial government, and its adherents were often subjected to persecution. In the year 313, the Emperor Constantine declared Christianity to be a legal religion. Christianity is a monotheistic religion that believes in one supreme God and is based on teachings from the Holy Scriptures. It comprises three major branches: Roman Catholicism and Eastern Orthodoxy (the two split from one another in 1054 AD), and Protestantism, which came into existence during the Protestant Reformation of the sixteenth century. Protestantism is further divided into smaller groups called denominations. The fundamentals of the Christian faith can be found in the Old Testament; the New Testament, composed by followers of Jesus during the first century; and the patristic literature, which comprises the writings of early church leaders and theologians until the end of the fifth century. During this era, the beliefs and practices of the new faith were articulated and refined; such controversies included issues relating to the divinity of Christ and the nature of redemption. Gradually, a core set of beliefs developed within the orthodox structure and was promoted through church organization. Both the faith’s doctrine and hierarchy were established by the late fifth century; both the doctrine and the Christianity hierarchy differ in some respects between Western Europe and the Byzantine culture of the East. Christian identity is rooted in the experience of the Holy Spirit. Life is considered to be a sacred gift from God that should be protected, transmitted, cultivated, cared for, and fulfilled in God. For many Christians, the ultimate reality is the Holy Trinity: the Father, source of the other two fully divine persons; the Son, forever born of the Father; and the Holy Spirit, forever proceeding from the Father. Human beings are created as a composite of body and spirit, as well as in the “image and likeness” of the Holy Trinity. “Image” refers to those characteristics that distinguish humanity from the rest of the created world: intelligence, creativity, the ability to love, self-determination, and moral perceptivity. “Likeness” refers to the individual’s potential to become “Godlike.” The work of redemption and salvation is accomplished by God through the Son, the second person of the Holy Trinity who, with the exception of sin, took on human nature as the person of Jesus Christ. Christ taught, healed, gave direction, and offered Himself upon the cross for the sins of humanity. His resurrection allowed him to conquer the powers of death, sin, and evil. C repeatedly remind the people of Israel to do justice and that the true service of God is the pursuit of justice. Justice is primarily related to God. According to Christianity, human justice is a response to God’s justice that human beings can experience between each other. However, Jesus ordered his disciples to practice strict adherence to this law, but asked them to go beyond the strict requirement of the law. Justice is not denied as an important value but love goes beyond justice demanded by law. Justice gives a person what might be considered to be due to him or her after weighing all relevant considerations. In contrast, love presupposes the implementation of justice and then may allocate to the individual more than would be demanded by justice alone. As an example, the Old Testament speaks of the Sabbath Year, during which the Israelites were to provide rest for themselves, their animals, their land, and forgive debts. In essence, the law functioned as a mechanism for the redistribution of wealth. In comparison, Jesus warned about the dangers of accumulating materially and asked individuals to distribute their wealth to the poor. This advisory was not for the purpose of effectuating social change, but was rather for the purpose of achieving spiritual perfection. The concern was not with equity, but with love. Applied Christian Values Christianity and Caring for the Sick Christianity and the Principle of Justice and Equity Even within a developed region such as Europe, disparities exist between different countries in terms of the quality of health care and the ability to access health care systems. Many relatively wealthy countries that are able to provide comprehensive health systems must nevertheless deal with issues of rationing and the fair distribution of resources. Therefore, the principle of equity is central to any consideration of health care. Justice is both a social concept and an important Christian concept. Christianity does address the issues of equity and fairness in health care. The Holy Scriptures’ focus on justice may be best understood by the modern reader as charity or love. The Old Testament reflects the concept of justice through its conferral of equal status of all men and women before God. Every human being is believed to have been created in the image of God; this quality belongs to all individuals, independent of any other differences. The Prophets From its beginnings, Christianity has been concerned with health and hospitality. Philanthropy and charity provided the foundation for the establishment of hospitals starting in the fourth century in the East, until modern times in the West. Medical tasks have often been central to the church’s missionary efforts. Christianity often views the source of suffering as outside of the sufferer. The source of an individual’s suffering is often perceived to be the thing that is causing the pain, the pain itself, the individual’s life circumstances, or a stroke of fate. On the other hand, suffering almost always involves a self-conflict. Both on a religious and a secular basis, it is not unusual for suffering persons to believe that their suffering is a form of selfless service to others. This is why the meaning is essential to suffering; the suffering associated with a threat to an individual’s physical integrity necessarily raises the issue of the meaning of the pain and its implications. As an example, the crucifixion of Jesus, which was an evil, was transformed by God into 429 C 430 C Christianity Christianity’s central saving act and a demonstration of the power of love over suffering. A Christian Protestant perspective asserts that God is in control and that there is a greater meaning or purpose in illness of which we may not be aware. Some Christian Protestants pray for miraculous cures as a sign of God’s authority. Many believe that a miracle could occur but also believe that God works through human ingenuity and technology to cure illness and relieve suffering. Believers are warned not to attribute to physicians and medical interventions more power than they actually have and to remember that it is God who is in control. Although Christian theology views physical health as important, it maintains that it may be an obstacle to the supreme good, which is believed to be spiritual health. It is believed that the soul is more valuable than the body, and that care for the body should not conflict with care for the soul. Christians are counseled to accept and appreciate both sickness and health. Sickness can correct or restrain one from engaging in sin, help an individual to increase patience and reduce pride, and facilitate the individual’s reliance on God. Within orthodox Christian theology, the origins of human death and disease are perceived as the consequence of divine judgment on human sin. When illness occurs, Orthodox Christianity affirms an ethical duty to struggle against sickness, which if unaddressed can lead to death. The moral requirement to care for the health of the body indicates it is appropriate to use healing methods that will enhance health and maintain life. Depending upon the particular denomination of Christianity, spiritual healing, such as prayer, and different forms of medicine may be utilized concurrently. Christianity and End of Life Values Christians have an obligation to attend to the sick and the poor of the community. To do so signifies not only Christian love but also a respect for life that is rooted in the belief that every human being was formed in the image of God. Accordingly, all human life is deemed to be of value, and therefore needs to be addressed with compassion and care. Christianity maintains that we have a duty to protect the life given to us by God; accordingly, suicide, active euthanasia, and “mercy killing” are prohibited. However, there is a distinction between ordinary and extraordinary measures; a person is obligated to use ordinary measures but can choose whether or not to accept extraordinary measures. A persistent theme in Christian reflection on death is the view that death serves to transform the individual into another form of existence; it is not the annihilation of the self. In other words, it is believed that the individual human being survives death, perhaps for all eternity. Death may represent a life that is free of sorrow, suffering, and separation. Some may believe that death does not have the power to cut them off or separate them from the life of the community and the life of God. Accordingly, death is viewed as a meaningful stage in the life cycle. In general, Christianity traditionally defines death as the moment the spirit leaves the body. Signs of the spirit’s departure include the absence of breathing, a heartbeat, and a pulse. Many Christian theologians have accepted a brain-oriented definition of death, sometimes analogizing this to the departure of the spirit from the body. Christianity and Immigrants Christianity and Immigrants’ Integration into the Host Country Some scholars have argued that after the first generation, immigrants in the United States would abandon their native languages and ethnic traditions but retain their religions and use religion as a way of melting into America’s heterogeneous population. In fact, religious identities may increase in importance among immigrants compared to its role in their nations of origin because of the role religion can play in preserving ethnic identities. Religion can be used not only to construct a religious identity, but also to develop or retain an ethnic identity. For example, studies involving Korean Christians have demonstrated how religious organizations can help to preserve ethnic traditions by combining and making religious and ethnic rituals synonymous. Campus-based evangelical Christian organizations have been shown to provide Asian Americans with cultural resources for reinforcing the image of Asian Americans as model minorities. Churches may also serve as important social and educational centers that support the development and maintenance of relationships between individuals who Christianity speak the same language and share the same culture, thus providing group ties, identity, and acceptance. The practice of a religion in the destination country may also serve as an empowering resource for women, taking less patriarchal forms in organizations in the United States than in the immigrants’ countries of origin. One ethnographic study demonstrated how a Taiwanese evangelical Christian church provided a space for women to construct a distinct sense of self as separate from the family. Christianity also plays a role in developing social identity from a citizenship point of view. Development of an identity as a citizen first requires that one be a citizen. Gaining citizenship involves navigating the application process, which may be impeded by language barriers and other impediments to gaining legal status as an American citizen. Christian organizations often provide social service resources, such as assistance with learning the English language and help studying for the US citizenship exam. This has been demonstrated to be helpful in a study that was conducted with Asian Americans living in the five metropolitan areas with the highest numbers of immigrants. The differences between the Orthodox and Catholic churches are important and may potentially influence the immigrants’ lives. First, Eastern Orthodoxy never developed a worldwide central authority equivalent to the Papacy of Roman Catholicism. Orthodox Christians consider themselves to be part of one worldwide church that shares the same faith and sacraments; however, in church governance Orthodox Christianity is actually a unity of independent national churches. Unlike Roman Catholicism, Orthodox Christianity never developed an institutional unity that could transcend national, ethnic, and linguistic barriers. Second, in the United States, Orthodox Christianity generally arrived later than Catholicism. Although monks from Russia established an Orthodox mission in Alaska in 1794, most Orthodox families came to America after 1900. They have integrated into American society more slowly than have Catholics because of the stronger ties between religious affiliation and ethnic community among the Orthodox. Ethnic consciousness appears even today to be more important for American Orthodox individuals than for Catholics. Further, various Orthodox church rules and traditions C may contribute to Orthodox individuals’ sense of ostracism from present-day mainstream American society. Thus, orthodoxy in the United States has supported more strongly the retention of immigrants’ religious identity than their integration into the host country. In the process of migration, a family or a person may lose a social network and the social and human resources on which they depend for both daily and long-term needs. An immigrant often experiences a sense of disorganization and disorientation that has been referred to as cultural exhaustion or shock. Others’ behavior and symbols no longer mean what they meant before migration and the new immigrant must expend considerable energy to understand their meaning. Attending to the basic needs of housing, obtaining food, learning the banking system, and mastering English all require much energy. This sense of disorganization may diminish over time. The extent to which an individual experiences this sense of disorganization and confusion depends upon the individual’s level of education, occupation, social status, formal social ties with the host country, personality traits, motivation for migration, and the extent of differences and similarities between the immigrant’s country of origin and the receiving country. The immigrant’s religion and religious community may serve as important sources of strength and may provide support during this period of difficulty. Religious beliefs are powerful determinants of demographic events such as marriage, divorce, and childbearing. Religious teachings relating to partnership, sexuality, and fertility can affect demographic patterns both directly and indirectly. As an example, church leaders may oppose the use of contraceptives, which may impact the birth rate within a particular community. Accordingly, Catholics once had a significant fertility advantage over Protestants among White Christian Americans, but this advantage lessened during the second half of the twentieth century. Evangelical Protestants continue to have higher fertility rates than those from more liberal Protestant groups. In the United States, the high numbers of individuals immigrating from predominantly Catholic Latin America helped to mask conversions and departures from Catholicism to Protestantism and secular nonaffiliation. 431 C 432 C Chronic Disease Christianity and Immigrant Health Many immigrants prefer to receive health information in a church setting. In the United States, the church has been found to be the most preferred location for attending a health education session compared to a community center, a hospital, or a local school. Studies have shown that churches and health care organizations can collaborate to implement successful health promotion programs and health education interventions. These programs and interventions focus on a wide range of health topics, such as smoking cessation, diabetes prevention, nutrition, physical activity, and cancer screening. Many church leaders provide immigrants with practical assistance, such as accompanying a church member to physician appointments, providing translation services, assisting with completing forms, etc., and consider this to be a core component of their Christian mission. Over 70% of Koreans in the United States attend churches on a regular basis, in contrast to only 14–30% of Koreans residing in Korea. Therefore, Korean churches in the United States may play an important role in health research for this immigrant population. Related Topics ▶ Gender role ▶ Health care ▶ Health care utilization ▶ Religion, religiosity, and spirituality Suggested Readings Benn, C., & Hyder, A. A. (2002). Equity and resource allocation in health care: Dialogue between Islam and Christianity. Medicine, Health Care and Philosophy, 5, 181–189. Cadge, W., & Ecklund, E. H. (2006). Religious service attendance among immigrants. The American Behavioral Scientist, 49(11), 1574–1595. Cadge, W., & Ecklund, E. H. (2007). Immigration and religion. Annual Review of Sociology, 33, 359–379. Jo, A. M., Maxwell, A. E., Yang, B., & Bastani, R. (2010). Conducting health research in Korean American Churches: Perspectives from church leaders. Journal of Community Health, 35, 156–164. Krindatch, A. D., & Hoge, D. R. (2010). Satisfaction and morale among parish clergy: What American Catholic and Orthodox priests can learn from each other. Journal for the Scientific Study of Religion, 49(1), 179–187. Nairn, T. (2009). Immigration, charity care and ethics: What should Catholic hospitals do? Health Progress, 90, 6–8. Niebuhr, R. (2001). Moral man and immoral society: A study in ethics and politics. Louisville: Westminster John Knox. Post, S. G. (Ed.). (2003). Encyclopedia of bioethics (3rd ed.). New York: Gayle Cengage Learning. Skirbekk, V., Kaufmann, E., & Goujon, A. (2010). Secularism, fundamentalism, or Catholicism? The religious composition of the United States to 2043. Journal for the Scientific Study of Religion, 49(2), 293–310. Chronic Disease ERIN M. FEKETE1, STACEY L. WILLIAMS2 1 School of Psychological Sciences, University of Indianapolis, Indianapolis, IN, USA 2 Department of Psychology, East Tennessee State University, Johnson City, TN, USA Immigrant status and nativity (i.e., country of birth) are strongly related to health, mortality, and incidence/ prevalence of chronic illness. Compared to US-born, non-Hispanic Whites, immigrants tend to have a health advantage, including a longer life expectancy and lower mortality rates. However, in some cases immigrants from ethnic groups experience higher rates of chronic illness. Chronic illness is characterized as any illness that persists over time and requires management through medical treatment (e.g., medication, surgery) or lifestyle changes (e.g., dietary changes, exercise). Many chronic illnesses are caused in large part by stress and poor health behavior choices such as having a poor diet, sedentary lifestyle, or other negative health behaviors such as smoking or drug/alcohol abuse. The major chronic illnesses attributed to lifestyle behaviors include heart disease, cancer, type 2 diabetes mellitus, and HIV/AIDS. Although medical treatment such as surgery or medication may be necessary, the main aspect of management for these chronic illnesses includes maintaining healthy lifestyle changes such as eating a healthy diet, getting adequate exercise, and medication compliance. Heart disease. Heart disease is a major cause of death for many ethnic minority groups in the USA. New immigrants tend to have a lower risk of heart disease than minorities and nonminorities in their Chronic Disease host country. However, over time this risk becomes similar to or greater than the risk of heart disease for native-born individuals. Cancer. Overall, nativity and immigrant status do not appear to have strong links to cancer, but among different ethnic groups, the link between immigrant status and cancer is strong. In some cases, these links appear to be genetic, such as Asian immigrant’s offspring tendency to have lower rates of ovarian cancer. In other cases, however, the links between immigrant status and cancer are due to poor health behaviors, such as higher rates of oral cancer in Asian immigrants from habitual use of tobacco, or higher rates of cervical cancer in Latino and Haitian women due to lower knowledge about and screening for HPV (human papillomavirus). Type 2 diabetes. Research is mixed regarding the association between immigrant status and the development of type 2 diabetes, which occurs as a result of poor lifestyle behaviors. Some research suggests that nativity has protective effects, such that some ethnic groups appear to have lower rates of diabetes due to genetic factors. However, similar to heart disease, there is a general tendency for the incidence and prevalence of diabetes in immigrants to be highly correlated with incidence and prevalence of diabetes in their host culture. HIV/AIDS. Research on the prevalence of HIV/ AIDS in immigrant populations suggests that in general, immigrants and native-born individuals have similar rates of HIV-infections, although women from Sub-Saharan Africa tend to have higher rates of HIV/ AIDS and Asian Pacific Islanders have lower rates of HIV/AIDS. Longitudinal data also suggests that many immigrants tend to become infected with HIV postimmigration. C beliefs, and normative behaviors that carry over into cognition, development processes, social functioning, and comprehension. Taken together, an individual’s identity, self-image, and reality are a product of their culture. Thus, when immigrants are living with a chronic illness, the extent to which they identify with their native versus host culture (i.e., acculturation) can strongly influence how they understand, cope with, and manage their illness. In addition, their illness experience will also depend, in part, on the extent to which they are able to seek out adequate health care, have access to adequate health care, and receive quality health care that is sensitive to their cultural values and norms. Acculturation and Chronic Illness in Immigrants Acculturation is the process and result of an individual from a minority group adopting the cultural norms and beliefs of the dominant group or host culture. The stages of acculturation include contact, accommodation, and assimilation. Therefore, becoming acculturated includes behavioral and attitude changes such as changes in language preference, the adoption of common attitudes and values, and changes in political or ethnic identification. Research generally suggests that immigrants are healthier than both their US-born counterparts and US-born Whites. This advantage is due, in part, to both a healthier lifestyle in their country of origin and selectivity of healthy immigrants. When immigrants first arrive in the USA, cultural factors such as religiosity or support networks tend to act as a buffer to the negative health behaviors and negative health events immigrants are exposed to (e.g., smoking, poor dietary behaviors). However, these health advantages tend to diminish as acculturation and duration of residency increase. Cultural Influences on Immigrants’ Health Health Behaviors and Risk Factors Although data clearly suggest that social and behavioral factors influence the incidence and prevalence of illnesses in immigrant populations, research on chronic illness still has a tendency to neglect the extent to which culture can influence an individual’s chronic illness experience. Sociocultural theory provides a strong framework for understanding immigrants’ chronic illness experience. Each culture has different values, A great deal of research finds a positive association between acculturation and the decline of health behaviors, including being overweight or obese, eating unhealthy foods, having a sedentary lifestyle, and engaging in negative health behaviors such as smoking and unsafe sexual practices. For example, as some immigrants become acculturated they have higher rates of being overweight or obese. As these negative 433 C 434 C Chronic Disease health behaviors are primary causes of many major chronic illnesses, it is likely that as immigrants become acculturated their risk for developing heart disease, cancer, type 2 diabetes, and HIV increases as well. Immigrants may have less knowledge about signs and causes of chronic illness due to language barriers and cultural beliefs. Some immigrants may not engage in preventive care, such as regular mammography or Pap smears, because they lack knowledge about the importance of the behaviors. There may be a lack of knowledge about where to obtain health care, fear of a language barrier between patient and provider, or fear of not receiving adequate care because of their inability to communicate effectively. In some cases, immigrants may be suspicious of their host country health care providers because the health care system in their host country is different than the health care system in their native country. As immigrants become acculturated, they may engage in better preventative health behaviors and illness management because their knowledge and trust of the host country’s health care system increases. Once diagnosed with a chronic illness, immigrants may have a difficult time making or maintaining lifestyle changes associated with illness management because of cultural influences, including traditional foods or religious beliefs. Immigrants with type 2 diabetes may modify their diet to an extent, but they may engage in deliberate deviations from their diet when culturally traditional foods, that are not necessarily healthy, are concerned. Many immigrants rely heavily on religious institutions as a means of emotional and instrumental support. Religious institutions often provide a sense of indirect social control in that members of the religious institution feel obligated to avoid behaviors that are not condoned by most churches, such as sexual promiscuity, excessive drinking, and smoking. As immigrants become acculturated, religiosity may become less important to them and therefore behaviors that were once restricted may no longer be seen as taboo. Gender/Social Roles Gender role theory suggests that men and women are socialized to engage in gender-specific behaviors from the time of childhood, and these behaviors often carry over into their adult behaviors and attitudes. Men tend to be independent and agentic, and are often seen as breadwinners of the family, whereas women are more often seen as communal as they engage in many of the caregiving aspects of the marital/familial relationships. In many Western and developed countries, it is becoming common for gender roles to be less pervasive in relationships and for men and women to be more egalitarian. However, in many traditional cultures, gender roles are still very persistent, and sometimes play a more dynamic role in the management of health and chronic illnesses. Compared to non-Hispanic White cultures, Black and Hispanic cultures are generally more familial and have small, close-knit social networks. Immigrants coping with stigmatizing chronic illnesses such as HIV may not be able to disclose information about their illness to family members due to fear of rejection and social isolation as a result of the behaviors often associated with HIV-infection (e.g., homosexuality, drug use). As a result, immigrants may lack the social resources needed to cope with their illness, and they may also fail to engage in appropriate health behaviors such as medication compliance or attending regular health appointments in an attempt to hide their illness. Many immigrant cultures place emphasis on the role of a woman as the caretaker of her family. As a result, the personality characteristic of unmitigated communion, or focusing on others to the detriment of the self, may be fostered in immigrant women. In this sense, immigrant women place so much emphasis on the health and well-being of their family that they do not tend to their own health care needs, including both preventive medicine and chronic illness management. Health Care Utilization The experience of chronic illness may be impacted by immigrants’ utilization of health care. Although utilization of the health care system may be in part attributable to individual-level factors affecting the decision about whether or not to seek care, a number of factors at varying levels contribute to such utilization decisions and behaviors. In particular, not only are decisions impacted by structural factors like global access to care and the quality of the care once it is sought or received, but also the social and cultural context within the lives of specific immigrant groups. Chronic Disease Compared to nonimmigrants, immigrants are more likely to underutilize and delay the utilization of health care services. In addition, immigrants are less likely to discuss health promotion behaviors with physicians, and are less likely to get appropriate preventative services. For instance, female immigrants seek out preventative gynecological services less regularly. A behavioral model of health services use, or the Anderson model, has been proposed to organize the themes of barriers to access and use of services. The model considers predisposing factors, enabling factors, as well as need. For instance, nativity, according to this model, is a predisposing factor to access and use of services, while health insurance and language, ease of making an appointment, and availability of providers are examples of enabling characteristics. Need might be based on illness and chronic illness as well as sex- or age-appropriate screenings and preventive care which can predict service use. Access to Care There is some evidence from nationally representative studies of US-born and foreign-born adults that having insurance and a usual source of care are less predictive of seeking both preventive and non-preventive health visits. Yet, other findings indicate that unmet medical needs are greater among those who lack insurance than among those insured – whether immigrant and nonimmigrant. Indeed, foreign-born individuals living in the US, and especially those who are noncitizens, are less likely to have health care insurance. This includes children as well as the elderly. Similarly, these individuals are less likely to have a usual source of care. This patterning corresponds with the trends found for rates of actual health care seeking; in particular, those who are noncitizens (undocumented and legal status) seek less health care than citizens. This is generally true for preventive care as well, such as mammography and Pap tests. It is perhaps more even more difficult to access services when living in rural locations, where immigrants (e.g., Hispanics) are increasingly found. Thus, it may be that utilization of health care is attributable more to access, which is positively correlated with socioeconomic status. For example, after studies adjust for factors such as demographics, insurance, regular C source of care, and other similar factors, immigrants appear equally likely to get preventive care. It is also possible that acculturation issues and better health in combination with fewer health-enabling issues explain lower health care service use. These factors may be barriers to service seeking and many negatively impact the course of chronic illness. There may also be some fear on the part of the immigrant of negative or limited treatment due to their minority status. Data on African people living with HIV in the US have shown barriers to care that include individual perceptions such as fatalistic views about HIV and fear of isolation. Other barriers included fear of deportation and lack of knowledge of the health system and HIVrelated services. Quality of Health Care In addition to understanding how health care access affects immigrants’ chronic illness experience, it is also important to acknowledge immigrants’ experience once inside the health care system. Quality of health care is the extent to which services are aligned with professional knowledge, and the extent to which individuals receive appropriate services in a competent and communicative way. To this end, typically expected characteristics of quality may include shared decision making between the patient and the health care provider, as well as sensitivity to cultural differences and concerns. Such quality is important because it contributes to a greater likelihood of continued service use and better health outcomes. The Anderson model of service access and use includes quality of care. Considering the patient and physician interaction as a context for determining quality of care, specific indicators of quality might include patients’ perceptions of (1) whether the doctor listened to the patient, (2) whether the patient understood the doctor, (3) whether the patient had questions that went undiscussed, (4) patient trust of physician, (5) whether the doctor treated the patient with respect, (6) whether the doctor involved the patient in decision making, and (7) whether the doctor spent the amount of time with the patient that is wanted. Considering the association between nativity status and patient perceptions of the patient–physician interaction, foreignborn, as compared to US-born individuals, are at increased odds of reporting their physician as not 435 C 436 C Chronic Disease involving them in their care as much as they would have liked. In addition, foreign-born persons are at increased odds of reporting their physician did not spend as much time with them as they would have liked. Additional reports of research show that at times immigrants perceive health care as not helping to the fullest degree. Given the role of language in communication, language differences and other cultural differences can contribute to immigrants’ quality of care as well. Language appears to increase the difficulties with patient–physician communication when the patient is an immigrant. For instance, individuals who are less proficient in English tend to receive fewer of the appropriate tests and preventive screenings than those more English-proficient. Those less proficient in English tend to have worse health and more distrust that physicians understand their medical problems. Further, those who have difficulties with language and communication report less adherence to medical regimen and chronic illness management. Foreign-born individuals also are more likely to report perceived discriminatory experiences in the health care system; being non-White and a noncitizen is related to more such reports. Other Cultural and Social Contexts Several other factors related to cultural and social contexts might contribute to health care utilization and subsequently the chronic illness experience among immigrants. For example, lower service use and the fewer enabling factors to service seeking may be exacerbated within the social context of intimate partner violence in the lives of immigrants. Considering women in particular, partner violence puts immigrant women at risk for some chronic health conditions such as sexually transmitted diseases. Further, legal issues related to being undocumented may prevent these women from seeking health care. Moreover, in some cultures, partner violence may be perceived as extremely personal and not within the realm of topics to be discussed with health care providers. In this social context of private partner violence and a distrust of the health care arena, individuals may feel helpless to change their situations or appropriately handle other health-related concerns. Immigrants’ personal and familial relationships may contribute to health care use and the illness experience. Some research has shown, for instance, that immigrant women’s adult daughters may play an important role in their health care and health care seeking. This pattern may be especially true when the daughter is more proficient in English language skills and is able to help navigate the health care system. In fact, some evidence suggests immigrants may connect with other immigrants as well as with family and friends to navigate the health care system. This solidarity may contribute to a greater likelihood of receiving adequate health care. Further, the challenges or barriers to care reported above may also apply to children of immigrants, whether or not they themselves have chronic conditions which require treatment. Thus, access to care and quality of care, as well as cultural issues contributing to perceptions of the health care system impact not only individual immigrants who may be suffering with chronic conditions but also can influence families as they navigate the health care system. Another contextual reality for immigrants is that chronic illness is often comorbid with other illnesses, including mental illness. Mental health problems may be greater among immigrants particularly as they remain in their host country for longer periods of time. This link between acculturation and mental health perhaps reflects greater risk for psychiatric disorders with increased exposure to minority status. Further, immigrants’ experiences of having less access to health care, less quality health care, and greater stigma and fear of deportation associated with health care, can contribute to greater psychological distress. Finally, in many cultures, mental health problems are not acknowledged or addressed. As immigrants acculturate to their host country, they may feel more comfortable seeking mental health treatment. Some variations in mental health patterns by gender and ethnic category exist, leading to the question of whether factors related to specific immigrant groups contribute to mental health. The National Survey of American Life found that Caribbean immigrant men fared better psychologically than their US-born Black counterparts, whereas Caribbean immigrant women fared worse as compared to US-born Black women. The combination of increased mental health issues and lowered mental health care seeking could exacerbate the negative experience of immigrants with Chronic Disease chronic illness. An increased focus on immigrants’ health care needs and utilization in the context of mental health needs and care seeking seems necessary. In this realm of mental health and psychiatric care, it is perhaps an additional charge of the primary healthcare system to address such issues that are not traditionally in the preview of health care and yet may be ever present. Indeed, immigrants and US-born alike disproportionately use the general medical sector for treating mental health problems. Given the lowered utilization of mental health care, perhaps integration of psychologists into primary care could reduce the stigma associated with seeking care. To illustrate, Asian Americans experience various emotional or behavioral problems, and yet underuse existing mental health services except when culturally and linguistically sensitive. Culture-bound syndromes and misdiagnosis can occur. Due to Asian traditions of viewing the body and mind as one rather than two separate systems, individuals tend to focus more on physical than emotional symptoms, leading to overrepresentation of somatic issues. Perhaps the integration of psychology into primary care practice can address both the physical and mental health contexts. Need for Cultural Competence in the Health Care System It is important for researchers and health care professionals to understand that while immigrants and individuals from minority populations may integrate and incorporate beliefs from their host environment, they will retain some of their traditional beliefs and practices. As such, each ethnic and minority group within a larger culture develops a unique mix of social and cultural roles, expectations and beliefs, and frameworks that shape the health behaviors and health decisions of individuals coping with chronic illness. The differences in immigrants’ and minorities’ cultural belief systems may contribute to the health disparities seen in many immigrant and minority populations. One way to address the health disparities seen in the incidence of, treatment for, and health care usage in chronic illness in minority populations is through increasing cultural competence in researchers, medical professionals, and health care providers. Cultural competence can be conceptualized as a systematic set of C behaviors, attitudes, and policies that enable professionals or agencies to work effectively in culturally diverse settings. This can be implemented through cultural competence education in physicians and other health care professionals. Cultural competence can be best implemented and most effective if resources are available to provide appropriate care, medical professionals and health care providers know the population they are providing care to and respond to the needs of their patients appropriately, and health professionals are committed to providing high quality and comprehensive care across culturally diverse settings. A potentially effective method for becoming knowledgeable about the population to whom physicians are providing care may be to conduct focus groups with individuals who experience challenges to seeking care and yet successfully navigate the health care system, obtaining care that is needed and helpful. This strategy has been used with results showing that many immigrants feel embarrassed, helpless, and discouraged from seeking care and yet can overcome obstacles into the system through solidarity with other immigrants, friends or extended family, and connections with health service personnel. These networks of care enabled Latinas to access a complicated health care system and offer lessons for providers and policy makers concerned with improving the delivery of care to this population. Interventions In addition to a call for cultural competency in the health care professions, research should also keep culture at the forefront of their research programs. Although the roles of culture and ethnicity are becoming common considerations for clinicians and researchers, few culturally sensitive interventions have been implemented. Instead, the traditional “one size fits all” method of interventions tends to prevail. Instead, researchers need to design interventions based on what types of interventions will work best for whom and under what circumstances. The process of conducting culturally sensitive research and interventions involves consideration of cultural contexts across all phases of the scientific research process, including ethnographic methods such as focus groups, translating measures into culturally appropriate 437 C 438 C Chronic Disease language, data collection that includes comparison groups, and culturally appropriate analysis and interpretation of data. Conclusions Immigrants often experience lower rates of illness until they have acculturated to their host country. Many immigrants do not have or develop the knowledge about health and preventive behaviors needed to prevent many of the major chronic illnesses. Immigrants are less likely than nonimmigrants to seek out and utilize health care for a variety of reasons, many of which reflect challenges of being an immigrant such as less access to enabling characteristics to service use, and cultural and contextual issues. The challenges to needed care that immigrants encounter, particularly in combination with lower perceived quality of care, may further contribute to feelings of stigma and avoidance of the health care arena. These patterns could indicate an eventual negative health impact for immigrants, as lack of use of the health care system could contribute to an exacerbation of symptoms and health risk over time. Additional conclusions based on limited but promising research, however, suggest that variations in health care–related factors may be indicated for specific immigrant groups, locations, or regions. Despite the challenges to health care, some immigrants do successfully navigate the health care system. These findings suggest the need for further investigation into the ways in which health care is accessible and of good quality for immigrants, as well as the characteristics of the immigrant groups who are successful at navigating the system. Information garnered from such investigation can be used to implement better health care situations for other immigrants. Related Topics ▶ Acculturation ▶ Acquired immune deficiency syndrome ▶ Behavioral health ▶ Cancer ▶ Cardiovascular disease ▶ Diabetes mellitus ▶ Health care utilization ▶ Healthy immigrant ▶ Lifestyle ▶ Nativism Suggested Readings Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67–82. Cristancho, S., Garces, D. M., Peters, K. E., & Mueller, B. C. (2008). Listening to rural Hispanic immigrants in the Midwest: A community-based participatory assessment of major barriers to health care access and use. Qualitative Health Research, 18, 633–646. Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1998). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center. Dallo, F. J., Borrell, L. N., & Williams, S. L. (2008). Nativity status and patient perceptions of the patient-physician encounter: Results from the Commonwealth Fund 2001 Survey on disparities in quality of health care. Medical Care, 46, 185–191. DeRose, K. P., Bahney, B. W., Lurie, N., & Escarce, J. J. (2009). Immigrants and health care access, quality, and cost. Medical Care Research and Review, 66, 355–408. Ell, K., & Castaneda, I. (1998). Health care seeking behavior. In S. Loue (Ed.), Handbook of immigrant health (pp. 125–143). New York: Plenum. Groce, N. E., & Zola, I. K. (1993). Multiculturalism, chronic illness, and disability. Pediatrics, 91, 1048–1055. Hummer, R. A., Rogers, R. G., Nam, C. B., & LeClere, F. B. (1999). Race/ethnicity, nativity, and US adult mortality. Social Science Quarterly, 80, 136–153. Scarinci, I. C., Beech, B. M., Kovach, K. W., & Bailey, T. L. (2003). An examination of sociocultural factors associated with cervical cancer screening among low-income Latina immigrants of reproductive age. Journal of Immigrant Health, 5, 119–128. Siddiqi, A., Zuberi, D., & Nguyen, Q. C. (2009). The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada. Social Science & Medicine, 69, 1452–1459. Vygotsky, L. (1986). Thought and language. Cambridge, MA: MIT Press. Zambrana, R. E., & Carter-Pokras, O. (2010). Role of acculturation research in advancing science and practice in reducing health care disparities among Latinos. American Journal of Public Health, 100, 18–23. Suggested Resources Centers for Disease Control, Immigrant and Refugee Health. Retrieved from http://www.cdc.gov/immigrantrefugeehealth/ Homeland Security, Division of Immigrant Health Services. Retrieved from http://www.inshealth.org/ Kaiser Family Foundation, Minority Health. Retrieved from http:// www.kff.org/minorityhealth/index.cfm U.S. Department of Health and Human Services, The Office of Minority Health. Retrieved from http://www.minorityhealth. hhs.gov/ Chronic Pain Chronic Pain BRANDY L. JOHNSON Rynearson, Suess, Schnurbusch & Champion, L.L.C., St. Louis, MO, USA Pain is an unpleasant feeling, which can range from mild, localized discomfort to agony and is usually a symptom of some injury, disease, or disorder. Pain can be acute or chronic. Acute pain is typically a response to an injury and lasts only until the injury is healed. Unlike acute pain, chronic pain persists past the resolution of an injury or is the result of a longstanding condition. It can be a continuous discomfort of varying degrees or a recurrent pain. Depending on the doctor, chronic pain is diagnosed after the individual experiences the pain for between 3 and 6 months. Chronic pain can stem from different sources and can be physical and/or neurological. Chronic pain can be caused by damage to, or inflammation of, the joints. Examples of this type of chronic pain are osteoarthritis and rheumatoid arthritis. Chronic pain can also result from nerve conditions. Individuals with diabetic neuropathy, failed back syndrome, or spinal cord injuries suffer from this type of chronic pain. Another common source of chronic pain is muscle conditions. Epicondylitis and temporomandibular joint disorder (TMJD) are examples of muscle conditions that can result in chronic pain. Organ damage can cause chronic visceral pain. Liver cancer, gallbladder disease, and bowel inflammation can result in visceral chronic pain. Studies have also suggested dietary deficiencies, specifically a lack of vitamin D, can result in a higher incidence of chronic pain. Such a deficiency may place immigrant groups at a greater risk for chronic pain. It has been theorized that immigrants are at a higher risk of 25-OH vitamin D deficiency due to darker skin color, low sun exposure, diet, and traditional dress. In addition to injuries, chronic pain can result from a disease. Individuals with diseases such as cancer, AIDS, or multiple sclerosis usually experience chronic pain. Repetitive use can cause painful chronic conditions like carpal tunnel syndrome or cubital tunnel syndrome. Even the aging process can result in C conditions that are painful and chronic, for example, degenerative joint disease, degenerative disc disease, and arthritis. Some people, however, suffer chronic pain that does not have an identifiable source. Psychogenic or psycho-physiological pain does not have an identifiable source or the level of the pain being experienced exceeds any obvious cause. Examples of this type of pain include fibromyalgia and reflex sympathetic dystrophy. The forms of chronic pain vary and can depend upon the cause of the pain. Symptoms can include muscle pain, cramping, spasms, soreness, and swelling. Some individuals suffer from headaches, migraines, joint pain, sciatica, and pain that can be sharp, aching, burning, and/or tingling. Chronic pain sufferers may experience weakness, easy fatigability, numbness, and a lack of energy. Chronic pain is a very complex condition, as it often involves more than the mere pain symptoms experienced by the individual. Chronic pain often affects the individual emotionally as well as physically. Problems often experienced by individuals with chronic painful conditions include depression, anxiety, fatigue, a weakened immune system, and a decreased ability to sleep. Irritability, anger, and feelings of helplessness are also common in people with chronic pain. Individuals with chronic pain tend to be more aware of their physical conditions, their pain, and often worry about their pain or health. This creates a propensity for depression, fear, anxiety, and feelings of hopelessness and helplessness. As emotional states can affect how pain is felt, stress, anxiety, and/or depression can amplify the pain. Chronic pain can affect how the individual sees himself or herself and the ability to participate in activities of daily living. It can reduce the individual’s quality of life. Sufferers of chronic pain often see their relationships with family, friends, and even coworkers change or diminish altogether. Chronic pain can be treated. However, the success of the treatment varies from individual to individual. The most common form of treatment for chronic pain is a medication regime. It is often recommended that sufferers of chronic pain take anti-inflammatory medication. Such medication can be purchased over-thecounter or in a prescription form. Aspirin and 439 C 440 C Chronic Pain acetaminophen are also common over-the-counter medications used as part of a medical regime for chronic pain. A chronic pain sufferer’s medical regime will probably also include prescription medication. The type of prescription medication varies from patient to patient and is based upon the source of the chronic pain (i.e., joint inflammation versus neuropathic pain) and the patient’s response to the medication. As with any medication, different individuals will respond to, and tolerate, the medication available in varying manners. For nerve-related pain, the individual’s medication regime may include tricyclic antidepressants, anticonvulsants, and/or antiarrhythmics. Although originally developed to treat conditions like depression and seizure, these classes of medications have proven beneficial in the treatment of nerve-related chronic pain. Opioids, like morphine and oxycodone, are often part of a medication regime. The utilization of opioids to treat chronic pain is not without controversy. Prolonged use of this type of drug can lead to side effects and secondary conditions, such as loss of benefit, hyperalgesia (a condition wherein the person has an abnormally increased sensitivity to pain), and testosterone deficiency. Fifty-one percent of all patients utilizing opioids experience at least one adverse side effect. Moreover, as the medication is a narcotic, there is a higher potential for abuse as the individual’s tolerance level increases. Tolerance to opioids tends to occur over a period of months to years. As their tolerance increases, many people will misuse the medication to achieve the desired effect. In the United States, between 1999 and 2006, opioid poisoning was noted to be the second leading cause of injury death, overall, and the leading cause of injury death in those between the ages of 35 and 54. Given the dangers associated with opioids, it has been argued they should only be included in a treatment regime if the medication is shown to both provide relief and increase the individual’s level of functioning. Many practitioners are now requiring patients to enter into an agreement or treatment contract, whereby the patient agrees to the objectives of treatment, to refrain from obtaining medication from another source, and to use the medication only as directed. In addition to a medication regime, there are other forms of therapy that should be included in the treatment regime for chronic pain. A home exercise program is highly recommended. A lot of people with chronic pain avoid additional movement and exercise due to the pain. It is generally agreed, however, that such a program helps prevent further weakness and deterioration. Regular exercise can also increase the individual’s energy level, ability to sleep, and production of natural endorphins. Hot and cold compresses are encouraged for individuals suffering from chronic joint or muscle pain. Massage is another treatment option people with chronic joint or muscle pain find beneficial. Acupuncture may ease chronic pain, especially in those suffering from headaches, low back pain, and osteoarthritis. Electrical stimulation, through a transcutaneous electrical nerve stimulation (TENS) unit or an implanted spinal cord stimulator, is an additional option for chronic pain sufferers. Finally, cognitive behavior therapy, psychological/psychiatric therapy, support groups, and stress management techniques are often utilized when treating chronic pain. Cognitive behavior therapy teaches a chronic pain sufferer skills to help cope with the pain. Stress management techniques, such as biofeedback and relaxation therapy, aid the individual in learning to influence the body’s physical response to pain. Psychological or psychiatric therapy provides the individual with a tool to help come to terms with the fact they will live with chronic pain, the changes that may occur in the ability to work, dependency, or relationships with others, and any resulting depression. Depending upon their access to health care, immigrants may be able to try some, or all, of the above therapies. However, many immigrants do not have access to doctors willing to treat chronic pain and/or are able to afford prolonged treatments. Additionally, immigrant populations often tend to have less trust in the health care system and unfamiliar treatment regimes. Instead, immigrants may turn to therapies with which they have more cultural familiarity. For example, Chinese immigrants tend to be more familiar with acupuncture and, therefore, are more willing to undergo this form of treatment. Although acupuncture has been shown to provide some relief with certain types of chronic pain, it is possible that a higher degree of relief could be obtained with a different treatment or a combination of treatments. Chronic Pain When the treatment is not effective, the individual’s problems are often compounded by secondary conditions. Depression, insomnia, fatigue, hopelessness, a loss of purpose, and a decrease in general physical functioning can all occur when an individual is not able to successfully cope with, and treat, his or her chronic pain. A downward spiral can result when chronic pain and these secondary conditions occur; each feeding off of the other. Suicide is not unheard of when the individual no longer feels he or she has any value, is a burden upon others, and cannot continue to cope with the pain. This is why treatment for chronic pain, as illustrated above, is often multimodal and should address more than the pain alone. It has been estimated that chronic pain affects one out of every ten adults. In addition to the effect it can have both physically and emotionally, chronic pain can also have an effect on an individual’s memory, concentration, or ability to problem solve (cognitive functioning). Studies suggest most people with chronic pain complain of cognitive difficulties. Specifically, problems with memory and attention were reported. The studies have suggested objective cognitive deficits in the domains of memory, attention, speed in performance of structured tasks, speed in responding to stimuli of a cognitive task, verbal ability, and mental flexibility. As chronic pain, by its very definition, can last a long time, if not a lifetime, the costs for treatment of the condition can be quite high. The cost of treatment can, and does, affect the chronic pain sufferer’s access to health care and medication. This is especially true when the chronic pain is so disabling that the individual cannot work. The effects of the cost of treatment for chronic pain and, therefore, the ability to access such care may not be as devastating in countries with some form of universal health care. However, in countries without universal health care, such as the United States, individuals with chronic pain may find themselves without access to health care and medication if they do not have access to insurance through a job or spouse, cannot afford the insurance, and do not qualify for Medicare or Medicaid. Immigrant groups, especially undocumented immigrants, often have reduced access to the health care system. The cost of the prolonged treatment for C a chronic condition also makes the care prohibitory for many immigrants. Additionally, even in countries that have a form of universal health care, language barriers and an inability to understand and navigate the health care system can further limit immigrants’ access to care for chronic pain conditions. The inability to access to health care and medication leaves an individual with few choices. Many turn to illegal drugs and/or alcohol. Self-treatment with alcohol is not a truly effective tool in pain management, as it acts as a depressant, effects the individual’s mental and physical ability to function, and wears off after a relatively short period of time. Regular misuse of alcohol leads to the development of tolerance and, with prolonged use, painful conditions such as alcoholic myopathy, alcoholic neuropathy, and liver disease. Marijuana is another drug that is turned to for selfmedication. The act of buying and possessing marijuana is a crime in many countries. Additionally, marijuana use for chronic pain has drawbacks. Smoking marijuana can affect the lungs and prolonged usage can result in dependency and memory loss. However, studies have shown that the active ingredient in marijuana, tetrahydrocannabinol (THC), can have some benefits with regard to pain control. The medical benefits of the drug have resulted in legalization in some places. In the United States, several states have enacted, or are in the process of enacting, legislation permitting use of proscribed medical marijuana. Some countries, such as Canada and Austria, have made the use of medical marijuana legal. Other countries have essentially decriminalized it when used in small amounts for medical purposes. Medical marijuana is available in both cigarettes and pill form. In summary, when the pain lasts for a prolonged period, it is classified as chronic pain. Chronic pain varies from individual to individual in both symptoms and severity. The underlying condition, therefore, must be considered when determining the best treatment approach. However, it is generally agreed the treatment regime should be multimodal and include more than pain medication. Chronic pain is not uncommon and can have life changing consequences. Consequentially, ensuring access to affordable health care is essential to providing individuals with chronic pain a positive quality of life. 441 C 442 C CIOMS Related Topics ▶ Acupuncture ▶ Chronic disease ▶ Cortisol ▶ Depression ▶ Disability ▶ Pain ▶ Stress Suggested Readings Carter, G., Gieringer, D., & Rosenthal, E. (2008). Marijuana medical handbook: Practical guide to therapeutic uses of Marijuana. Oakland: Quick American. Caudill, M., & Benson, H. (2009). Managing pain before it manages you (3rd ed.). New York: The Guilford. Couto, J., Romney, M., Leider, H., Sharma, S., & Goldfarb, N. (2009). High rates of inappropriate drug use in the chronic pain population. Population Health Management, 12(4), 185–190. Finn, R. (2004). More than half of patients with major depression have chronic pain. International Medical News Group, 34(20), 38. Kreitler, S., & Niv, D. (2007). Cognitive impairment in chronic pain. Pain Clinical Updates, International Association for the Study of Pain, 15(4), 1–4. Mechcatie, E. (2009). Guidelines Focus in using opioids for chronic pain: Screening and assessment tools available. Internal Medicine News, 42(5), 1–2. Straube, S., Moore, R. A., Derry, S., Hallier, E., McQuay, H. (2010). Vitamin D and chronic pain in immigrant and ethnic minority patients – Investigation of the relationship and comparison with native Western populations. International Journal of Endocrinology, doi:10.1155/2010/753075. Suggested Resources American Chronic Pain Association. (2011). ACPA consumer guide to pain medication & treatment. Retrieved April 29, 2011, from http://www.theacpa.org/uploads/ACPA_Consumer_Guide_2011% 20final.pdf American Chronic Pain Association. http://www.theacpa.org National Institute of Neurological Disorders and Stroke, National Institute of Health. (2010). NINDS chronic pain information page. Retrieved April 29, 2011, from http://www.ninds.nih.gov/ disorders/chronic_pain/chronic_pain.htm The Mayday Pain Projects. http://www.painandhealth.org CIOMS ▶ Council for International Organizations of Medical Sciences Citizenship TAMBRA K. CAIN Barrett, Twomey, Broom, Hughes & Hoke, LLP, Carbondale, IL, USA A citizen is a person who is a native or naturalized member of a State or nation and who owes allegiance to its government and is entitled to its protection. In some countries, individuals may also derive citizenship through their parents if the specified conditions are fulfilled. Citizenship means to have the status, rights, privileges, and duties of a citizen. Conversely, an alien is one who has citizenship in a country other than his or her residence. In addition to having the status of citizen or alien, a person may also be a national, which means a person who, while not a citizen, owes permanent allegiance to a country. Each country has its own requirements to be a citizen. The Fourteenth Amendment of the United States Constitution provides that all persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. In the United States, the Immigration and Nationality Act of 1965 (INA) provides the guidelines for who is a citizen and who may become one. Also, in 2000, Congress passed the Child Citizenship Act (CCA), which allows any child under the age of 18 who is adopted by a United States citizen and immigrates to the United States to acquire immediate citizenship. An individual is a natural citizen of the United States if the person is born in the United States; is born abroad to parents who are both United States citizens, one of whom has had a residence in the United States or one of its outlying possessions prior to the birth; is born abroad to at least one United States citizen parent who has been physically present in the United States or one of its outlying possessions for a continuous period of 1 year at any time prior to the birth of such person; or is of unknown parentage found in the United States while under the age of 5 years, until shown, prior to his attaining the age of 21 years, not to have been born in the United States. It should be noted that the specific requirements for deriving citizenship from a parent or parents have changed over time. Citizenship In most cases, a person seeking to become a United States citizen must have resided continuously within the United States for a period of at least 5 years, at least half of which must have been spent physically in the United States; have lived at least 3 months in the state in which the application for citizenship is being made; reside in the United States from the time he or she makes the application until the admission of citizenship; and be a person of good moral character, attached to the principles of the Constitution of the United States, and well disposed to the good order and happiness of the United States. An applicant must understand the English language, including an ability to read, write, and speak words in ordinary usage in the English language. He or she must have a knowledge and understanding of the fundamentals of the history and of the principles and form of government of the United States. The language and governmental principles requirement shall not apply to any person who is unable to meet these requirements because of physical or developmental disability or mental impairment, is over 50 years of age, and has been living in the United States for periods totaling at least 20 years subsequent to a lawful admission for permanent residence, or is over 55 years of age and has been living in the United States for periods totaling at least 15 years subsequent to a lawful admission for permanent residence. The right to become a naturalized citizen is not absolute. Citizenship can be refused. Any person who at any time during which the United States has been or shall be at war has deserted the military or has gone beyond the limits of the United States with the intent to avoid any draft into the military is permanently ineligible to become a citizen of the United States. No person shall become a naturalized citizen of the United States who advocates, or is a member of or affiliated with, any organization that advocates opposition to all organized government, or who is a member of the Communist Party or any other totalitarian party, or of any foreign state, or who, advocates or is a member of any organization that advocates the overthrow by force or violence or other unconstitutional means of the Government of the United States. However, any person who establishes that such membership or affiliation is or was involuntary, or occurred and was terminated prior to reaching 16 years of age, or that such C membership or affiliation is or was by operation of law, or was for purposes of obtaining employment, food rations, or other essentials of living and where necessary for such purposes may be allowed naturalization. Citizenship may also be lost. A United States citizen, whether by birth or naturalization, may lose his or her citizenship by obtaining naturalization in a foreign country after having reached 18 years of age, by making a formal declaration of allegiance to a foreign country, by serving in the armed forces of a foreign country if such armed forces are engaged in hostilities against the United States, by making a formal renunciation of nationality, by committing any act of treason against the United States, or by attempting by force to overthrow or bearing arms against the United States. In 2008, 1,046,539 people became naturalized United States citizens. Of the people naturalized in 2008, 1,032,281 were civilians and 4,342 were military personnel; 121,283 petitions were denied. This is a marked difference from 1998, when 461,169 people became naturalized citizens, and 137,395 petitions were denied. A person’s citizenship status may impact the quality of life in many ways. For example, a person who is not a United States citizen may be limited in the types of employment available to him or her, certain governmental benefits, such as financial assistance and medical assistance, may not be available to a noncitizen; and if the noncitizen is in the United States illegally, he or she may be even more limited in access to employment or healthcare for fear of discovery and deportation. Related Topics ▶ Immigration processes and health in the U.S.: A brief history ▶ Public health insurance Suggested Resources Department of Homeland Security. Preserving our freedoms, protecting America. Web. Retrieved March 12, 2010, from http://www.dhs.gov/xlibrary/assets/statistics/yearbook/2008/ois_ yb_2008.pdf Immigration and Nationality Act of 1965, 8USCS1101, et seq. Legal Information Institute (LII). U.S. Code: Home. LII | Legal Information Institute at Cornell Law School. Web. Retrieved March 12, 2010, from http://uscode.law.cornell.edu/uscode 443 C 444 C Civil Rights Act of 1964 (U.S.) U.S. Citizenship and Immigration Services. Citizenship in the United States. USCIS home page. Retrieved March 12, 2010, from http:// www.uscis.gov/files/nativedocuments/Citizenship_2004.pdf United States Constitution, 14th Amendment Civil Rights Act of 1964 (U.S.) BETTINA RAUSA Salk Institute for Biological Studies, La Jolla, CA, USA On July 2, 1964, the US Congress passed landmark legislation called the Civil Rights Act. Signed by President Lyndon Johnson, the law made racial segregation and discrimination illegal in the USA. The Civil Rights Act had five major components: (1) it barred unequal application of voter registration requirements; (2) it outlawed discrimination in hotels, motels, restaurants, theaters, and all public places; (3) it encouraged desegregation of public schools and granted the US Attorney General the authority to file suits to force desegregation; (4) it authorized the withdrawal of federal funds from programs that practiced discrimination; and (5) it made discrimination in employment illegal for any business with more than 25 employees and created the Equal Employment Opportunities Commission, a body set up to review employment discrimination complaints. The Civil Rights Act of 1964 was driven by a desire to improve the quality of life for African Americans and other minority groups in the USA. There was a significant buildup of events that preceded the passage of civil rights. Two of the earliest occurrences included large numbers of Black Americans moving into northern cities to live and work and Black soldiers serving in World War II. Prior to these two events, people in many parts of the USA, excluding the South where Black Americans predominantly lived, were mostly unaware of the issues that Black Americans faced and the important contributions they made during the war. In addition, even as early as 1945, legislation designed to enforce equality helped lay the groundwork for the eventual passage of civil rights legislation. For example, there were presidential orders that ended discrimination in the military and in federal employment, including work done under government contracts. In 1954, the Supreme Court made a critical decision that had enormous effects on the civil rights movement: it struck down legal support for school racial segregation in what was coined “separate but equal” in the case of Brown v. Board of Education in Topeka, Kansas. Brown v. Board of Education was born out of a demand for better conditions at schools for African American youth. Black children were segregated from White children in the education system: they were not allowed to attend schools near their homes and instead were bused to other schools. Often, those schools were inferior both structurally and in the quality of education. For example, teachers of schools for Black students were severely underpaid compared to other teachers, and teaching resources and materials were far fewer. However, as important as this case was in setting the stage for strong federal support for civil rights, Brown v. Board of Education did not address the treatment of African Americans. In the early 1960s, Congress and President John F. Kennedy’s administration also made advances that added to the trajectory that eventually led to the passage of civil rights legislation. In 1961 and 1962, presidential executive action was taken to ensure minority rights in housing, transportation, education, and employment. Social conditions during this period were also very influential. There were many protests and marches in cities and towns across the nation that brought attention to the concerns of and for African Americans on a number of social inequalities. These included how segregation prevented them from using public facilities on an equal basis with White people, and how they were restricted from using public transportation, parks, and restrooms, and their limited educational opportunities all based on years of systemic and accepted racism. Along with the protests and marches, boycotts and sit-ins were also carried out, many of which were organized by African American community and religious leaders and others. Dr. Martin Luther King, Jr., who became the most prominent Black leader of the Civil Rights Movement, led several boycotts and sit-ins. He lent much legitimacy and increased awareness and visibility of the civil rights movement across the nation. Although Dr. King and many other organizers and leaders insisted on peaceful and Civil War nonviolent demonstrations, many acts of violence occurred, including riots, often spurred by angry counterprotestors that required using federal troops to restore calm and order. The nation’s media outlets focused much attention on the social unrest and events, bringing scenes which often included beatings, protestors being sprayed with fire hoses and even killed, into the homes of Americans everywhere. It soon became undeniable that the social conditions of this period required government intervention. Congress and other elected officials could no longer ignore the social unrest. Churches everywhere and elected officials also became vocal on the issue of civil rights. National polls reflecting the positive attitudes of Americans toward racial integration had risen to 72% in 1963 representing a 30% increase over the last 20 years. President Kennedy began to come out strongly in favor of legislative action by Congress to address racial segregation in the USA. The Justice Department was tasked with the responsibility of crafting what would eventually become the Civil Rights Act. It was critical that this work was conducted in a bipartisan fashion, considering the concerns of both Democrats and Republicans, in an attempt to avoid filibusters or legislative defeats. Even though the polls showed that the vast majority of Americans favored ending racial segregation, not everyone was in favor of these changes. On June 19, 1963, a bill was submitted to Congress for a vote. The House of Representatives debated the bill, and nearly 100 amendments that attempted to weaken the bill were rejected. The House eventually passed the bill after 70 days of public hearings and 275 public testimonies. The bill then moved to the Senate where it was debated again at length under threats of filibusters by opposing senators, but it eventually passed with 289 votes and was signed by President Johnson on July 2, 1964. In the following year, the US Congress also passed the Immigration and Nationality Amendments Act of 1965. Instead of using nationality and racial criteria to admit immigrations, this new legislation implemented a system based primarily on family reunification. The Civil Rights Act was a fundamental tool for the new immigration legislative and policy changes because for many, the new changes in immigration laws were seen as an extension of the civil rights movement. Foreign policy concerns were also considered as the USA C 445 preferred to be seen by other countries as a place where equality and respect for all people was the standard. Related Topics ▶ Discrimination ▶ Racism Suggested Resources Braziel, J. E. (2000). History of migration and immigration laws in the United States. University of Cincinnati. Department of English and Comparative Literature. Retrieved February 23, 2010, from http://www.umass.edu/complit/aclanet/USMigrat.html Brownvboard.org. Brown v. Board of Education about the case. Retrieved February 1, 2010, from http://brownvboard.org/ content/background-overview-summary History.com. U.S. immigration since 1965. Retrieved February 1, 2010, from http://www.history.com/topics/us-immigrationsince-1965 The Dirksen Congressional Center. CongressLink. Major features of the Civil Rights Act of 1964. Retrieved February 1, 2010, http://www.congresslink.org/print_basics_histmats_ from civilrights64text.htm U.S. National Archives & Records Administration. Civil Rights Act (1964). Retrieved February 1, 2010, from http://www. ourdocuments.gov/doc.php?doc=97 Civil Surgeon ▶ Medical examination (for immigration) Civil War RYAN C. W. HALL Department of Psychiatry, University of South Florida, Tampa, FL, USA At its simplest level, a civil war is defined as a conflict between opposing groups of citizens from the same country who are fighting over who has the legitimate right to govern. This definition does not necessarily take into account many of the complexities involved in modern civil wars, which may involve several groups located in the same geographic region of a country that C 446 C Civil War have never seen themselves as sharing a common identity. Many of the most recent civil wars have begun following the collapse of a former European colonial system of government (e.g., Angola), the fighting produced by Cold War proxy conflict (Vietnam), and/or the end of the Cold War (e.g., Bosnia). The colonial system and the Cold War created strong central governments that maintained order, but at times arbitrarily nationalized various ethnic groups that oppressed other groups within the national boundaries (e.g., Rwanda with Tutsi and Hutu, Yugoslavia with Bosnians and Serbs). These “civil wars” occur in “nations” where the goal of the fighting is not simply to maintain political power (e.g., Khmer Rouge in the Cambodian civil war), but also to facilitate the ethnic cleansing of the region based on tribal identification (e.g., Rwanda), religious divisions (e.g., Bosnia), or longstanding historical grievances (e.g., Bosnia). Narcoterrorism has also produced civil wars in Latin America (e.g., Mexico, Colombia), as have radical differences between right- and left-wing forces attempting to govern (e.g., Chile, Argentina, Peru, Nicaragua, and Honduras). Civil wars are often brutal, resulting in mass causalities, as seen with “the killing fields” of Cambodia, where over one million people were slaughtered, and the genocide in Rwanda, where an estimated 800,000 were killed. Such brutality leads to the commission of systemized war crimes intended to disrupt the cultural and personal identity of groups of people and to shatter their sense of self-worth and belonging. In Rwanda, there was the systematic rape of women and girls and the slaughter of males in an attempt to ethnically cleanse the Tutsi from the region. In addition, torture, beatings, and mental coercion are used to intimidate the remaining local populace and maintain power and control over their territory. Immigrants from civil wars are often reluctant to discuss the torture that occurred because of their concern that such reports might affect their immigration status or produce some form of retaliation from their “home” country or countrymen. Immigrants from civil wars present unique and complex challenges to the countries that provide them with asylum and naturalization. Depending on the nature of the conflict the immigrant is coming from, they often have few resources, little family/social support, and less education than traditional immigrants. Immigrants from civil wars also typically have greater need for health care services. Many have physical/traumatic wounds (e.g., amputees) and suffer from the long-term effects of malnutrition, infectious diseases (e.g., tuberculosis, cholera, leishmaniasis), and long-term psychiatric conditions (e.g., major depression, anxiety disorders, organic mental states secondary to head injury, and torture). Many studies indicate that the psychological effects caused by a civil war can persist for decades. The resulting effects produce long-term economic and social service problems for the host countries. Civil war immigrants held in refugee camps prior to immigrating are at high risk for experiencing revictimization while in the camps, which further increases their likelihood of physical or psychiatric complications. Refugee camps are often crowded, disorganized, and may have serious problems maintaining adequate levels of sanitation and security. Individuals in refugee camps are often the victims of violent crime and sexual assault. The “legal limbo” that most camp refugees face adds additional stress on an already vulnerable individual. Fear of death, displacement, physical violence, rape, isolation, and return to the parent country all breed fear, anxiety, mistrust, demoralization, and marked feelings of uncertainty and helplessness in refugees, which can further compound or produce the most commonly experienced mental health problems seen in civil war immigrants, chronic major depression and posttraumatic stress disorder. Other factors associated with higher rates of mental illness in civil war immigrants include: poor fluency in the language of the new country in which they settle; being single (e.g., widowed, separated, never married), unemployed, “retired,” physically disabled/injured; and lacking financial resources (e.g., poverty). Older immigrants are more likely to experience these problems than younger individuals and also have more difficulty resolving them. The elderly have greater difficulty acculturating to their new country (e.g., learning the language, customs, and skills) and obtaining work or work at levels equivalent to that which they had before immigrating. They lose more during the process of immigration (e.g., position in the community, finances) and have more physical ailments and Cocaine infirmities. All of these factors make their adjustment to their new society more difficult. Providing medical and psychiatric care to immigrants who speak a different language is difficult. This is especially true for immigrants escaping a civil war who are often mistrustful of both foreigners, as well as their own countrymen. Trained translators are needed, but are often in short supply due to often large and unexpected influxes of immigrants and/or refugees. In general, it is best not to rely on family members to act as translators because the patient may be unwilling to discuss important concerns, painful recollections, failings, or symptoms to save face in front of their family or spare the family from learning about certain painful or humiliating information. Also, the family members serving as translators may not directly translate the patient’s comments out of a need to protect the patient and/or family from embarrassment, retaliation, or possible deportation. Untrained third-party translators may understand both languages, but may not recognize the importance of repeating questions or responses verbatim, instead of summarizing. They may lack an understanding of medical terminology and may converse with the patient, inserting their own thoughts and opinions, rather than just translating what the doctor and patient are discussing. Refugees from civil war may fear revealing information about themselves or making errors that could result in their return to their homeland and further prosecution, torture, or death. The fact that they fled and claimed special refugee status could in and of itself result in their imprisonment and/or death in some cases. Related Topics ▶ Acculturative stress ▶ Asylum ▶ Behavioral health ▶ Convention Against Torture ▶ Ethnic cleansing ▶ Refugee ▶ Refugee camp ▶ Telephone interpretation services ▶ Torture ▶ War-affected children C 447 Suggested Readings Hall, R. C. W., Hall, R. C. W., & Chapman, M. J. (2006). Medical and psychiatric casualties caused by conventional and radiological (dirty) bombs. General Hospital Psychiatry, 28, 242–248. Marshall, G., Schell, T., Elliott, M., Berthold, S., & Chun, C. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association, 294, 571–579. Sabin, M., Lopes-Cardozo, B., Nackerud, L., Kiaser, R., & Varese, L. (2003). Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict. Journal of the American Medical Association, 290, 635–642. Schwarz-Langer, G., Deighton, R., Jerg-Bretzke, L., Weisker, I., & Traue, H. (2006). Psychiatric treatment for extremely traumatized civil war refugees from former Yugoslavia: Possibilities and limitations of integrating psychotherapy and medication. Torture, 16, 69–80. Shanks, L., & Schull, M. (2000). Rape in war: the humanitarian response. Canadian Medical Association Journal, 163, 1152–1156. Suggested Resources Bellevue/New York University Program for Survivors of Torture: http://www.survivorsoftorture.org/resources/furtherreading. Accessed January 23, 2010. Department of State: http://www.state.gov/. Accessed January 23, 2010. Clinical Breast Examination ▶ Breast cancer ▶ Breast cancer screening ▶ Breast self-examination ▶ Mammography Cocaine BEATRICE GABRIELA IOAN Department of Legal Medicine, Medical Deontology and Bioethics, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania Cocaine is a psychoactive drug, highly addictive, and one of the most dangerous and widely consumed drugs. Cocaine is an alkaloid extracted from the leaves of Erythroxylon coca bush cultivated in South American countries. According to United Nations Office on C 448 C Cocaine Drugs and Crime (UNODC), in 2008, the production of pure cocaine hydrochloride was of 845 tons, of which 51% originated in Colombia, 36% in Peru, and 13% in Bolivia. Currently, organized criminal groups in Colombia control the worldwide distribution of cocaine. Cocaine may also be obtained by chemical synthesis, but this method is more expensive and less common. Most of the illicit trafficking of cocaine in the USA is held by the border with Mexico. On this route, Colombian traffickers use Mexican drug trafficking organizations to bring cocaine into the USA, to the South Texas region. However, in recent years, the quantity of cocaine seized on this route decreased sharply (from 22.656 kg in 2007 to 17,085 kg in 2009) as result of reduced cocaine production in Colombia, the joint efforts of the US and Mexican official agencies to reduce illegal cocaine trafficking, and diversion of the illegal cocaine trafficking to Europe. As a consequence, the availability of cocaine on the illicit US market decreased, and Europe became the most rapidly growing cocaine market. Currently, cocaine is distributed in the US illicit drug market mainly by Dominican, Colombian, and Mexican drug organizations. Cocaine is illegally trafficked using various vehicles such as trucks, aircraft, vessels, and also by body packers. The body packer strategy consists of ingestion or introduction of small packages of drugs into the body in the vaginal or anal cavity, with the aim of transporting them into a foreign country, cocaine being the drug most commonly transported in this way. In recent years, trafficking cocaine by body packing method has become a common problem in European airports. People who take this route to transport drugs may be the country’s citizens, tourists, legal or illegal immigrants. The main danger faced by the body packers is death by overdose caused by breaking of the packages or drug diffusion due to the low quality of the cover of the pack. The use of cocaine for its psychoactive properties has been documented for about 5,000 years, coca leaf chewing being a millennial habit among South American Indians and continued due to its stimulant, anorexic, and euphoric effects. In 1859, C. Niemann extracted the cocaine, as pure substance, from coca leaves. In 1878, Bentley recommended the use of cocaine as a substitute in the treatment of morphine addiction, opening the way for a more dangerous addiction. In his paper Uber Coc, published in 1884, a botanical monograph containing data on the origin, stimulant and antidepressant properties of cocaine, Sigmund Freud recommended it for the treatment of psychiatric disorders such as: hypochondria, hysteria, and melancholia. In 1884, Karl Koller, an Austrian physician, demonstrated the local anesthetic effects of cocaine, which contributed to its widespread use in medical practice. Following the alarming increase in cocaine use in the USA (a fivefold increase between 1890 and 1903), largely based on nonmedical consumption, it was classified in 1914 as a narcotic drug and included in the prohibited substances list. Currently, in the USA, cocaine is included in the Controlled Substances Act Schedule II (DEA. Title 21, Section 812.) due to its addictive potential and the possibility of its use in medicine as a highly effective topical anesthetic. Cocaine was also included in Schedule I of the Single Convention on Narcotic Drugs, issued by the United Nations in 1961. According to the National Survey on Drug Use and Health conducted in 2008 in the USA, 5.8 million people aged over 12 years have used cocaine at least once in the past year and 1.1 million people over 12 years used crack at least once in the past year. Official statistics stress that cocaine and crack cocaine consumption in the USA has stabilized in recent years, albeit at high levels. In the European Union countries, there has been an increase in the cocaine consumption over the last 10 years, cocaine being the most used illicit drug after cannabis. About 13 million Europeans aged 15–64 years have consumed cocaine at least once during their lifetimes. The highest prevalence of cocaine consumption during the last year was recorded in the age group 15–34 years (7.5 million). An increased prevalence of cocaine use in the EU is recorded in Spain, United Kingdom, Denmark, Italy, and Ireland. With respect to immigrant populations, research shows that US Hispanics have a high rate of deaths caused by the consumption of drugs, especially marijuana and cocaine, and the Puerto Ricans show the Cocaine most prevalent consumption rates. US Hispanic teens have higher cocaine consumption rates than White and African American teens (5.7% versus 3.8% and 2.2%). Cocaine is a white powder with a specific odor. It can be taken by snorting, smoking, subcutaneous or intravenous injection. Crack cocaine is the freebase cocaine which is taken only by smoking. The entry of crack cocaine into the US market led to lowered prices and increased the availability of the drug on the market, leading to expansion of cocaine consumption from high and middle classes of society to minorities in cities. In the short-term, cocaine has psychoactive properties producing: euphoria, increased self-esteem, improved physical and mental performance, increased aggressivity, increased body temperature, blood pressure, and heart rate. Death may occur due to overdose by central respiratory depression or severe cardiac arrhythmia, or suddenly, during the first administration of the drug (“cocaine shock”) due to the paralysis of the respiratory center in individuals with particular sensitivity. Cocaine addiction, mostly at a psychological level, occurs after a few weeks or months of repeated intake of doses. At this stage, the cocaine addict suffers from hallucinations, perception and thinking errors, and behavioral disorders. After 5–10 years of cocaine use, the drug addict reaches a state of physical and mental deterioration, abandons her/his social and professional life, and may commit various felonies, such theft or violence, in order to get money for buying drugs. Cocaine or crack use during pregnancy, often associated with a disorganized lifestyle and adverse environmental conditions (disharmonious parental relationship, stress, violence, poverty) may affect fetal development in variable degrees. Newborns may show: prematurity, low birth weight, small head perimeter, and various neurobehavioral deficits (so called “crack babies”). Cocaine-using pregnant women have higher rates of miscarriage and placental rupture at birth. Children exposed to cocaine in utero are not a homogeneous group in terms of their short- and long-term physical and behavioral development. The environment in which the children grow up can affect their long-term development, the drug-induced biological vulnerability, making them more vulnerable to C adverse environmental conditions. Poverty plays an important role in this relationship, and studies show that many children exposed to drugs in utero are from poor class of society. In some U.S. states, drug use during pregnancy is equivalent to child neglect or child abuse, which can lead to loss of custody. Immigrant women often face financial problems, especially at the beginning of their stay in the host country. This limits their access to prenatal care and to treatment for addiction and may determine, along with cocaine abuse, damage to fetus. From a social perspective, their access to health resources is limited due to stigma associated with drug use in pregnancy. Illegal immigrant status, fear of expulsion from the host country, and the possibility of allegations of neglect or child abuse decrease the chances that pregnant immigrant women who use cocaine or crack cocaine can access the health care system and admit their drug addiction. Related Topics ▶ Addiction and substance abuse ▶ Drug abuse ▶ Drug use ▶ Substance use Suggested Readings Flavin, J. (2002). A glass half full? Harm reduction among pregnant women who use cocaine. Journal of Drug Issues, 32(3), 973–998. Fosados, R., McClain, A., Ritt-Olson, A., Sussman, S., Soto, D., Baezconde-Garbanati, L., & Unger, J. B. (2007). The influence of acculturation on drug and alcohol use in a sample of adolescents. Addictive Behaviors, 32(12), 2990–3004. Kaplan, B. J., & Sadack, V. A. (1998). Kaplan & Sadock’s synopsis of psychiatry behavioral sciences/clinical psychiatry (10th ed.). Baltimore: Lippincott, Williams, & Wilkins. Lester, B. M., & Tronick, E. Z. (2006). The effects of prenatal cocaine exposure and child outcome. Infant Mental Health Journal, 15(2), 107–120. Loue, S. (2003). Diversity issues in substance abuse treatment and research. New York: Kluwer/Plenum. Suggested Resources European Monitoring Centre for Drugs and Drug Addiction. http:// www.emcdda.europa.eu/ National Survey on Drug Use and Health. (2009). Retrieved August 28, 2010, from http://www.samhsa.gov/ The U.S. Immigration and Customs Enforcement. http://www. ice.gov 449 C 450 C Cognitive Testing Cognitive Testing NATASHA T. J. RAMING The Institute for Palliative Medicine, San Diego Hospice, San Diego, CA, USA Cognitive tests are used to assess cognition: the mental act of perceiving and manipulating information. Generally, cognitive tests measure two specific types of mental abilities, crystallized and fluid. Tests of crystallized abilities assess domains such as verbal knowledge, semantic memory, higher reasoning skills that involve conceptual relatedness, episodic memory, visual–spatial manipulation, mathematical ability, and executive function skills such as judgment and problem solving. Fluid abilities allow us to attend to, perceive, process, store, and retrieve information, and they are the means by which we collect, organize, and accumulate knowledge, the basis of crystallized abilities. Cognitive Assessment In the clinical setting, cognitive test data are used to assist in the diagnosis of conditions resulting from developmental abnormalities, traumatic brain injury, stroke, mild cognitive impairment, vascular or frontotemporal dementia; and neurodegenerative processes such as Alzheimer’s, Parkinson’s, or Huntington disease. In such cases, a cognitive assessment, consisting of multiple tests that measure mental processes associated with one or more specific domains, is conducted by a psychometrist, an individual trained in the administration and scoring of cognitive measurement tools. This assessment commonly takes place in a one-on-one interview, involving stimulus materials, paper and pencil tests, or a computerized presentation device. Materials are presented in a standardized manner and information about the participant’s performance and reaction time is recorded. Following the interview, the results are analyzed and interpreted to determine the severity of impairment associated with a potential diagnosis and whether specific treatment or therapy is necessary. Historically the development, use, and validation of cognitive tests focused on White, non-Hispanic, formally educated populations in the United States. Repeated testing and systematic study of cognitive measures have occurred more recently in African American and Hispanic groups. Normative data compiled from these studies allow for the development of statistical methods that are used to make adjustments to cognitive test data based upon age, education level, gender, and race. The use of normative data is the primary method for interpreting an individual’s cognitive test scores and statistical applications based on such data are used to make predictive interpretations of one’s cognitive abilities. Diagnostic Use and Interpretation Although cognitive abilities are considered to be universal and fairly uniform across all races, the development of such skills has not only a genetic basis, but is contingent upon environmental, social, and cultural influences. Systematic study of cognitive measurement and interpretation of data in highly diverse populations has not been prolific. Consequently, there are not sufficient normative data available for most immigrant populations, and interpretation of test results using existing normative data may not be appropriate because it does not account for the linguistic, educational, cultural, and socioeconomic differences between groups. Therefore, the diagnostic use and clinical interpretation of cognitive measures in this population can result in predictive validity errors. For example, cognitive test data are interpreted as a false positive, resulting in a neurologically intact individual being misdiagnosed as cognitively impaired or in the opposite case, a false negative indicating that an impaired person has no deficits. Fairness and Bias Ethically, the intention of cognitive assessment is to make a fair and accurate measurement of cognitive ability. In this context, fairness equates to the absence of bias, ensures equal treatment throughout the testing procedure, and allows for an opportunity to learn the material being tested and to receive feedback about test performance. Bias is the result of systematic error inherent in the design and administration of cognitive measurement tools or in the interpretation of test results. Two specific types of bias that may be inherent in the test itself are referred to as “construct” and Cognitive Testing “differential item functioning” bias. Construct bias may result when a test is designed to measure a cognitive construct, or domain, that has specific cultural relevance and differs between groups. Consequently, the measurement tool cannot validly measure this domain without demonstrating between group differences. This is because individual test questions are highly sensitive and do not capture important aspects of the domain as they translate to each population, or this type of bias occurs when the question is too generally worded, the domain is measured in such a broad way that the test captures extraneous or irrelevant information. Differential item functioning bias occurs within the individual test items themselves, resulting from poorly translated words or phrases, ambiguous meaning, and the inclusion of cultural connotations. The validity of a cognitive test is questionable when more than one population repeatedly produces scores that do not have the same meaning across groups. In other words, the cognitive test’s ability to make fair, accurate, and valid measurement is lost in translation. Instrument and administration bias are also threats to the fairness principle known as equitable treatment and stem from how the test instrument captures information (for example, use of pen and paper versus a computerized tool) and the environment in which it is administered (for example, not reasonably accommodating for a disability). Bias can arise when interaction and communication between the psychometrist and the individual being tested impede the administration of the measurement tool. Due to the number of biases that arise from systematic error inherent in the design and administration of cognitive tests, it is important to take into consideration an individual’s educational experience, language proficiency, and socioeconomic context when making interpretations and predictions about the results of cognitive assessment in diverse minority groups, including immigrant populations. Cognitive Testing and Social Factors Language Age at the time of immigration plays a critical role in language acquisition; upon immigration, children are likely to receive exposure to the new language by way of C education and social interactions, which facilitate engagement in the nonnative language. Early learners of a second language are likely to develop well-versed bilingual competency when they regularly engage in their native language with family and friends or act as translators for other native language speakers. On the opposite end of the bilingual spectrum, older immigrants may have less exposure to the majority language depending upon their age, occupation, and social-cultural role in the family or community. To varying degrees, these factors limit exposure and engagement in the majority language; this situation may be further compounded by reliance upon translation and living in ethnic enclaves. In cognitive testing language, comprehension and fluency are important variables to consider, not only in regard to the fairness of the cognitive test and differential item functioning bias, but the difference between the cognitive activity that is required of bilingual versus monolingual individuals. Bilingual individuals are required to suppress or control engagement in one language when they are being tested in another. This behavior requires cognitive control, and the amount of effort required may vary, depending on how efficiently the appropriate information is processed, accessed, and retrieved by the brain and whether or not there is interference from the suppressed language. On the other hand, the cognitive practice that bilingual persons engage in is also believed to be a benefit to various aspects of cognition such as semantic memory and executive function. Socioeconomic Status Socioeconomic status (SES) is not always considered when interpreting cognitive test scores in the clinical setting. Immigrant populations with low SES may not have access to appropriate education, be subjected to financial stress, unable to find substantial employment, or have limited access to health care. Low SES immigrants may experience heightened financial, psychosocial, and acculturative stress, and are at increased danger for the development of diseases that result in cognitive impairment. Some studies indicate that controlling for SES may normalize cognitive data sufficiently and perhaps be more important than controlling for race, thus reducing predictive validity errors in cognitive measurement tools. 451 C 452 C Collectivism Current Directions in Cognitive Testing Research and Development Currently, there is a cross-cultural focus on the development and use of specific cognitive tools, but research that specializes in cognitive assessment of immigrants and immigrant subgroups is not abundant. In order to validate specific tools in this unique population further research is needed, via one-on-one interviews or by working with focus groups, to learn more about how group members understand cognitive test questions and whether or not the information elicited by the test question is an accurate and valid assessment of the mental processes and domains being evaluated. Furthermore, investigation in this area should take into account differences in cognitive test performance related to sex, age, and race, as well as environmental factors that are highly influential in immigrant populations, such as regional migration patterns, familial migration history, educational experience, language proficiency, and socioeconomic status. Such research would allow for the tabulation of population-specific normative data and allow for greater accuracy when comparing an individual’s cognitive performance to that of their peers, thus ensuring a more accurate assessment of one’s cognitive abilities. Suggested Readings Cronbach, L. J., & Meehl, P. E. (1955). Construct validity in psychological tests. Psychological Bulletin, 52, 281–302. Retrieved from http://psychclassics.yorku.ca/Cronbach/construct.htm. Accessed March 15, 2010. Gasuoine, P. D. (2009). Race-norming of neuropsychological tests. Neuropsychology Review, 19, 250–262. doi:10.1007/s11065-0099090-5. Glymour, M. M., & Manly, J. J. (2008). Lifecourse social conditions and racial and ethnic patterns of cognitive aging. Neuropsychology Review, 18, 223–254. doi:10.1007/s11065-008-9064-z. Pedraza, O., & Mungas, D. (2008). Measurement in cross-cultural neuropsychology. Neuropsychology Review, 18, 184–193. doi:10.1007/s11065-008-9067-9. Perez-Acre, P. (1999). The influence of culture on cognition. Archives of Clinical Neuropsychology, 14, 581–592. doi:10.1016/S08876177(99)00007-4DOI:dx.doi.org. Rivera, M. M., Arentoft, A., Kubo, G. K., D’Aquila, E., Scheiner, D., Pizzirusso, M., et al. (2008). Neuropsychological, cognitive, and theoretical considerations for evaluation of bilingual individuals. Neuropsychology Review, 18, 255–268. doi:10.1007/s11065-0089069-7. Suggested Resources National Institutes of Health. (2010). Cognitive and emotional health project: The healthy brain. http://trans.nih.gov/cehp/HBPcog1. htm. Accessed March 15, 2010. UNESCAP. (2010). What is cognitive testing? How is it useful? www. unescap.org/stat/.../pre.../background-note-on-cognitive-testing. pdf http://www.unescap.org/. Accessed March 15, 2010. Collectivism Related Topics ▶ Acculturation ▶ Behavioral health ▶ Cultural background ▶ Dementia ▶ Depression ▶ Education ▶ English as a Second Language ▶ Ethnic minority group ▶ Ethnicity ▶ First generation immigrants ▶ Intelligence testing ▶ Intergenerational differences ▶ Language acculturation ▶ Linguistic minority community ▶ Low literacy level ▶ Poverty JULIA LECHUGA Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin, Milwaukee, WI, USA Collectivism is a learned culture-derived value and psychological alterable characteristic that is often contrasted with the value individualism. The term, which refers to the need to fit-in, is also known as interdependence, and contrasts with the need to standout also known as independence. Researchers have developed the independence-interdependence psychological measure to understand the influence that culture-level socialization practices have on an individual’s endorsement of independence-interdependence. Colombia Cross-cultural psychological research, conducted for over 3 decades, suggests that individuals born and raised in China, Greece, and Mexico, on average, tend to score higher on measures of interdependence when compared to individuals of Caucasian descent from Germany, Great Britain, and the United States. It is posited that on average, China, Greece, and Mexico engender individuals who will value belongingness and in-group harmony. On the other hand, it is posited that, on average, Germany, Great Britain, and the United States engender individuals who value competition, agency, and a strive for achievement. Research also suggests that individuals born and raised in a collectivist culture can reject the value of interdependence in favor of independence, vice versa, or may favor an integration of both values. As a result of the blurring of cultural boundaries brought about by innovations in communications and technology, societies are becoming increasingly culturally and linguistically heterogeneous. Consequently, researchers are increasingly interested in measuring immigrants’ health. However, a more complete understanding of immigrant health issues has been hindered by the failure to recognize that culture can be operationalized and measured beyond broad indicators such as ethnicity or race. Typically, ethnic groups are perceived as homogeneous and static regarding values and beliefs. This preconceived “homogenization” has resulted in the inadequate exploration of within and between ethnic group differences regarding the endorsement of cultural values. Thus, it is important to assess the degree to which an individual endorses interdependence and the way other factors such as acculturation, gender, and socioeconomic status influence such endorsements. Even if an individual immigrates into an individualist culture from a collectivist culture, other factors will influence the degree to which the immigrant retains or sheds values derived from the culture of origin. Health research aimed at improving immigrants’ health can explore the role that the endorsement of interdependence plays in the conceptualization and assessment of health-related constructs. For example, an individual’s belief in his/her own ability to adopt a healthy behavior, also known as self-efficacy, is perceived as influenced solely by psychological aspects, which are internal to the individual. However, a recent study indicates that the construct of self- C efficacy can be expanded to include aspects external to the individual such as the amount of social capital available. Researchers have found that the availability of social capital influences the self-efficacy of individuals who value interdependence. Related Topics ▶ Acculturation ▶ Cultural background ▶ Ethnicity ▶ Gender ▶ Individualism ▶ Poverty ▶ Social capital Suggested Readings Burke, N. J., Bird, J. A., Clark, M. A., Rakowski, W., Guerra, C., et al. (2009). Social and cultural meanings of self-efficacy. Health Education & Behavior, 36, 111–129. Hofstede, G. (1980). Culture’s consequences: International differences in work-related values. Beverly Hills: Sage. Kim, U., Triandis, H. C., Kagitcibasi, C., Choi, S.-C., & Yoon, G. (Eds.). (1994). Individualism and collectivism: Theory, methods, and applications (Vol. 18). California: Sage. Kitayama, S., & Cohen, D. (2007). Handbook of cultural psychology. New York: Guilford. Oishi, S., Schimmack, U., Diener, E., & Suh, E. M. (1998). The measurement of values and individualism-collectivism. Personality and Social Psychology Bulletin, 24, 1177–1189. Triandis, H. C. (1996). The psychological measurement of cultural syndromes. The American Psychologist, 51, 407–415. Triandis, H. C., & Singelis, T. M. (1998). Training to recognize individual differences in collectivism and individualism within culture. International Journal of Intercultural Relations, 22, 35–47. Colombia LUIS F. RAMIREZ Quality Outcomes Training, Brecksville, OH, USA Background Colombia is located in the upper corner of South America, where it is bordered by Panama on the northwest, Venezuela and Brazil on the east, and Peru and Ecuador on the southwest. Colombia is considered by many to be one of the most beautiful countries in South 453 C 454 C Colombia America due to the magnificent combination of mountains, valleys, and the coasts of two oceans. The name of the country, Colombia, comes from Cristóbal Colón (English: Christopher Columbus), acclaimed as the discoverer of America; it was adopted by Francisco Miranda to all the territories under Spanish rule. In 1819, the Viceroyalty of New Granada, consisting of Colombia, Panama, Venezuela, and Ecuador, became known as the Republic of Colombia. After a series of political and demographic changes, this region became known in 1886 as the Republic of Colombia, the name which is retained to today. The capital city of Bogota has more than seven million inhabitants. Cali and Medellı́n each claim two million residents. Barranquilla has a population of more than one million and Cartagena has close to a million residents. There are almost 46 million individuals in an area of 401.042 square miles. History and Politics Little is known about the history of the Indian cultures living in the area before Columbus. Two main cultures were in the area: the Tayronas in the Caribbean Region and the Muiscas in the highlands near Bogota, who were considered to be as advanced as the Incas in Peru. Many of the Indian tribes were decimated by warfare and illness, reducing the indigenous population a great deal and causing the increase of the slave trade from Africa by the beginning of the sixteenth century. The Colombian territory was explored by Rodrigo de Bastidas from the north, Vasco Nuñez de Balboa from the northeast, and Gonzalo Jimenez de Quesada in the center of the country, where he founded the city of Bogotá. Almost from the beginning several rebel movements were commenced against the Spanish domination but they were not successful until 1804 when St. Domingue (present-day Haiti) won its independence. In Colombia, a movement initiated by Antonio Nariño led the opposition against the Spanish government. This was followed by the independence of Cartagena in 1811. Following the rebellion headed by Simón Bolivar, independence from Spain was declared in 1819 with the creation of the Republic of Colombia; this was organized as a union of Ecuador, Venezuela, and Colombia (which included Panamá). This union did not last long and Venezuela became independent in 1829, with Ecuador doing the same 1 year later. In 1903, the Department of Panamá, influenced by the United States, became independent. After a period of political stability, Colombia was devastated by an incredible conflict known as “La Violencia” (“The Violence”) caused by bloody fights between members of the two political parties following the April 9, 1948, assassination of the leader of the Liberal party, Jorge Eliecer Gaitán. During the next several years, thousands of Colombians were killed until the military coup of Gustavo Rojas Pinilla and the government of the Military Junta. There were additional violations of human rights, including forced recruitment, the disappearance of individuals, and sexual violence. After the military regimes, the two traditional political parties agreed to the creation of a “National Front” whereby the Liberal and Conservative parties would govern jointly. This agreement eliminated “the Violence” but many believe that the contradictions and disagreements between the parties were the forces responsible for the development of the Marxistoriented groups such as the M-19, the Revolutionary Armed Forces of Colombia (FARC), and the National Liberation Army (ELN). To complicate this fragile and violent sociopolitical situation, powerful and violent drug cartels developed in the late 1970s, 1980s, and 1990s. These cartels influenced and financed the illegal armed groups, thereby creating incredible instability in the government and severe violence in the nation. This led to one of the largest displacements of people in the world, with more than two million Colombians leaving the country. In August 2000, the United States government approved “Plan Colombia,” pledging $1.3 billion to fight drug trafficking. President Pastrana used the plan to undercut drug production and prevent guerrilla groups from benefiting from drug sales and expanded the rights of the military in dealing with the rebels. As a result of the internal violence, approximately 1.6 million individuals had been internally displaced by mid-2005. In 2003 alone, almost one-half of internal displacements were believed to be the direct result of actions of the paramilitary and guerilla groups, with the remaining displacements due to the actions of other illegal groups and the Colombian military. Colombia In May 2002, Alvaro Uribe of the Liberal Party was elected president and promised to increase the attack on the guerrillas, increasing military spending and seeking US military help. Many believe that Colombia is back on track to recuperating from years of violence and unlawful acts. Economy Historically Colombia has had an agrarian economy, a situation that has changed rapidly during the twentieth century. Colombia is rich in natural resources and its main exports are petroleum, coal, coffee, and gold. Also, Colombia is the world’s leading source of emeralds and the largest exporter of flowers to the United States (70% of the market). Tourism is also a popular industry in Colombia with close to three million visitors per year despite warnings about security. Despite its political difficulties Colombia has enjoyed a strong economy with a healthy growing of the Gross Domestic Product (GDP). The country had a recession in 1999 but recovered well and has one of the highest rates of growth in Latin America. Nevertheless, Colombia continues to have serious social problems, with 20% of the population having a 63% share of the income/consumption and approximately 18% of the population living on less that $2 a day. Immigration to Colombia Historically there has been relatively little immigration to Colombia from other countries. Spain initially discouraged immigration to the area beginning in the early 1500s, in order to prevent other countries from claiming its colony. More recently, the violence associated with the civil war (La Violencia) has dissuaded individuals from resettling in the country. Currently, skilled workers are welcomed in the country and work visas may be available. Venezuelans make up almost one-half of current immigrants to Colombia (41%), and Ecuador follows second (8.5%). Other foreign nationals living in Colombia include citizens of Spain, Germany, Italy, Lebanon, and several Latin American countries. Emigration from Colombia As a result of the armed conflict, there has been massive emigration from Colombia during the past decade. Approximately one out of every ten Colombians now C lives outside of the country. Primary destinations of Colombian citizens who have chosen to emigrate elsewhere include the USA; Canada; several Central American countries (Costa Rica, Guatemala, Mexico, and Panama); the Caribbean countries of Aruba, Curacao, and the Dominican Republic; various South American countries (primarily Venezuela, Ecuador, and Argentina); several European countries (primarily Spain); Australia; Japan; and Israel. According to the Census Bureau’s 2008 American Community Survey (ACS), there are 47 million Hispanics in the United States and close to 1 million of them are identified as Colombians, accounting for 1.9% of the US Hispanic population in 2008. Approximately two-thirds of Colombians are foreign born, compared with 38.1% of Hispanics and 12.5% of the US population overall. A proportion of the Colombians in the United States have received asylum or refugee status based on their persecution in Colombia. Colombia is believed to be the fourth-leading source of undocumented immigrants to the United States. Most of the immigrants from Colombia (58.7%) arrived in the USA in 1990 or later and less than onehalf (48.8%) are US citizens. The median age for Colombians in USA is 36 years, which is the same as the median age of the USA. The majority of Colombians in the USA speak English proficiently and have a higher educational level than the Hispanic population overall. They are also more likely to be married and live mostly in Florida (31.9%) and in the New York–New Jersey area (29%). Remittances from the emigrants to their families in Colombia have risen by more than 20% per year since 1999. These remittances are believed to total more than three times the country’s revenue from coffee exports and two and one-half times the revenue from coal. It is believed that more than three-quarters of these remittances are spent on the essentials of daily living, such as food, rent, and education. Related Topics ▶ Asylum ▶ Hispanics ▶ Internally displaced persons ▶ Labor migration ▶ Latinos ▶ Refugee 455 C 456 C Colon Cancer and Screening Suggested Resources Bérubé, M. (2005). Country profiles: Colombia in the crossfire. Retrieved April 29, 2011, from http://www.migrationinformation/org/ Profiles/display.cfm?ID=344 For information about Colombia. http://www.colombia.com United National High Commissioner for Refugees. (2009). Global report: New threats, new challenges. Retrieved April 29, 2011, from http://www.unhcr.org/gr09/index.html Colon Cancer and Screening ANNETTE E. MAXWELL1, FRANK ANTHONY P. ALIGANGA2 1 Jonsson Comprehensive Cancer Center, School of Public Health and UCLA Kaiser Permanente Center for Health Equity, University of California Los Angeles (UCLA), Los Angeles, CA, USA 2 Charles Drew University/UCLA Medical Education Program, David Geffen School of Medicine at the University of California Los Angeles (UCLA), Los Angeles, CA, USA Colorectal Cancer Incidence Among Immigrants Colorectal cancer incidence, defined as the number of new cancer cases occurring within a defined time period, varies widely. In more developed countries, the colorectal cancer incidence is substantially higher than in less developed countries. Risk factors for colorectal cancer are increasing age, inflammatory bowel disease, a personal or family history of colorectal cancer or colorectal polyps, rare genetic syndromes and lifestyle factors, such as lack of physical activity, low fruit and vegetable intake, a low-fiber and high-fat diet, overweight and obesity, alcohol consumption and tobacco use. As immigrants move from less developed countries to more developed countries, they adopt the lifestyle of their host country, such as low fiber intake and high meat consumption, which increases their risk for colorectal cancer. For example, Chinese and Filipino persons who are born in Asia and later immigrate to the United States have a higher risk of colorectal cancer than their counterparts who remain in Asia. They have a lower risk of colorectal cancer than the general population in the United States because they may be slow to adopt the lifestyle of the host country. Studies of recent immigrants in the United States have shown an increased colorectal cancer incidence within one generation. There is very little information on colorectal cancer screening among immigrants in other countries. Therefore, this entry is limited to immigrants in the United States. In the United States, colorectal cancer is the third most common cancer and the second most common cause of cancer death. Most of the immigrants who arrived in the United States after 1970 were from countries in Latin America and Asia. The most recent statistics (2007) show that 54% of the foreignborn US population is from Latin American, 27% from Asia, 13% from Europe, and 6% from other areas, including Africa and Oceania. Colorectal Cancer Screening Among Immigrants Through screening, health care providers can capitalize on the relatively long premalignant phase of colorectal cancer. The progression of polyps into cancerous lesions is often slow; therefore, if found early, precancerous polyps can be removed. Additionally, colorectal cancer prognosis is tied closely to the stage at which the cancer is diagnosed. Almost 90% of colorectal cancer patients survive for at least 5 years if their cancer is diagnosed in its early, localized stage, but only about 10% survive for at least 5 years when the cancer is diagnosed at a late stage, when it has spread to other parts of the body. Thus, colorectal cancer screening tests are indispensable tools for identifying individuals early in their disease, when they are often asymptomatic, and allow for treatment that prevents further progression and metastasis. The US Preventive Services Task Force (USPSTF), an independent panel that issues guidelines on cancer screening, recommends routine screening of all men and women 50 years and older. This recommendation is based on several randomized trials that showed that regular screening after 50 years of age greatly reduces deaths from colorectal cancer. Colorectal cancer screening is unique in that a number of different types of screening tests are recommended. The Fecal Occult Blood Test (FOBT), also called stool blood test, analyzes fecal material for the presence of occult (hidden) blood. For a stool blood test, individuals must collect a small stool sample and send it to a provider for analysis. Two types of stool blood tests are currently available. Guaiac FOBT uses Colon Cancer and Screening the chemical, guaiac, to detect heme, a component of red blood cells; immunochemical FOBT or Fecal Immunochemical Test (FIT) utilizes antibodies against human hemoglobin protein to detect the presence of blood in stool. Alternatively, screening by endoscopy is more invasive and more expensive. In an outpatient procedure, a long, flexible instrument equipped with a video camera is inserted through the rectum to inspect the lower colon (sigmoidoscopy) or the entire colon (colonoscopy). With endoscopy, lesions can be visualized and those appearing precancerous or cancerous can be removed during the screening procedure. The ability to detect and remove lesions in one session makes this the preferred choice for health care providers and, in the United States, screening by colonoscopy is increasing in the general population. However, because stool blood tests are lower cost, more convenient alternatives, interventions to increase screening in larger populations often advocate their use. The US Preventive Services Task Force recommends annual stool blood tests for individuals 50–75 years old or sigmoidoscopy every 5 years or colonoscopy every 10 years. Other screening options are also available, such as virtual colonoscopy, double contrast barium enema, and digital rectal exam. Additionally, research involving experimental screening methods such as wireless capsule endoscopy showcases the technological advances in possible cancer screening modalities. Despite the recommendations and multiple choices of screening tests, colorectal cancer screening is underutilized. In the general US population, colorectal cancer screening prevalences are substantially lower than screening prevalences for breast or cervical cancer by mammography or Pap smear. Several campaigns promote colorectal cancer screening and the proportion of the population that has received a colorectal cancer screening test according to the guidelines has steadily increased (from 20–30% in 1997 to almost 55% in 2008). However, screening disparities among racial/ethnic groups continue to persist. Based on a large California population-based survey (California Health Interview Survey), the prevalence of colorectal cancer screening increased significantly among Whites and Latinos but not among African Americans and Asian Americans between 2001 and 2005. Screening prevalence varied substantially among Asian subgroups, with Koreans, Filipino, and Vietnamese C Americans having the lowest prevalence. Many members of these Asian subgroups are immigrants. In contrast, Japanese Americans who have a long history of living in the United States had one of the highest screening prevalences. Another study conducted using data from the 2000 National Health Interview Survey concluded that foreign-born individuals not only had lower colorectal cancer screening prevalences than US-born non-Latino Whites, but also had significantly lower screening prevalences than US-born members of their ethnic community. In addition, a recent analysis of colorectal cancer screening in Filipino American immigrants suggests that within ethnic subgroups, more educated and acculturated persons with higher income may tend to obtain endoscopies, whereas more recent immigrants with lower levels of education and income tend to obtain stool blood tests. Thus, even within an immigrant group from the same country, disparities may exist with respect to the type of colorectal cancer screening test received. Factors Associated with Colorectal Cancer Screening Studies in general population samples have found certain demographic variables, such as higher education, higher income, having health insurance, and being married, to be positively associated with colorectal cancer screening and other cancer screening tests. Factors such as lack of symptoms, lack of time, inconvenience, lack of interest, cost, discomfort associated with the procedure, and embarrassment have been found to be common barriers to colorectal cancer screening. To date, only a few studies have explored factors associated with colorectal cancer screening in immigrant populations. Studies in several immigrant populations (Latinos, Filipino Americans, Korean Americans, and Chinese Americans) found that older age and longer duration of residency in the United States, having health insurance, and higher levels of education and income were associated with increased colorectal cancer screening. In these populations, barriers to screening include being unaware of cancer screening tests or underestimating their importance, lack of health insurance to cover screening tests, and not having a regular health care provider. Cultural barriers also play a role. They may include modesty (an issue when undergoing 457 C 458 C Colon Cancer and Screening endoscopy), fatalism (there is nothing I can do to prevent getting colorectal cancer), crisis orientation toward health and illness (consulting a physician only when seriously ill), and use of Eastern medicine instead of Western medicine. For example, in one study, Latina women who were given access to free screening were more likely to get screened if they had less fatalistic attitudes. Undocumented legal status and use of home remedies instead of seeing a physician have also been suggested as barriers to screening for Latino immigrants. A physician recommendation to get screened remains one of the most important promoters of colorectal cancer screening in the general population and among immigrants. California Health Interview Survey data suggest that Korean and Vietnamese Americans are less likely than other Asian American groups to report a recent doctor recommendation for screening. This may be due to language barriers, not seeing a physician for routine checkups, and not asking physicians for routine screening tests. In a study that explored why Korean American physicians did not recommend colorectal cancer screening to their Korean American patients, physicians identified the following barriers for recommending colorectal cancer screening: barriers directly attributable to the physicians themselves (i.e., lack of knowledge, fear of medicolegal liability), barriers associated with their patient characteristics (i.e., patient’s unfamiliarity with the concept of screening and preventive medicine), and barriers that result from the limitations of the health care system or local clinics (i.e., lack of referral network for endoscopy, poor reimbursement). One study that included Latino and Chinese immigrants who were patients in a primary care clinic in New York found that the vast majority obtained a colonoscopy after a physician referral. This finding underscores the importance of a physician recommendation for colorectal cancer screening among immigrants. Interventions to Increase Colorectal Cancer Screening Programs and interventions to increase colorectal cancer screening have been developed and tested, although they are usually not exclusively targeting immigrants. Several interventions have been developed for Latino and Asian American populations, both of which have large proportions of immigrants. Programs may include reminder letters, educational videos and brochures, oneon-one or small-group educational sessions, and help for patients to make appointments for colorectal cancer screening and to “navigate” the health care system. Studies of clinic-based interventions, where patients are recruited at clinics and interventions are delivered by health professionals or trained peer navigators, have been shown to increase colorectal cancer screening among immigrants. These programs have the advantage that all patients have access to health care and can receive colorectal cancer screening at the program site. However, clinic based programs can only reach those immigrants who have health insurance and a regular source of care. Immigrants who lack health insurance can be reached through programs at community-based organizations and churches that promote colorectal cancer screening. Only a few studies have been conducted among immigrants in nonclinical settings, and not all have been successful in increasing colorectal cancer screening. These programs typically include education to increase knowledge and awareness of the screening tests and discussion of barriers to screening and how to overcome these barriers. Some programs provide free colorectal cancer screening, typically a low cost stool blood test. Linguistically and culturally appropriate telephone counseling has also been shown to be effective. Other programs to increase screening are targeting physicians to increase recommending screening to patients, and system barriers, such as instituting reminder systems at clinics. For example, the medical charts or electronic health records of patients who are not up to date with colorectal cancer screening can be flagged to remind the physician to recommend screening to these patients, and reminder letters can be mailed to these patients. In addition, health insurance coverage for colorectal cancer screening is increasing. For example, Medicare has expanded coverage to include all recommended screening tests, including colonoscopy. These programs are expected to increase colorectal cancer screening in future years in the general population and among immigrants. Acknowledgment This work was supported by the American Cancer Society (grant RSGT-04-210-05 CPPB). Colonialism C Related Topics Suggested Resources ▶ Access to care ▶ Cancer health disparities ▶ Cancer incidence ▶ Cancer mortality ▶ Cancer prevention ▶ Cancer screening ▶ Colorectal cancer American Cancer Society. Colorectal cancer facts & figures 2008– 2010. Atlanta. http://www.cancer.org/Research/CancerFactsFigures/ colorectal-cancer-facts–figures-2008-2010. Accessed July 19, 2010. US Preventive Services Task Force. (2008). Recommendation statement. Screening for colorectal cancer. US Dept of Health and Human Services. http://www.ahrq.gov/clinic/uspstf08/colocancer/ colors.htm. Accessed June 21, 2010. Suggested Readings Aragones, A., Schwartz, M. D., Shah, N. R., & Gany, F. M. (2010). A randomized controlled trial of a multilevel intervention to increase colorectal cancer screening among latino immigrants in a primary care facility. Journal of General Internal Medicine, 25(6), 564–567. Flood, D. M., Weiss, N. S., Cook, L. S., Emerson, J. C., Schwartz, S. M., & Potter, J. D. (2000). Colorectal cancer incidence in Asian migrants to the United States and their descendants. Cancer Causes & Control, 11, 403–411. Gorin, S. S. (2005). Correlates of colorectal cancer screening compliance among Urban Hispanics. Journal of Behavioral Medicine, 28(2), 125–137. Jandorf, L., Ellison, J., Villagra, C., Winkel, G., Varela, A., QuinteroCanetti, Z., Castillo, A., Thélémaque, L., King, S., & Duhamel, K. (2010). Understanding the barriers and facilitators of colorectal cancer screening among low income immigrant Hispanics. Journal of Immigrant and Minority Health, 12(4), 462–469. Jo, A. M., Maxwell, A. E., Rick, A. J., Cha, J., & Bastani, R. (2009). Why are Korean American physicians reluctant to recommend colorectal cancer screening to Korean American patients? Exploratory interview findings. Journal of Immigrant and Minority Health, 11(4), 302–309. Maxwell, A. E., & Crespi, C. M. (2009). Trends in colorectal cancer screening utilization among ethnic groups in California: Are we closing the gap? Cancer Epidemiology Biormarkers & Prevention, 18(3), 752–759. Maxwell, A. E., Danao, L. L., Crespi, C. M., Antonio, C., Garcia, G. M., & Bastani, R. (2008). Disparities in the receipt of fecal occult blood test versus endoscopy among Filipino American immigrants. Cancer Epidemiology Biormarkers & Prevention, 17(8), 1963–1967. Shih, Y. T., Elting, L. S., & Levin, B. (2008). Disparities in colorectal screening between US-born and foreign-born populations: Evidence from the 2000 National Health Interview Survey. Journal of Cancer Education, 23, 18–25. Tu, S. P., Taylor, V., Yasui, Y., Chun, A., Yip, M. P., Acorda, E., Li, L., & Bastani, R. (2006). Promoting culturally appropriate colorectal cancer screening through a health educator. A randomized controlled trial. Cancer, 107, 959–966. Walsh, J. M. E., Salazar, R., Nguyen, T. T., Kaplan, C., Nguyen, L., Hwang, J., McPhee, S. J., & Pasick, R. J. (2010). Healthy colon, healthy life: A novel colorectal cancer screening intervention. American Journal of Preventive Medicine, 39(1), 1–14. Colonialism JENNIFER BURRELL Department of Anthropology, University at Albany, The State University of New York (SUNY), Albany, NY, USA Colonialism is the long-term political, social, economic, and cultural domination of a people and territory by a foreign power. Modern colonialism can be traced to the European “Age of Discovery,” particularly to colonizing projects carried out by the England, Spain, France, and the Netherlands that extended to the Far East and to the Americas. Throughout the nineteenth and into the twentieth century, colonialist regimes were established throughout the world, frequently with “civilizing” ideologies at their core, such as “the White man’s burden,” adopted by the British, and the “mission civilisatrice” of the French. Underlying these ideologies was the intent to move beyond governing to the modernization and eventual assimilation of people, often accomplished through great violence and through the establishment of cultures of terror. Colonies took a variety of forms meant to support economic exploitation of people and land. These included (1) settler colonies, in which people from colonizing nations moved in large numbers in new territories; (2) dependencies, in which governing regimes or administrations managed local populations; (3) plantation colonies, in which land and people were used to produce agricultural products; and (4) trading posts, including forts and other quasi-military installations that controlled trading and selling in a particular 459 C 460 C Colorectal Cancer area. Whatever the form, the project of establishing a colony and of producing colonial subjects entailed the implementation of power structures and division of places and people in ways that were frequently arbitrary inventions. New countries were produced through these encounters, as well as new categories of people. These hierarchies, categorizations, and other mechanisms of power shaped how colonizers and the colonized interacted and were able to move and make choices within a society, producing races, ethnicities, classes, sexualities, and ways of being in the world large. The colonized often experienced untold horrors as they were forced into imperialist projects. But as Cooper and Stoler argue in their 1997 Tensions of Empire, these mechanisms also produced contemporary Europe as a bourgeois society and order was remade and expanded in relation to imperialism. It has been argued that colonialist ideologies persist in the world, under new labels, but with similar mechanisms. Escobar, for example, suggests that development and development policies have become as pervasive, effective, and controlling as their colonial counterparts. Development ideologies and projects have adopted categories that have shaped world thinking on how people are to be “helped” or pushed toward modernity, even as many of these projects do not succeed. Indeed, Ferguson suggests that development projects often fail, but something else is accomplished, often the expansion of State or governing power in realms where it was formerly thin on the ground or nonexistent. Processes of colonialism and development (or underdevelopment) have been central to shaping our world and the possibilities that exist for all people. Many contemporary inequalities and disparities result from these processes, among them the struggles of indigenous people’s throughout the world and the horrors of genocide in places like Rwanda, where the divisions that led to the mass killing were the direct legacy of the German and Belgian colonial projects in that region of Africa from the 1890s onward. Related Topics ▶ Discrimination ▶ Racism ▶ Slavery Suggested Readings Cooper, F., & Stoler, A. L. (2007). Preface. In Tensions of empire: Colonial cultures in a bourgeois world (pp. vii–x). Berkeley, CA: University of California Press. Escobar, A. (1995). Encountering development: The making and unmaking of the Third World. Princeton, NJ: Princeton University Press. Ferguson, J. (1994). The anti-politics machine. Minneapolis, MN: University of Minnesota Press. Scheper-Hughes, N., & Bourgois, P. (2004). Introduction. In N. Scheper-Hughes & P. I. Bourgois (Eds.), Violence in war and peace (pp. 1–32). Malden, MA: Blackwell. Taussig, M. (1984). Culture of terror–space of death: Roger Casement’s Putamayo Report and the explanation of torture. Comparative Studies in Society and History, 26(1), 467–497. Colorectal Cancer TIMOTHY E. O’BRIEN MetroHealth Medical Center, Cleveland, OH, USA Incidence Colorectal cancer is uncommon in developing countries but is the second most frequent malignancy in affluent societies. More than 940,000 cases occur annually worldwide, and approximately 639,000 people die from it each year. In the United States there were around 150,000 new cases of colorectal cancer diagnosed in 2009 and it was the second leading cause of cancer death. The risk increases with increasing age, particularly starting at age 50, and colorectal cancer is quite rare in patients under age 40. Cause Some studies suggest that a “Western diet,” rich in fat, refined carbohydrates, and animal protein, may lead to colon or rectal cancer, particularly if combined with low physical activity. It has been proposed that a sedentary lifestyle allows greater exposure of the inner lining (epithelial) cells of the colon or rectum to carcinogenic substances in the diet. Some studies suggest that this risk can be reduced by decreasing meat consumption (particularly processed meat), increasing the intake of vegetables and fruits, and increased exercise. Immigrant populations rapidly reach the higher level of risk of the adopted country, another sign that Colorectal Cancer environmental factors play a major role. Although there are inherited forms of the disease, genetic susceptibility appears to be involved in a small number (less than 5%) of cases. Patients with longstanding inflammatory bowel disease, particularly ulcerative colitis involving the entire colon, are also at increased risk. Before becoming invasive cancer, cancers of the colon and rectum generally start out as benign (i.e., nonmalignant) growths of cells lining the colon (endothelial cells) called polyps. After further damage to the endothelial cells’ DNA, their growth becomes disorganized and uncontrolled. The cells become abnormal or dysplastic, a precursor to cancer. After more DNA damage (presumably from environmental toxins), the dysplastic cells become malignant and invade into tissue; at this point the cells are called colorectal cancer cells (adenocarcinoma). Because of the relative orderly progression from adenomatous polyp to dysplasia to overt carcinoma (cancer), screening tests which detect nonmalignant polyps are an effective way to prevent the development of colorectal cancer by removing the earlier precursor form of the disease before overt cancer has developed. C complete but is not very sensitive at detecting colorectal cancers, which may bleed intermittently or not at all. Flexible sigmoidoscopy is very sensitive at detecting polyps and cancers in the rectum and sigmoid colon but misses the rest of the colon, so that around 1/3 of colon tumors in men and 2/3 in women will be missed with this test. Its sensitivity can be improved, though, if a barium enema (a radiographic imaging study) is combined with the flexible sigmoidoscopy to image the rest of the colon. Clinical Manifestations Many patients will not have any symptoms and are diagnosed through a screening test, such as a colonoscopy. Colon cancer patients may present with symptoms of iron deficiency anemia, such as fatigue, or notice a change in stool caliber, have vague abdominal pains, or less commonly notice blood in their stools. Rectal cancer may become noticeable as pain on defecation, blood in the stools, or obstructive symptoms such as lower abdominal pains, nausea, and vomiting. Staging Screening The best screening test for colorectal cancer is a colonoscopy. It is recommended that all people should get a screening colonoscopy starting at age 50; if it is normal then the screen should be repeated every 10 years. Patients with a first-degree relative (parent, sibling, or child) with colon or rectal cancer should have their first colonoscopy at an age 10 years younger than their relative was at their diagnosis. Screening colonoscopies are covered by most health insurance carriers in the United States and Medicaid patients starting at age 50. Virtual colonoscopy involves a noninvasive radiographic test of the colon and rectum. It may be as effective as the colonoscopy in detecting most precursor polyps but is not yet widely available. Other screening tests which have been shown to be effective in reducing colorectal cancer-related mortality include stool hemoccult testing and flexible sigmoidoscopy. Stool hemoccult tests (tests for blood in the stool) involve sending in three stool smears on a card, which are then tested for microscopic blood. This has the advantage of being inexpensive and easy to Like most cancers, colorectal cancer goes through four stages. The stage determines prognosis and is based, in part, on depth of penetration into the bowel wall. Stage I cancers invade into the layer just underneath the colon or rectal lining (submucosa) or into the muscle layer; stage II tumors go all the way through to the bowel wall but without involvement of surrounding lymph nodes; stage III cancers involve surrounding lymph nodes; and stage IV means that the cancer cells have spread (metastasized) to other organs (usually the liver or lungs). All patients with stage I, II, and III are potentially curable; most stage IV patients are not curable but there are some exceptions (see below). Treatment Early Stage Colon Cancer Stages I–III are treated with surgical resection, which is potentially curable. Following surgery, those with stage III (node involvement) should be offered chemotherapy. This has been shown to significantly improve survival and reduce recurrence of colon cancer. 461 C 462 C Common Law Marriage Early Stage Rectal Cancer Unlike the colon, the rectum is not enveloped by a protective sheath called the peritoneum. For this reason, rectal cancer recurs far more commonly in the area of resection (locally), as opposed to throughout the body (systemically). As a result, treatment for early stage (stages I–III) rectal cancer is different than that of colon cancer. Radiation, which interferes with DNA replication and treats one small area (local), plays an important role. Chemotherapy, which is given intravenously or orally, is delivered by the blood to all the tissues of the body (systemic therapy). Because patients with early stage rectal cancer may recur locally or systemically, both chemotherapy and radiation are indicated. Combined chemotherapy and radiation should be offered prior to surgery in patients with stages II and III rectal cancer. This has been shown to result in better local control of the rectal cancer than having surgery followed by chemotherapy and radiation. These patients are all treated with curative intent. Advanced Colorectal Cancer Most of these patients are incurable. The exception is the patient with localized spread to one part of the liver which can be resected, along with the primary colon or rectal cancer. Without treatment, patients with metastatic colon or rectal cancer will live about 12 months. Over the past decade tremendous progress has been made, such that the median survival now with modern therapies is about 2 years. Treatment regimens include systemic chemotherapy along with bevacizumab, an antibody which is directed against vascular endothelial growth factor, a substance which allows blood vessels around tumor cells to grow. Studies have shown that the addition of this agent to chemotherapy improves survival time. In addition, a newer class of drugs called epidermal growth factor receptor (EGFR) inhibitors also improves the effects of chemotherapy. These drugs, which include cetuximab and panitumumab, are antibodies against EGFR on the colorectal cancer cell. They are effective only in patients whose colorectal cancer cells do not have a mutation called k-ras. If the cells are mutant in k-ras, which is seen in about 40% of cases, then the EGFR antibodies will not work. All of these patients should be encouraged to enroll onto clinical trials, as this will be the only way to make improvements in the management of colorectal cancer. This is particularly important for immigrant minorities, who are often underrepresented in clinical trials. Summary Cancers of the colon and rectum are particularly common in immigrants coming from affluent countries. Screening tests can detect these at precancerous, highly curable stages and so should be done in anyone over age 50, or younger if in a high-risk group. Early stage colon and rectal cancer is very curable, with surgery playing the dominant role. Advanced colorectal cancer is generally not curable but recent advances have been made which have significantly improved the survival in these patients. Related Topics ▶ Breast cancer ▶ Cancer ▶ Cancer health disparities ▶ Cancer prevention ▶ Cancer screening ▶ Liver cancer Suggested Resources American Cancer Society. http://www.cancer.org/docroot/CRI/ CRI_2x.asp?sitearea=&dt=10 American Society of Clinical Oncology. http://www.cancer.net/ patient/CancerTypes/ColorectalCancer National Cancer Institute. National Cancer Institute website. http:// www.cancer.gov/cancertopics/pdq/screening/colorectal/Patient/ page2 World Health Organization. http://www.who.int/features/factfiles/ cancer/10_en.html Common Law Marriage ▶ Marriage Communicable Disease Control ▶ Infectious diseases Communicable Disease of Public Health Significance Communicable Disease of Public Health Significance MIHAELA-CATALINA VICOL Department of Bioethics, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania The risks of communicable diseases of public health significance reveal the need for early detection, prophylaxis, and treatment. From this point of view, dealing with an immigrant population usually means dealing with diseases with high incidence and prevalence in their origin country. For example, hepatitis B virus is endemic in Asian countries; consequently, 15% of Southeast Asian immigrants are chronic carriers of this infection and the percentage of carriers among Indo-Chinese immigrants is between 14% and 20%. This is why, currently, almost every country has a set of screening procedures for different communicable diseases of public health significance, in order to avoid the possibility of disease transmission within the population, to detect diseases early, and to treat them promptly. For example, according to American Public Health Association (2002), and to the US Centers for Disease Control and Prevention (CDC), immigrants are screened prior to their entry into the USA and prior to adjustment of status for several communicable diseases with potential impact on public health. These include tuberculosis, syphilis, HIV infection, chancroid, gonorrhea, granuloma inguinale, lymphogranuloma venereum, and Hansen’s disease. Prior to entry in the USA or during the period of adjustment, intending immigrants are also required to complete or to demonstrate completion (as age-appropriate) of a set of immunizations for several vaccinepreventable diseases such as hepatitis B, influenza B, mumps and measles, pertussis, polio, rubella, tetanus, and diphtheria toxoids. Depending on the native country, other diseases might be considered, such as malaria, varicella, etc. Immigrants who are found to test positive for such diseases usually are treated. In addition, besides screening for diseases listed above, and the documentation of vaccine C history and vaccination required, immigrants are also screened for drug addiction and for physical and mental health disorders that could determine harm to the person or to the others. Besides this situation of legal immigrants who must pass through a screening filter for communicable diseases that can potentially impact public health, there is the situation of illegal immigrants. In their cases, they cannot be screened. In addition, they may not seek healthcare except for emergencies, out of fear of deportation because of their illegal status. This may have a great impact on the public health. It has been asserted that the health status of illegal immigrants is poorer than the rest of the population and that their access to healthcare is limited by different kind of barriers. Although screening for communicable diseases that may impact on public health plays a very important role in the control of disease transmission, early detection and treatment are also critical. This suggests the need for the early detection and treatment of such diseases in the immigrant population that settles for some time in their second country. This issue relates directly to the extent to which health care is accessible to immigrants and particularly those with uninsured status, low income, illegal immigrant status, language and cultural barriers, social barriers, etc. For example, a significant decrease in the prevalence of tuberculosis (TB) has been noted among US native citizens. Unfortunately, this decrease has not been mirrored by a similar decrease in the prevalence of TB in the US immigrant population. In 2003, in New York, the rate of tuberculosis was four times higher among foreign-born citizens (especially among individuals born in China, Ecuador, Haiti, Mexico, India, and the Dominican Republic) than in US-born New York citizens. These data argue for the need for efforts in addition to the screening currently conducted prior to or upon immigrants’ arrival to their destination country. It indicates the need for health policy measures to improve and to stimulate immigrants’ access to health care. Such measures may have positive consequences not only for the health of immigrants, but also on the general population. 463 C 464 C Communication Barriers Related Topics ▶ Acquired immune deficiency syndrome ▶ Health policy ▶ Immigration processes and health in the U.S.: A brief history ▶ Medical examination (for immigration) ▶ Panel physician ▶ Sexually transmitted diseases ▶ Tuberculosis Suggested Readings Kemp, C., & Rasbridge, L. (2004). Refugee and immigrant health: A handbook for health professionals. Cambridge: Cambridge University Press. Post, S. G. (Ed.) (2004). Immigration, Ethical and health issues of. Encyclopedia of bioethics (3rd ed.). New York: Macmillan Reference USA/Thomson/Gale. Suggested Resources American Public Health Association (APHA). (2002). Understanding the health culture of recent immigrants to the United States: A cross-cultural maternal health information catalog. Retrieved July 1, 2010, from www.apha.org Centers for Disease Control and Prevention. Immigrant and refugee health. Retrieved July 1, 2010, from http://www.cdc.gov/ immigrantrefugeehealth/exams/diseases-vaccines-included.html New York City Department of Health and Mental Hygiene. (2006, June). The health of immigrants in New York City. A report from the New York City Department of Health and Mental Hygiene. Retrieved August 1, 2010, from www.nyc.gov Communication Barriers MARTHA WOMACK HAUN Valenti School of Communication, University of Houston, Houston, TX, USA Communication is the process by which senders and receivers of messages establish shared meaning in a specific context. Effective communication requires that a message, verbal and/or nonverbal, oral or written, be created by the source and be successfully understood/received at the destination by the receiver/target. This may involve people, animals, or computers. This is an ongoing, reciprocal, transactional process. Transactional means that we are sending and receiving messages simultaneously, even when we are asleep. Various barriers can result in the poor or distorted reception of the message. Poor Message Creation The speaker or sender has a responsibility to create a message that is clear, coherent, and understandable by the receiver. If the sender does not consider the interests and educational level of the receiver, the result may be confusion and/or rejection of the ideas in the message. Poor reasoning, disorganization, irrelevant or confusing examples can all result in messages that are not effective for the receiver. The receiver is an important part of this process and can contribute positively by paying attention to the messages. The environment must be conducive to message exchanges. It should be free of distractions and interruptions. Barriers in the communication cycle may occur at any point and may be attributed to the message, sender, receiver, or the environment. Noise The term noise is often used to refer to disruption or interference in the communication process. Noise may be external as poor technical reception, interference in the environment such as a door slamming, a phone ringing, loud music, people talking loudly near you, or other factors that make it impossible for the receiver to clearly hear the message being sent. More often the “noise” is internal. This may be psychological noise such as daydreaming or wishful thinking. Instead of paying attention to the other person, minds wandering, thinking about things that need to be done or plans that need to be made may disrupt the receiver’s attention. Sometimes the language being spoken is not familiar or comprehensible. Lack of a common language quickly reduces the communication exchange to a series of hand signals and other nonverbal signs. The same language may be used but the meaning of the words being used is different. Vocabulary words like “expediency,” or “dissonance,” or “integrity,” may be strange to the receiver. This is called “semantic” noise. Inability to accurately assign meanings in a timely manner destroys the communication process. Communication Barriers Double Meanings Messages between senders and receivers are usually both verbal and nonverbal. In any language, the use of the voice – through pitch, inflection, tone, and timing – adds nuances and meanings to the words so that what is understood as having one meaning on the verbal level actually takes on a different meaning on the nonverbal level. “Come see us again,” said in a flat tone of voice may suggest that the return visit should not be any time soon. Thus, greetings that have special cultural contexts and meanings may be offensive if not used correctly and trigger unexpected or negative responses. Disconfirming Communication In interpersonal communication intentionally or unintentionally barriers may be created by poor listening and by the type of responses given to the other person. When listening, do you give the other person your full attention or are you trying to do several things at the same time? Can you repeat back in your own words accurately what the other person has said? Are you leaving out part of the message? Adding bits and pieces? Or simply incorrectly stating the content? When someone is talking to you, do you look bored by averting your eyes and yawning frequently? Do you ignore what they are saying? Do you make an unrelated response or simply change the topic, content, or direction of the conversation? Such responses are perceived very negatively and result in poor communication, creating barriers to future effective communication. C after the communication or did it cost you time you didn’t have? Did it cost other resources? Did you have to buy dinner or forego some other activity of interest? Repeated cost escalation will ultimately become a barrier to effective communication. Rewards of effective communication include the satisfaction of being clearly understood and of developing positive successful relationships. Positive or Negative Arousal People like to hear positive, confirming, complimentary messages. Criticism, disagreement, or hostile remarks are uncomfortable. Senders and messages that create this “negative arousal” may generate avoidance. Remembering names and remembering conversations, for example, indicates active listening and interest in the other person and is positive arousal. Negative arousal, however, poses a significant communication barrier. The Environment The communication environment affects the effectiveness of the communication process. Noisy, crowded public places make it difficult for persons to hear each other and concentrate on what is being said. If the room is too hot or too cold, or the furniture is uncomfortable, persons may find it impossible to concentrate. A culturally different environment may result in discomfort. A pleasant, quiet restaurant or a walk in the park on a nice day may provide the needed comfort and privacy to offset such barriers. Blaming Aggressive Communication Sometimes receiver responses are hostile and have a negative emotional element. Persons may intentionally use “trigger” words and say things (perhaps through name-calling) to emotionally arouse and annoy the other person and initiate a conflict. Picking an argument and blaming it on the other person by showing dissatisfaction with a selected restaurant, movie, or television show, for example, is an aggressive approach that is a strong communication barrier. An effective communication exchange involves both cost and rewards. It takes time to stop and talk with a person. Are you satisfied with the return? Was the exchange positive or negative? Did you feel satisfied Blaming the other person is a common barrier and occurs when we do not take responsibility for our reactions to messages. “You’re just stupid” (name-calling), as an example, could be restated more productively as “I’m sorry but I don’t understand what you are saying.” Saying “You make me so angry” (blaming the other person), for example, could be stated more effectively as “I feel disrespected when my car is returned with no gasoline in it,” or “I feel unimportant to you when you keep me waiting for an hour for dinner.” Lying While small untruths or omissions of information may be viewed as acceptable to protect the feelings of 465 C 466 C Communication Barriers another person or to keep a confidentiality, telling blatant untruths (fabrication or falsification) or failing to report known information (omission) or intentionally dodging or avoiding an issue by making irrelevant responses or changing the topic creates negative and unproductive communication. Inappropriate Disclosure As people explore the process of getting acquainted, they typically reveal information layer by layer, a little at a time, and by taking turns. Safe, factual information about themselves is revealed initially and, after some time, more personal, intimate details about themselves not known to “the public” is disclosed. This process involves risk and trust with a danger that the other person may not like them when the information is revealed. There is also a risk that one or both of the parties will not keep certain information confidential. Conversely, if a person reveals too much information too quickly, discomfort will result because the receiver does not know how to handle so much new information at one time. Information Load Too much information received too quickly exceeds the individual’s ability to handle or manage the information and it becomes overwhelming to the receiver. Too little information, however, creates a boring or uninteresting situation for the receiver. Individuals have their own rate and capacity for handling simple or complex information. communication, blaming, disrespect, and other causes of poorly constructed messages may be avoided. The following perspectives can be helpful in creating positive communication: (1) Fearful environments such as job interviewing or a threat of deportation may require extra care in message creation. (2) When cultural norms and nonverbal expressions are unfamiliar, communication may breakdown. (3) Language may be a significant barrier to overcome. (4) Positive arousal, negative arousal, and double meanings of words are all intensified by language. (5) Lying, blaming, and disrespect may occur when cultural differences exist or life experiences include a history in which immigrants have been lied to or disrespected. (6) Disclosure may be difficult when an individual has a history of punishment or is threatened with deportation. (7) Often immigrants have interpreters to reduce these problems, especially in health care circumstances, but sometimes these are children or other family members who may misinterpret. Immigrants may often experience an unfamiliar culture as well as a foreign language that exacerbates the communication challenges. Communication is an essential process and each person has an important responsibility to make it successful! Related Topics ▶ Language ▶ Language barriers ▶ Low literacy level ▶ Media ▶ Telephone interpretation services Disrespect The individual point of view (ethnocentrism) is a common human characteristic. Attitudes are based on values, beliefs, and experiences that have evolved over time. With aging, the more likely such attitudes are to be “locked in” to our personality. Disrespect or disdain for persons who do not share these attitudes, may be a tremendous barrier to effective communication. It may result in contempt or anger for those holding opposing viewpoints. Such emotions and attitudes can be barriers to effective communication. Conclusion An understanding of interpersonal communication is important so that barriers such as aggressive Suggested Readings Floyd, K. (2009). Interpersonal communication: The whole story. Boston: McGraw-Hill. Haun, M. J. (2010). Communication theory and concepts (7th ed.). Dubuque: McGraw-Hill. Wood, J. T. (2002). Interpersonal communication: Everyday encounters. Belmont: Wadsworth. Suggested Resources http://www.colorado.edu/conflict/peace/problem/cultrbar.htm http://ezinearticles.com?Culture-As-A-Barrier-to-Communication& id=55341 http://ezinearticles.com?Overcoming-Communication-Barriers-BetweenPeople&id=119628 Community Community MARK EDBERG Department of Prevention and Community Health, School of Public Health and Health Services, The George Washington University, Washington, DC, USA Immigrant and Refugee Populations: A Brief Demographic Portrait To understand the evolving composition of immigrant communities, a brief portrait of current immigrant/ refugee population patterns is useful. According to a recent United Nations (UN) report on migration, there were close to 200 million immigrants in 2006, about 3% of the world’s population. The distribution and nature of immigrant communities is intricately connected to the overall pattern of globalization and its inherent flow of labor. The countries with the highest number of immigrants include the United States, the Russian Federation, Germany and other European nations, Canada, Saudi Arabia, India, and the Ukraine. However, countries with the highest percentage of immigrants are primarily in the Middle East, reflecting labor requirements. Regions that are the major sources of immigrants include Asia (e.g., China, Indonesia, India, Philippines), Latin America/ Caribbean (e.g., Mexico, Central America), and Africa (e.g., West Africa, Congo, Somalia, Sudan, Ethiopia). Refugees are also migrants, but forced migrants, not moving for reasons of labor or family but to escape violence, disaster, or political persecution. The source countries for refugees vary considerably depending on political situation, but most recently include Afghanistan, Iraq, Somalia, Democratic Republic of the Congo, and others. Depending upon the nature of available labor as well as (for refugees) resettlement patterns, immigrant communities may be urban or rural, though predominantly the former. Defining Immigrant/Refugee Communities The term “community” is used in so many contexts that before outlining its meaning in terms of immigrant/refugee health, it is worth reiterating some of that usage. “Community” can refer to: C 467 ● A geographic and social space that has boundaries of some kind where people live and interact. ● An emotional feeling – for example, one can feel a “sense of community” with other individuals due to a situation (e.g., a shared emergency) or shared commitment (e.g., with respect to faith). Anthropologist Victor Turner referred to this sense of social togetherness as communitas. ● A group of individuals who share an interest or lifestyle pattern, and who interact with each other regarding that interest, as in “the community of recreational fishing boat owners.” ● A self-identified ethnic or national population, as in “the Italian community,” which may or may not refer to people living in a specific geographic space, but could in fact be global. It could also be an “imagined community” whose existence can be seen as a construction in the popular imaginary. There are also other kinds of definitions: intentional communities for example, are voluntarily formed by groups of people who want to put in practice a particular philosophy of living together, whether religious, environmental, or utopian; virtual communities are groups of people who interact regularly via the Internet around games, issues, or interests. For this essay, since the focus is on public health, “community” may include any of these to some degree, but primarily we are referring to a geographically bounded space that can be understood as a social ecology. That is, within that bounded (yet porous) space, there is a particular combination of individuals who live and/or work there, social groups, cultures and practices, economic relationships, environmental conditions, and resources, all interacting to form a certain kind of interdependent sociocultural unit. Moreover, this “unit” is nested within larger political, economic, social, and cultural structures, so it cannot be considered in isolation. Community is defined in this way in part to interact, theoretically and in practice, with the ecological model of health determinants now prevalent in public health literature, which can be visually depicted as, for example, concentric circles illustrating multiple levels of influence on a particular health issue – moving from the individual, to social groups and networks, to community and society, culture and political economy (Fig. 1). It is also intended to encompass C 468 C Community ECOLOGICAL ‘LEVELS’ Political/Economic/Structural Cultural/Societal Community/ Population Group from increasing assimilation, to fragmentation that occurs when different (e.g., generational) segments of the community use those media in very different ways. These impacts affect health and health-related behavior. Social Group/ Dynamics Individual Community. Fig. 1 “Levels” in the ecological model of health the structural relationships between communities and the social orders of which they are a part. Studying Communities: Anthropology, Sociology, and Media/ Communications Perspectives Both anthropology and sociology have long traditions of studying urban and rural communities in ways that have had increasing impacts on public health approaches. In sociology, the focus has been on social networks, social capital, hierarchy and class, and patterns of social relations. Studying communities as unique sociocultural settings and as representative of particular cultures was indeed the domain of traditional ethnographic work in anthropology, in remote, rural, and urban communities. It is only more recently that anthropologist Robert Redfield’s portrayal of relatively self-contained “little communities” has changed, with more recent work addressing the nature of specific urban or rural communities in relation to broader and transnational structures of power and globalization, and in keeping with the broadening of anthropological inquiry beyond place-based strictures. Much of the work on health issues within medical anthropology takes this latter perspective. In addition, contributions from media and communications studies show that those transnational structures must also include the broad reach of media and online activities, which can have multiple impacts on immigrant communities, Challenges in Defining Immigrant/ Refugee Communities Multiple population groups and subgroups. Defining a community in the context of immigrant/refugee health presents complex challenges, even as the nature and composition of a given community is tied to important factors affecting health, including language issues, access to care, beliefs/practices, social and cultural capital, and socioeconomic status. Most communities with immigrant/refugee populations do not consist of just one such population, although in some cases – such as Hmong communities in California in the USA – there is primarily one population. A community in which the author collaborates for public health interventions, for example, includes peoples from South Asia, the Caribbean, West Africa, and Southeast Asia, along with a predominant Central American/Latino segment. Moreover, even within specific immigrant groups in a community, there are subgroupings of significance. In the same community referred to above, the Central American population includes immigrants from El Salvador, Guatemala, Honduras, and Nicaragua, as well as immigrants from neighboring Mexico. Each of these groups present significant differences: the Guatemalan immigrants, for example, are largely indigenous peoples, some whose first language is not Spanish. In the metropolitan area overall, the Vietnamese immigrant population encompasses people who came to the USA in successive refugee “waves,” each of which involved different circumstances, personal resources, and demographic characteristics. The Thai and Korean metro area populations, on the other hand, did not come as refugees. As another example, in the urban Caribbean immigrant communities of Amsterdam, The Netherlands, there have been separate populations from Suriname, Curacao, and Aruba – all from former Dutch colonies in the Caribbean/South America. Yet even the two Antillean immigrant communities (From Curacao and Aruba) have their differences. Community Urban versus rural/small town. Most immigrant/ refugee communities are found in “gateway” urban or suburban settings, but this is not always the case. There are important rural and small-town immigrant/refugee communities, for example, in the West, Southwest, and East Coast areas of the USA, in Canada, in South Africa, and other locations. Often these communities are linked to employment sources such as agricultural work, food processing, mining, or light assembly/ manufacturing. In the case of refugees, they may also be located in certain areas because of organizations that were involved in their resettlement. Generational issues. The successive immigration waves are connected to generational segments in the community, which are much more of a factor for immigrant/refugee populations than for others. Typically, for migration from less-developed to developed countries, first generation immigrants arrive in the host country with better than average health, but may then experience a decline over time. The decline is related to a number of factors that can be seen as an immigrant/ refugee health trajectory First generation adults often bring with them diet and other health practices that may or may not be protective (e.g., high salt or carbohydrate intake), but which had different impacts in the home country where physical activity was connected to daily work and transportation patterns were different. In addition, the process of migration itself may have involved trauma and severe deprivation, which have health consequences after arrival. Depending upon the kinds of services available in the host country, access to care may be very limited. Finally, the first generation is more likely to be comfortable with indigenous, home-country health beliefs and practices, and may not utilize biomedical-based services. Children of these first-generation immigrants, on the other hand, are more likely to adopt developed country dietary and lifestyle patterns, including fast food and sedentary free time. The parent generation may not know about the risks associated with such practices and may even value them as signs of attainment in the new country. In addition, family organization in a community may be affected by language, where the largely home languagespeaking first generation becomes dependent on its more fluent and acculturated children for certain needs. C Legal issues. As another key dimension, some immigrant/refugee communities include significant numbers of undocumented members, while others do not. This often depends upon the political circumstances surrounding emigration, and whether those circumstances were recognized by the host government as enough to warrant support for asylum, resettlement, and other assistance. The degree to which legal status is an issue for one or more populations in an immigrant community affects a range of health-related factors and plays a key role in social marginalization. Transnational relationships. Moreover, immigrant communities are typically transnational – including individuals and families who move back and forth from their home countries, and where host and home-country populations are linked by remittances – transfers of money and resources to the home community. These remittances in turn create a social and economic infrastructure linking the sending and receiving communities and countries across formal borders. According to the World Bank, total remittances flowing to the developing world amounted to $316 billion in 2009, with a 6.2% increase expected for 2010, despite recent economic conditions. Health Interventions and Communities The interplay of immigrant/refugee populations and sectors within communities forms one of the most delicate and political dimensions affecting health and health interventions, and may be one factor either impeding or supporting community efficacy with respect to addressing health issues. As explained further under the entry entitled “Community Programs,” gaining some understanding about the complex composition of these communities is an important starting point for planning any health-related intervention. Based on the epidemiological data, it is then necessary to determine whether interventions need to be directed to: ● All subgroups within the geographically defined area (the entire community) ● One or more social or cultural subgroups in the geographic area ● A subset of individuals who are involved in specific risk behaviors (e.g., injection drug users, sex workers) 469 C 470 C Community Health Workers ● In some cases, a subset connected to a particular Suggested Resources organizational or employment category/type (e.g., day laborers or restaurant workers) ● Economic, political, and social structures (business, the health care industry, policymaking bodies, community-based organizations) that have an impact on the health problem in that community The Community Toolbox. http://ctb.ku.edu. (An on-line resource for planning, developing, implementing and evaluating community programs, managed through the University of Kansas. Useful in understanding a wide range of issues to consider in working with communities). Thus, whether it is for immigrants/refugees or any population, the necessity of understanding the nature of the community as an overall phenomenon, as well as in relation to specific health concerns, is a key part of health program planning and implementation. Related Topics ▶ Acculturation ▶ Assimilation ▶ Barriers to care ▶ Health determinants ▶ Transnational community ▶ Vulnerable populations Suggested Readings Ball-Rokeach, S. J., Kim, Y. C., & Matei, S. (2001). Storytelling neighborhoods: Paths to belonging in diverse urban environments. Communication Research, 28, 392–428. Edberg, M., Cleary, S., & Vyas, A. (2010). A trajectory model for understanding and assessing health disparities in immigrant/ refugee communities. Journal of Immigrant and Minority Health. doi:10.1007/s10903-010-9337-5 (on line). Edberg, M. (2007). Essentials of health behavior: Social and behavioral theory in public health. Boston: Jones & Bartlett. Gmelch, G.,Kemper, R.V.,&Zenner, W. P. (2010). Urban life: Readings in the anthropology of the city (5th ed.). Long Grove: Waveland Press. Leeds, A. (1994). Cities, classes and the social order, R. Sanjek (Ed.). Ithaca: Cornell University Press. Lin, J., & Mele, C. (2005). The urban sociology reader. New York: Routledge. Matei, S., & Ball-Rokeach, S. (2003). The internet in the communication infrastructure of urban residential communities: Macroor mesolinkage? The Journal of Communication, 53(4), 642–657. Portes, A. (1996). Globalization from below: The rise of transnational communities. In W. P. Smith & R. P. Korczenwicz (Eds.), Latin America in the world economy (pp. 151–168). Westport: Greenwood Press. Portes, A., & Rumbaut, R. G. (2006). Immigrant America: A portrait. Berkeley: University of California Press. Redfield, R. (1967). The little community, Peasant society and culture. Chicago: University of Chicago Press/Phoenix Books. United Nations. (2010). International migration 2009. New York: United Nations Department of Economic and Social Affairs, Population Division. Community Health Workers XIMENA URRUTIA-ROJAS1, MARY LUNA-HOLLEN2 Management Policy and Community Health, University of Texas-Houston School of Public Health, San Antonio, TX, USA 2 University of North Texas Health Science Center, Fort Worth, TX, USA 1 Background For over 300 years many communities around the world have been utilizing lay health workers as a source of regular health care services in the absence of trained medical professionals. The 1978 the World Health Organization’s (WHO) Declaration of Alma-Ata emphasized the use of community health workers (CHWs) as a key strategy for the delivery of basic health care services. CHWs are distinguished from other health professionals because they are hired primarily for their understanding of the populations and communities they serve, conduct outreach a significant portion of the time playing multiple roles, and have experience in providing services in community settings. In the USA, formal participation of trained workers in this role has been documented since the 1950s. By the late 1960s and early 1970s, CHWs were experimentally utilized in some of the low-income communities as a model of intervention for disease prevention and health education. Within this model, individuals with good personal and community skills and some health care training became valuable members of a health care team and help to improve patient communication and disease prevention in underserved communities facilitating early diagnosis of diseases and providing a more effective patient follow-up and improved health outcomes. The federal Migrant Health Act of 1962 and the Economic Opportunity Act of 1964 mandated Community Health Workers outreach activities that included employment of community-based service aides in many neighborhoods and migrant worker camps. The largest system to formally use the skills of CHWs in the USA was established in 1968, when the Indian Health Service adopted the fledging Community Health Representative Program from the Office of Economic Opportunity. The program was designed to bridge the gaps between people and resources and to integrate basic medical knowledge about disease prevention and care. The Community Health Worker National Workforce Study published in March of 2007 by the US Department of Health and Human Services Administration (US HRSA) described the evolution of the CHW workforce in four periods: 1. The early documentation period (1966–1972) is characterized by engaging CHWs in low-income communities and was more related to developing antipoverty strategies than to specific programs for disease prevention and health care. 2. The period between 1973 and 1989 was characterized by special projects funded by short term public and private grants, often linked to research with universities. 3. The State and Federal Initiatives Period followed between 1990 and 1998 when standardized training for CHWs received greater recognition. Many bills were introduced for CHW but none passed. The latest period (1999–to present) is significant for public policy actions. Legislation addressing CHWs’ training and certification was passed in several states and the Patient Navigator Bill was signed into law as a major piece of legislation at the Federal level addressing the work of CHWs. Of note is that the 2003 Institute of Medicine (IOM) report on reducing health disparities made recommendations regarding CHW roles in impacting health disparities. Coordinated efforts to professionalize the field in the USA began in the 1990s when CHWs from across the country agreed to use the title “Community Health Worker” as an umbrella term for the dozens of job titles that were in use among the workforce. At the same time, CHWs began to initiate local and national efforts to organize into professional networks and associations. Standardized training for CHWs also started to be developed in different areas of the country in the C 1990s, including the Community Health Education Center (CHEC) of the Boston Public Health Commission. A second CHW training program, the Outreach Worker Training Institute (OWTI) of the Central Massachusetts Area Health Education Center (CMAHEC), was initiated in 1999 with its courses starting in 2001. Massachusetts and Texas are two examples of the participation of the CHWs/Promotores de Salud at the community and health system level. Texas has 3,500–5,000 CHWs/Promotores de Salud, the majority of whom are of Hispanic ethnicity. The Texas Department of State Health Services (TDSHS) certification training includes 160 h of training and 20 h of CEUs every 2 years to maintain state certification. The curriculum meets 8 competency areas: communication skills, interpersonal skills, service coordination skills, capacity-building skills, advocacy skills, teaching skills, organizational skills, and knowledge base on specific health issues. Institutions continue to provide program-specific training additional to the certification training. Clients of CHWs/Promotores de Salud are generally immigrants, women, those uninsured, homeless, rural residents, migrant workers, and colonia residents. In 2001, the American Public Health Association passed an official policy resolution, “Recognition and Support for Community Health Workers’ Contributions to Meeting our Nation’s Health Care Needs,” which identified the need to “brand” the profession in order to promote policy, program development, program evaluation, and the growth of the field. In light of the increasing need for delivering effective health care to the low-income minority populations, the Health Resources and Services Administration (HRSA) and Bureau of Health Professions of the US Department of Health and Human Services (USDHHS) conducted an extensive study between 2004 and 2007 on the CHW workforce as a component of cost-effective strategies addressing the health care needs of underserved communities. The Health Resources and Services Administration 2007 study identified five roles of CHWs in the health care process: (1) member of health care delivery team, (2) navigator, (3) screening and health education provider, (4) outreach/enrolling/informing agent, and (5) organizer. These roles were not always mutually exclusive. This model of care enhances productivity of 471 C 472 C Community Health Workers the medical team in certain situations, such as patientprovider communication and tracking patients with unreliable addresses or transportation. Promotores De Salud All of the world’s cultures have a lay health care system made up of people who are natural helpers-community members whom neighbors approach for social support and advice. CHWs work throughout the world in countries such as Africa, Brazil, Korea, India, Ethiopia, China, Vietnam, Bangladesh, Haiti, Kenya, and Mexico. They work in areas such as surveillance, respiratory treatment, immunizations, birth control injections, chronic disease management, eye care, TB, neonatal mortality reduction, vaccinations, child survival, Malaria, and anemia. In Latin America and Latino communities in the USA, the term Promotores de Salud refers to CHW, community members who advocate for the well-being of their community and have the necessary training, experience, and dedication of their time to help improve the health and wellness of their community members. In the USA, Promotores de Salud are lay members of the community, who work either for pay or as volunteers in association with the local health care system in both urban and rural environments. They usually share ethnicity, language, socioeconomic status and life experiences with the community member subgroups they serve. They are usually of Hispanic/Latino descent, live in the Hispanic neighborhoods and immigrant communities, speak the Spanish language, and desire to help educate and empower the community on health issues. They come from all walks of life; they may have little education or be trained nurses, dentists or doctors from their countries of origin such as Mexico. Nationwide, there were approximately 86,000 CHWs/Promotores de Salud in 2000. Approximately 17 states are currently in some stage of state certification (Alaska, Arizona, California, Connecticut, Florida, Indiana, Kentucky, Massachusetts, Mississippi, North Carolina, New Mexico, Nevada, Ohio, Oregon, Texas, Virginia, and West Virginia). There are currently 6,300 estimated employers of CHWs/Promotores de Salud for the nation as a whole. Nationally, paid positions range from $7–$15/h. In some areas they are paid via stipends, other incentives such as mileage reimbursement, or other types of compensation. Implications for Immigrant Health Because the health of immigrant populations has the potential to deteriorate when they move to the host country there is the need to assist them with culturally appropriate services. Promotores de Salud have been granted the roles of health educator, client advocate, outreach, and health system navigator because they share the same cultural identity and can relate to the needs of the new comers in the host country. Similar levels of acculturation in terms of shared language and years of residence by the Promotor and the immigrant persons can play a vital role in improving immigrant’s trust and addressing their concerns. Unlike physicians, nurses, and other allied health professionals that work primarily in clinics or offices, promotores work mainly in community-based settings and in clients’ homes. This community-based work allows them to reach deep into their communities and to connect people who are isolated and hard-to-reach with needed health and human services such as immigrants. The potential of Promotores de Salud to assist immigrants and to improve their health have attracted the attention of several organizations that are funding innovative approaches to deliver health and social services to immigrants with the participation of Promotores de Salud. Examples of health services and health promotion activities include: (1) the Blue Cross and Blue Shield of Minnesota Foundation Healthy Together initiative that promotes the mental health and social adjustment of new Americans; (2) the Deaf Community Health Worker project, in St Paul Minnesota that provides community health worker services to deaf immigrants and their families to help them navigate the health care system; (3) The Vietnamese Social Services of Minnesota, in St. Paul, that provides mental health and social adjustment support for newly arrived refugees from Burma through the use of a community health workers; (4) the Faribault Diversity Coalition that engages immigrants and long-time residents in creating inclusive, welcoming communities in Faribault; and (5) the Mayo Clinic, Rochester, Minnesota project that documents how community health workers in primary care medical practices improve patient health outcomes. The CHW/Promotores de Salud are definitively making a difference and improving the health and the lives of immigrants and newcomers in communities in the USA and throughout the world. Community Organizing Related Topics ▶ Community-oriented primary care ▶ Community programs ▶ Cultural competence ▶ Promotora ▶ Social networking Suggested Readings Balcázar, H., Luna Hollen, M., Medina, M., Pedregn, V., Alvarado, M., & Fulwood, R. (2005). The north Texas salud para su corazon promotor/a outreach program: an enhanced dissemination initiative. The Health Education Monograph Series Special Issue on Minority Health, 22, 19–27. Luna Hollen, M., Balcázar, H., Medina, A., & Ahmed, N. (2002). The North Texas Salud Para Su Corazón (health for your heart) Outreach Initiative: Serving Hispanics in Fort Worth and Dallas. Texas Public Health Association Journal, 54, 5–12. Massachusetts Department of Public Health. (2005, March).Community health workers: Essential to improving health in Massachusetts. Findings from the Massachusetts Community Health Worker Survey. Boston (MA): Division of Primary Care and Health Access, Bureau of Family and Community Health, Center for Community Health, MDPH. Medina, A., Balcazar, H., Luna Hollen, M., et al. (2007). Promotores de Salud: Educating Hispanic communities on heart-healthy living. American Journal of Health Education, 3(4), 194–202. National Fund for Medical Education. (2006). Advancing community health worker practice and utilization: The focus on financing. San Francisco (CA): Center for the Health Professions, University of California at San Francisco. United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. (2004). REACH 2010 Promotora Community Coalition Model, Rio Grande Valley in Texas. El Paso (TX): United States-Mexico Border Health Commission. Suggested Resources Community Health Worker Training and Certification Program website, Part of the Office of Title V and Family Health. Retrieved May 10, 2010, from Texas Department of State Health Services Website: http://www.dshs.state.tx.us/chpr/chw/default.shtm General CHR Information, History & Background Development of the Program [Internet]. Rockville (MD): U.S. Department of Health and Human Services, Indian Health Service; [updated 2006 Mar 30/cited 2006 Oct 21]. Retrieved March 28, 2010, from http://www.ihs.gov/NonMedicalPrograms/chr/history.cfm U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions. Community Health Worker National Workforce Study, 2007. Retrieved May 3, 2010, from ftp://ftp.hrsa.gov/bhpr/workforce/ chw307.pdf C 473 Community Organizing CHAD T. MORRIS Roanoke College, Salem, VA, USA Immigrant health efforts are frequently more successful when community members play a significant role in goal setting, planning, and implementation. Community organizing refers broadly to any effort to bring together members of a given community to assist in the creation of social change. In practice, community organizing efforts vary greatly. Some community organizing efforts are expert-driven, beginning in a social service agency or academia, while others trace their (grass)roots to community members themselves. Targeted participants may include individuals, established organizations, or both. The goals of the organized group may approach multiple issues or a single issue, with varying degrees of specificity. Further, community organizing efforts vary tactically from conflict-based, wherein one or more community entities are specifically opposed, to consensus-based, wherein agreement from all stakeholders is seen as key to achieving the group’s goal(s). “Community” in this context often refers to a particular geographic location, but may also be based on shared interests or characteristics (e.g., ethnicity, immigrant status). In all cases, the principal benefit of community organizing is the combination of multiple perspectives and resources to affect change. This benefit is an increasingly common focus in public health practice, including efforts at health promotion and policy change for immigrant populations. While broader efforts at community organizing have arguably existed for millennia, the term itself is emergent from immigration and poverty discussions in the late 1800s, having first come into use alongside social reform efforts such as the settlement house movement in England, the USA, and Russia. Labor, civil rights, and other social movements worldwide throughout the nineteenth and twentieth centuries served to add to evidence of the effectiveness of community-based social change strategies. Today, such strategies are deemed by health and development agencies to be crucial not only for C 474 C Community Organizing creating change, but for building community capacity to ensure sustainability and future problem-solving ability. Community organizing is defined broadly by some as an overarching term synonymous with “community development” and “community-building,” but specifically by others as a methodological practice within community development, with community-building as an intended outcome. Evidence-based medicine, community-based participatory research, and the proliferation of the coalition model are all similar methodologies designed to bring multiple perspectives and/ or resources to bear in support of public health efforts, including immigrant health programs, and have all been encouraged by the World Health Organization (e.g., the Healthy Cities Movement) and other health and development agencies. Community organizing includes these benefits and may make use of the methodologies mentioned above, but differs in that community members play a role in community organizing efforts beyond that of serving merely as consultants or focus group/survey/interview respondents. This is especially important in immigrant health efforts, as such efforts are in danger of further marginalizing those they purport to serve absent immigrant voices in planning and implementation. Elements of Successful Organizing Efforts Successful community organizing efforts frequently begin with the identification of key community stakeholders – individuals or organizations within a given community whose networks are strong and who have a clear desire to create change. There is ample evidence that organizing efforts focused on immigrant communities should involve members of the immigrant population as early in the planning process as possible. Ideally, the organized group grows as additional stakeholders are added through member networks and purposeful flow of information about the group’s existence into the broader community. Effective leadership, diverse participation, and clear goal setting are seen as crucial elements of successful community organizing. Leadership skills such as conflict management, resource mobilization, and communication have all been found to correlate positively with effectiveness of community groups. Many successful immigrant-focused community organization efforts can be traced back to one or more dynamic leaders within the immigrant community with the time, energy, interpersonal skills, and community rapport necessary to coordinate change efforts and influence community participation. Agencies that have sought to create community organization efforts have often encountered success by turning over group leadership to a community member. Diverse participation is critical in both conflict- and consensus-based organizing efforts. Diverse participation combats marginalization by ensuring that multiple perspectives are included in any discussion of social change, heightens the chance of collateral benefits of organizing efforts in terms of increased community connectedness, and serves as a source of group momentum and influence. Diverse participation, however, requires that communicative barriers arising from different socioeconomic status, culture, historical background, and ethnicity be openly acknowledged and addressed. Members of oft-marginalized community groups, immigrant groups included, may, for understandable reasons having to do with historical and ongoing inequity, be reluctant to fully discuss their perspectives, holding back “hidden transcripts” that would be of great value to the change effort. Open discussion leads to the rapport required to bring hidden transcripts into group consciousness. Effective community organizing efforts do not ignore inequities and power imbalances in the community for fear of creating offense, but instead address them freely and openly, acknowledging that such differences continue to exist in society. Similarly, and especially in the context of immigrant health efforts, leaders should avoid viewing individual group members as spokespersons for the entirety of a particular ethnic or cultural group, preferring instead to continually expand group membership to include a wide variety of perspectives that reveal the complex interaction of gender, age, ethnicity, socioeconomic status, and other factors in shaping perspectives. Effective community organization efforts begin with this inclusiveness in mind, but also remain vigilant in ongoing recruitment in order to keep the group from becoming insulated from the broader community. As noted above, the goals of a given community organizing effort may vary in their specificity. Highly specific goals (e.g., hosting a health fair in a community Community Organizing with a high immigrant population) are effective in keeping a group moving in a unified direction, but may not achieve involvement from community members who have other priorities. Broad goals (e.g., improved fitness and nutrition for a city’s entire immigrant population) may appeal to a larger cross section of community members, but differing expectations of how to achieve said goals may result in frustration and barriers to effectiveness. In all cases, it is recommended that goals come from the immigrant community itself, not from a specific sponsoring agency or group. As many public health efforts are grant-driven, this may necessitate work alongside members of the immigrant population in grant writing, as well. The freedom of immigrant and other community members to establish their own priorities results in more community involvement and greater program efficacy. Second, goals should be clearly communicated to each group member and reinforced frequently. This practice helps ensure that the group doesn’t spend time and resources on efforts that some group members see as tangential, thus avoiding departures as member expectations aren’t met. Finally, goals should be periodically addressed and, if needed, redefined in accordance with changing community perspectives and resources. Conflict-Based Versus ConsensusBased Organization Both initial and ongoing stakeholder identification may require community organizers to envision one of two theoretical pathways: conflict- or consensus-based organization. Conflict-based organization, such as that popularized in the 1970s by Saul Alinsky’s Industrial Areas Foundation and similar efforts and used still today in some immigrant-focused organizing efforts, typically entails opposition to one or more established groups, such as policy makers or businesses that are seen as directly opposing or blocking the change community members desire. Protests and the media often play central roles in conflict-based organization, which tend to be designed to force change through pressures created by increased community awareness of a particular practice. Conflict-based organization is largely based on a perceived power disparity between the community and those the group is fighting, and may be best indicated in situations where there is ample evidence that those in power have no interest in C creating change. Supporters of conflict-based organization posit that this strategy improves the group’s focus by creating a common “enemy,” thus giving community members added motivation for participation in the group while simultaneously building a commonly held sense of community connectedness or ownership (“communitas” and “social capital” are terms frequently used to describe this phenomenon). Scholars who advise against conflict-based organizing observe that such tactics do result in large numbers of community participants, but that said participation tends to be minimal and brief, such as attendance at a particular protest event. Further, there is the belief that negative targeting of key stakeholders in an effort at social change is ineffective in the long run as it has the potential to create ongoing animosity between targeted decision makers (who are often in positions of power) and already-marginalized community groups. Consensus-based community organizing intentionally brings multiple stakeholders together with the expectation that effective outcomes will emerge as multiple perspectives and resources are combined. This type of community organizing is particularly useful in cases when governmental and social services agencies seek to improve outcomes by engaging the community knowledge base and creating change that is driven by the community itself, thus improving sustainability. Consensus-based community organizing may also have a non-agency, or grassroots, origin. While most consensus-based organizing efforts do not succeed in bringing all possible stakeholders to the metaphorical table, neither do they specifically target particular individuals or groups as enemies. Effective consensusbased organizing programs in immigrant health focus on identifying individuals and organizations that are willing to work for change, building a diverse member base inclusive of members of the immigrant community as well as those in positions of influence over, and those influenced by, the immigrant community. Through various discussion-based consensus-building interactions (meetings are most common, but newsletters, focus groups, surveys, and other informationsharing techniques have also been successful – the key is that group members both share and receive information), a clearer picture of priorities for change (community needs), resources available (community assets), 475 C 476 C Community Programs and mechanisms for achieving said change is achieved. Because the organized community is defining the focus of its efforts, the potential for development of an expert-driven, “top-down,” program that leaves out or harms certain community members is minimized. There are, however, limits to the number of community voices that can be effectively heard at a given time, or in a given meeting. As such, consensus-based approaches have a tendency to involve fewer people overall than conflict-based approaches. Reticence to seek diverse community involvement out of fear of multiple perspectives hampering group momentum is a common pitfall in consensus-based efforts, and perhaps particularly common in immigrant-focused efforts as “experts” discount the value of local understandings and networks, resulting in groups that falsely purport to be representative of a given community. A capacity for increased community connectedness exists in the consensus-based approach, but differs from that emergent from the conflict-based approach in that connections are made across levels of community influence but between fewer people overall. Finally, the consensus-based approach tends to address complexities surrounding a given issue more effectively than antagonistic approaches, which often rely on less nuanced oppositional viewpoints. Many immigrant health-focused community organizing efforts have effectively combined conflictand consensus-based approaches. A conflict-based grassroots effort that begins by protesting the closure of a health clinic, for instance, may transition to a consensus-driven approach after said clinic is preserved and group goals broaden to include local health promotion efforts. Similarly, a consensus-based group may decide that a march on the local mayor’s office is an effective one-time strategy in raising awareness of the group’s existence and concerns. As in all aspects of community organizing, care should be taken to ensure that all group members are involved in decisions regarding group activities and approach. Related Topics ▶ Community ▶ Community programs ▶ Community-based participatory research ▶ Environmental justice ▶ Social capital Suggested Readings Alinsky, S. (1971). Rules for radicals. New York: Vintage. Chaskin, R., Brown, P., Venkatesh, S., & Vidal, A. (2001). Building community capacity. New York: Walter de Gruyter. Chávez, V., Duran, B., Baker, Q. E., Avila, M. M., & Wallerstein, N. (2003). The dance of race and privilege in community based participatory research. In M. Minkler & N. Wallerstein (Eds.), Community-based participatory research for health (pp. 81–97). San Francisco: Jossey-Bass. Chrisman, N. (2005). Community building for health. In S. E. Hyland (Ed.), Community building in the twenty-first century (pp. 167– 189). Santa Fe: School of American Research Press. Freire, P. (1970). Pedagogy of the oppressed. New York: Continuum. Kretzmann, J., & McKnight, J. (1993). Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Chicago: ACTA. Medoff, P., & Sklar, H. (1994). Streets of hope: The fall and rise of an urban neighborhood. Boston: South End Press. Minkler, M. (Ed.). (2004). Community organizing and community building for health. New Brunswick: Rutgers University Press. Suggested Resources University of Kansas Work Group for Community Health and Development. (2010). The community tool box. Retrieved January 17, 2011, from http://ctb.ku.edu Community Programs MARK EDBERG Department of Prevention and Community Health, School of Public Health and Health Services, The George Washington University, Washington, DC, USA The Scope of Community Programs Community programs in this discussion will refer to health-related programs that are implemented at the community level and designed to address factors and characteristics of the community – in this case, immigrant/refugee communities. The term program in this sense does not generally refer to a clinical intervention or medical facility itself, but to a broad range of interventions that may or may not be linked to a clinic/ medical facility, encompassing health promotion and primary prevention efforts, support services for individuals who are ill (e.g., transportation, meals), or interventions to mitigate impacts or secondary transmission Community Programs for those already affected (e.g., tuberculosis, HIV/ AIDS), or human rights and protective programs (e.g., protection against exploitation of women). Most community programs fall in the first category of health promotion or primary prevention. These programs include education, public information/awareness campaigns, screening, outreach, patient advocacy and language interpretation, policy and public advocacy, and targeted behavior change efforts, and are typically implemented by community-based (CBOs) or nongovernmental organizations (NGOs), with funding from a government agency, global NGO, or foundation; evaluation as well as technical assistance are often provided through the latter organizations, a private consulting organization, or a college/university. What Is a Community? While there are many definitions of community for public health purposes the definition provided in the separate entry entitled “Community” is useful here: Community refers to a geographically bounded space that can be understood as a social ecology. That is, within that bounded (yet porous) space there is a particular combination of individuals who live and/ or work there, social groups, cultures and practices, economic relationships, environmental conditions, and resources, all interacting to form a certain kind of interdependent sociocultural unit. Moreover, this “unit” is nested within larger political, economic, social, and cultural structures, so it cannot be considered in isolation. This definition is intentionally aligned with the ecological model of health determinants now prevalent in public health literature, which refers to multiple levels of influence on a particular health issue – individual, social groups and networks, community and society, culture, and political economy. It also includes consideration of the structural relationships between communities and the social orders in which they are embedded. Communities are complex, and composed of multiple subgroups and layers. In immigrant/refugee communities, the interplay of subgroups can be crucial to marshaling the necessary resources to address an issue programmatically. Moreover, immigrant/refugee populations have unique patterns of health and health risk that include health beliefs/practices from the home country; trauma and distress related to difficult C migration experiences, including refugee camps; victimization during migration; loss of resources; and, when in the new country, loss of status and multiple barriers finding income and housing, much less health services, and generational or immigration “wave” differences. One truism for community interventions is that the intervention itself is almost always just part of the picture. Because a community is involved, the interests, needs, politics, resources (or lack thereof), and social structures of the community will inevitably play a role, in several ways: ● The politics of selecting target population(s) and health issue(s) to be addressed. As noted, in any community there are a number of health issues that are important in some way. Specific health issues may have political dimensions, in the sense that an advocacy group or particular interests within the community are trying to increase attention and resources directed to that issue. At the same time, the health issue of focus may be determined by available funding sources – state, local and global. ● Coalitions and community structures of power. Even beyond the selection of target populations and health issues, implementing a community program is typically done through – or at least in collaboration with – community structures of some sort. These may include: government agencies or a specific decision maker; community leaders; task forces or committees; a community advisory board; faith community representatives; businesses; advocacy groups; grassroots community organizations; professional groups, including organizations or associations of health providers; and community coalitions. Any of these kinds of groups and partnerships may have their own motives related to the politics of the community, of preserving or enhancing their position in the community, of gaining control over a particular (health) issue in order to be able to set the agenda, or other reasons. In addition, any of these groups may have internal conflicts and divisions that stem from individual rivalries or different goals/interests. Community expertise. Despite all the complexities, there is no better expertise on the community than 477 C 478 C Community Programs expertise from the community itself, and the diverse groups within it. These are the individuals who know community habits and customary practices, knowledge and attitudes, language, social groups, where things happen (locations), and much more. For this reason, it is important to establish a collaborative relationship so that the community and other program-related (outside) expertise are integrated. Levels of Intervention Given that communities are a mixing bowl in which multiple health-related factors interact, implementing a program typically requires some selection of contributing factors or groups. It is necessary to determine whether a program/intervention should be directed to: ● All subgroups within the geographically defined area (the entire community) ● One or more social or cultural subgroups in the geographic area ● A subset of individuals who are involved in specific risk behaviors (e.g., injection drug users, sex workers) ● In some cases, a subset connected to a particular organizational or employment category/type (e.g., day laborers, or restaurant workers) ● Economic, political, and social structures (business, the health care industry, policymaking bodies, community-based organizations, global organizations) that have an impact on the health problem in that community Program decisions often have to do with scale. Is it more effective to address the community in general with a broad-based or multilevel intervention? Or should the program try to reach a smaller, targeted group or setting that is at high risk for a particular health problem? Broader interventions can be called community interventions; the more targeted kind can be called interventions in a community. These terms are related to the way in which the Institute of Medicine in the USA classifies different types of interventions: universal prevention interventions are those that target a general population; selected prevention interventions are those that target individuals or groups that are at high risk for a particular health problem; and indicated preventive interventions are those targeting families, groups, and individuals with multiple risk factors for a health problem (e.g., programs that combine multiple types of activities and treatment to address multiple factors that occur together as a syndemic, such as poverty, high diabetes risk, and poor diet). In general, community interventions, if effective, tend to result in smaller changes, but over a larger (absolute) number of people. Mass media and community mobilization programs are of this type. Interventions in a community, if effective, tend to result in higher rates of change but with a smaller number of people. Outreach and specialized education or skillbuilding programs fall in this category. These kinds of programs can sometimes lead to broader community change if the targeted subgroup is influential or acts as a bridge to the community as a whole with respect to a health condition (e.g., sex workers and the spread of HIV/AIDS). Finally, a program might not focus on individuals at all, but on systems or policies in the community that affect access to care (e.g., requirements for gender representation, language interpretation, or culturally competent staff). The Process: Assessment, Planning, Implementation, and Evaluation For any kind of community program, there is basically a four-stage process involved. These same general stages are part of most planning models used for community programs in public health, including the PRECEDE-PROCEED and PATCH models, or COMBI (Communication for Behavioral Impact) in global health communications efforts (other planning resources available from the Global Health Council, www.globalhealth.org). The four stages are: ● Assessment: Conducting an assessment is the basis for identifying the nature of the problem, what the key contributing factors are, and who (which populations/subpopulations) is affected. Data useful for assessment may include local public health epidemiological data as well as interviews, surveys, focus groups, or other data you collect from key stakeholders and population representatives. ● Planning: Once you have completed (or are provided with) an assessment, the next task is to design/select an intervention that is appropriate for the problem, contributing factors and population group, and to identify and link up with the Community Programs resources, community collaborating partners, and staff needed to implement the program. It is also at this stage when an evaluation should be designed that matches what the planned program seeks to achieve. For immigrant/refugee programs, the planning stage is especially important because it is at this point when collaborations with community groups are key. ● Implementation: Carrying out the intervention also means collecting ongoing process data about how the program is being implemented, and in some cases adapting the program based on what is learned during implementation. ● Evaluation: There are three basic types of evaluation. The terms used occasionally vary, but the three types are: (1) process evaluation – ongoing program data that help determine if the program is implemented as planned; (2) outcome evaluation that assesses short-term changes resulting from the program (e.g., knowledge/skills change, new regulations, behavior changes); and (3) impact evaluation assessing longer term changes resulting from the program, such as increased utilization of health services, change in a specific environmental risk that was causing a problem (e.g., pollution sources), or actual change in the incidence/prevalence of a particular health condition. In the current program environment, evaluation is very important because that is where the evidence base for a particular program is derived, which in turn impacts potential funding. Other Issues: Tailoring, Adapting Programs, and Sustainability Built into this four stage process is the idea of tailoring – ensuring that the community program (1) is based on an assessment and understanding of the health problem as it takes shape in a particular population, subgroup, or community; (2) includes the community in designing, implementing, and evaluating the program; (3) refers, as much as possible, to situations, people, and issues relevant to the target community/population; (4) uses language and materials appropriate for the audience; and (5) schedules and locates activities so that members of the target population can participate. Develop vs. adapt? Though every community and population is unique, a decision must be made about C whether to develop a program or to adapt an existing one. There are often at least some commonalities across situations and communities with respect to a particular health problem, and programs may have been developed before that can be adapted – though this should be done carefully in order not to implement a “canned solution” to a unique situation. Potential program models for adaptation can be found through US or global agency clearinghouses, nonprofit associations focused on a particular health problem or population, professional associations, or government “model programs” databases. In the USA, such databases or compilations are available at the US Centers for Disease Control and Prevention (CDC) and through other agencies in the Department of Health and Human Services. In the global context, model program/best practice information tends to be diseasespecific. UNAIDS, for example, has published such information, but exclusively with respect to HIV/ AIDS programs. Sustainability. This is a sometimes vexing issue that routinely arises with respect to community programs. Funding for such programs is often relatively short term – three or 4 years. In complex community contexts, putting a program in place, and then achieving change, may take longer than that. Thus issues of sustainability and community capacity building must become part of program planning and implementation, for example, training/hiring members of the community to operate the program; engaging community stakeholders (business, civic organizations, etc.) that will have a stake in maintenance of the program; seeking additional sources of funds; applying for continuing funds, and training community members in these skills; and linking the program to others like it as well as to practitioners in the field. Related Topics ▶ Community ▶ Community-based participatory research ▶ Health determinants ▶ Health education ▶ Health outcomes ▶ Health promotion ▶ Refugee health and screening 479 C 480 C Community-Based Participatory Research Suggested Readings Brownson, R. C., Baker, E. A., & Novick, L. F. (1999). Communitybased prevention: Programs that work. Gaithersburg: Aspen. Castles, S., & Wise, R. D. (Eds.). (2007). Migration and development: Perspectives from the South. Geneva: International Organization for Migration. Edberg, M. (2007). Essentials of health behavior: Social and behavioral theory in public health. Boston: Jones & Bartlett. Edberg, M., Cleary, S., & Vyas, A. (2010). A trajectory model for understanding and assessing health disparities in immigrant/ refugee communities. Journal of Immigrant and Minority Health. doi:10.1007/s10903-010-9337-5 (online). Green, L. W., & Kreuter, M. W. (Eds.). (1999). Health promotion planning: An educational and environmental approach (3rd ed.). Mountain View: Mayfield. Kreuter, M. W. (1992). PATCH: Its origin, basic concepts, and links to contemporary public health policy. Journal of Health Education, 23(3), 135–139. Kreuter, M. W., Lezin, N. A., Kreuter, M. W., & Green, L. G. (2003). Community health promotion ideas that work (2nd ed.). Boston: Jones & Bartlett. Levine, R. (2007). Case studies in global health: Millions saved (Essential Public Health Series). Boston: Jones & Bartlett. Makinwa, B., & O’Grady, M. (Eds.). (2001). FHI/UNAIDS best practices in HIV/AIDS prevention collection. Arlington: Family Health International and Geneva: UNAIDS. Portes, A., & Rumbaut, R. G. (2006). Immigrant America: A portrait. Berkeley: University of California Press. Skolnik, R. (2008). Essentials of global health (Essential Public Health Series). Boston: Jones & Bartlett. Trickett, E. J., & Pequegnat, W. (2005). Community interventions and AIDS. Oxford: Oxford University Press. Community-Based Participatory Research LINDA S. MARTINEZ1, FLAVIA C. PERÉA2 1 School of Arts and Sciences, Community Health Program, Tufts University, Medford, MA, USA 2 Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA Community-based participatory research (CBPR) is an applied research approach designed to link theory, research, policy, and practice to inform decision making and foster positive change. CBPR provides academic institutions with a model to bring students, researchers, and community members together with a shared purpose to work toward mutually beneficial goals. In addition, CBPR incorporates knowledge sharing between community and academic partners, and collective social action to address societal inequities. Unlike traditional research approaches, CBPR recognizes the value of diverse community perspectives, and the knowledge they bring to the research process. As such CBPR emphasizes community participation and power-sharing throughout the research process, as well as ownership, capacity building, and empowerment. CBPR approaches are aimed at addressing the underlying social, political, and economic inequities that impact community health and well-being. CBPR has been described in the literature as emerging from the earlier area of action research cultivated by Kurt Lewin in the 1940s and the work of Paulo Freire in the 1970s. These approaches to research, like present day CBPR, accentuate the need to engage community voices that are not often represented in the research process, particularly those impacted by social inequities. Furthermore, early CBPR approaches such as participatory action research (PAR) sought to reduce the oppressive nature of research by promoting powersharing, and the notion of “research with,” as opposed to “research on” the community. CBPR today comes in many different forms which include but are not limited to the earlier models of action research. The Process Integral to CBPR is the research process – a focus on how partners come together in a joint effort to assess and identify community priorities, develop intervention strategies, and decide what strategies are used to facilitate participation, the enhancement of relationships, capacity building, and empowerment. The process in CBPR is vital, as it is centered on the development of trusting relationships between institutional and community stakeholders based on mutual respect, shared decision making, and equity among partners. Because CBPR is asset based and underscores the importance of building on existing community knowledge, all partners are encouraged to contribute throughout the entirety of the research process, learn from one another, and share resources for the creation of sustainable interventions that reflect community Community-Based Participatory Research concerns. With CBPR, the partnership itself can act as a catalyst for change, as residents, community leaders, and researchers take collective action toward a shared vision and mutually established goals. CBPR goals include empowering residents so they may act to advance positive social change at the community level and empowering researchers to engage in research that is meaningful. Empowerment means that communities and researchers alike feel they have the ability and skills to act on the contextual factors that shape local living environments. As such, empowered communities require opportunities for both participation and capacity building, as do empowered researchers. In CBPR, participation refers to the extent to which members of the partnership engage in project activities, fulfill their identified roles, and take on new roles. To overcome potential participation barriers, it is important to provide capacity building to assure that partners feel as though they can fully contribute. CBPR builds community capacity for self determination and leadership, through the development of new relationships and the provision of skills necessary to achieve community health goals. Capacity building provides the partnership with a shared language and strengthens technical expertise among the group by building on individual strengths and valuing the creativity diverse partners bring to the table. Developing partner capacity is necessary if the benefits of participation that facilitate empowerment are to be achieved. Because it is focused on empowerment and participation, CBPR has been identified as a promising approach to developing interventions to tackle health inequities. Its focus on community participation in science allows for the design of health interventions that are community relevant and culturally appropriate, tailored to the values, experiences, practices, and worldview of community members. This is critical as inequities in health have been well documented, yet poorly addressed. A complex set of interrelated social, political, economic, and environmental factors are responsible for the proliferation of health inequities, and the factors that create and sustain them vary across communities among racial/ethnic, cultural, and linguistic minority groups. It is therefore necessary to engage in research that may, by design and intention, C lead to evidence-based interventions to address inequities, especially in underserved immigrant and minority communities. Using CBPR, researcher content area expertise is contextualized by community knowledge, leading to the development of effective health interventions that address community health concerns. Simultaneously, community mobilization and empowerment has the power to spark local policy change to address distal factors that sustain inequities, such as inadequate education and a lack of economic opportunity. Underlying Assumptions There are four key assumptions upon which the principles of CBPR rest. First, partnership is authentic and as such results in “co-learning.” Working side by side in collaboration with community partners facilitates the development of new knowledge on the part of both the university researcher and the community member. While the community partner may be learning about the nature of the research process the researcher simultaneously may be learning about the distinct characteristics of the community and the ways in which historical policies or sociopolitical context shapes the health and well being of community residents. This knowledge is significant from a public health perspective, particularly given the complexity of communities and the multiple factors that determine health in a given community. A second important assumption is that the direct capacity-building efforts are built into the CBPR process. Building community research capacity is essential, as capacity is associated with participation. By building community research knowledge in conjunction with mutual respect and shared decision making, research partnerships can empower community members to participate in the decision-making process. For example, research often involves language that is not common, as well as discipline-specific acronyms. Such language can create barriers to participation and exclude those not trained as researchers. Capacitybuilding efforts such as trainings can be used to increase community knowledge of research terminology, thereby reducing language and disciplinary barriers that curve participation, creating a shared language. Thirdly, knowledge garnered should be of interest to and benefit all partners. That is to say that all partners 481 C 482 C Community-Based Participatory Research should be aware of the research findings and interested in the outcomes, implying that all are involved in the design and have a stake in or ownership of the research outcomes. Finally, it is assumed that the partnership has committed for the long term. Given the complexity of health disparities and the multiple factors that contribute to both creating and sustaining them, efforts at addressing them require a commitment over time. For example, a research partnership that designs and implements an intervention may be years later using their findings to advocate for local policy change. The Challenges Despite its benefits, the challenges to engaging in effective CBPR are many. Researchers have described key ethical challenges for the CBPR partnerships, for example, the notion of research that is. With CBPR the study focus or research question is described as emerging from the community. However, this is not generally the case as community priorities involve improving or creating services and programs, assuring access and grassroots action, not research. More often it is the case that the community is approached by a researcher with similar interests, the challenge being how to ensure that the focus area of the researcher is that of the community. Additionally challenging is discerning who or what constitutes community. Do agency leaders and service providers make up community or actual residents living in the community and if so, who? In essence, how can we be sure that the research agreed upon is reflective of community priorities, and that the partners at the table are representative of community? This is especially true given the disconnect that often exists between community service providers and consumers of services. As researchers begin to partner with communities, particularly immigrant communities, to engage in research partnerships it is essential that they explore the notion of who/what constitutes community first. Insider–outsider tensions are also described as a challenge in CBPR. Communities are complex, adaptive systems with unique sociopolitical histories; as such tensions can arise as the result of historical distrust of outsiders, such as researchers. Even when there is a cultural or racial concordance between researchers and the communities with which they are partnering, research holds a level of power and privilege that can lead community members to perceive them as outsiders. As such, partners must reflect on their position and what they bring to the table, recognizing their roles. Similarly, because CBPR is often practiced to address racial and ethnic disparities in health, issues of racism must be addressed – particularly as Whites are overrepresented among researchers. Dissemination is an additional challenge faced by CBPR partnerships. Consider the different ways in which researchers and community partners disseminate their work. While researchers are interested in scholarly publications, community partners are more likely to produce reports, use findings to improve service delivery, or to advocate for additional services. These activities are associated with different time frames – where community dissemination is immediate and scholarly dissemination is time consuming. In addition, researchers may want to hold back on sharing findings until peer-reviewed articles have been published, which is an ethical dilemma if the goal of CBPR is to move from research to action. This is particularly true because a basic principle of CBPR is to share research findings using them as a tool to facilitate grassroots action. Conclusions Although CBPR poses a number of challenges to researchers and the community, its benefits cannot be denied, partnering with community contextualizes research and interventions giving them meaning and relevance. This is crucial if the deleterious effects of the social hierarchy that produce and sustain health inequity are to be addressed. In addition, CBPR has the potential to generate new knowledge that is community specific and the power to move findings from theory into practice. Incorporating community perspectives and expertise throughout the research process increases the capacity of researchers to engage in the community and the capacity to incorporate research findings in advocacy efforts. This is particularly relevant as community demographics shift, given that new immigrant populations may experience the determinants of health differently, calling for community-specific and culturally appropriate interventions. Community-Oriented Primary Care Related Topics ▶ Community ▶ Community organizing ▶ Environmental justice ▶ Ethical issues in research with immigrants and refugees ▶ Health disparities ▶ Research ethics Suggested Readings Agency for Healthcare Research and Quality. (2007). National healthcare disparities report (No. AHRQ Publication No. 080041). Rockville: Agency for Healthcare Research and Quality. Allen, P. M. (1997). Cities and regions as self-organizing systems: Models of complexity. London: Gordon and Breach. Fawcet, S., Paine-Andrews, A., Francisco, V., Schultz, J., Richter, K., Lewis, K., et al. (1995). Using empowerment theory in collaborative partnerships for community health. American Journal of Community Psychology, 23(5), 677–697. Leung, M. W., Yen, I. H., & Minkler, M. (2004). Community based participatory research: a promising approach for increasing epidemiology’s relevance in the 21st century. International Journal of Epidemiology, 33(3), 499–506. Minkler, M. (2004). Ethical challenges for the “outside” researcher in community-based participatory research. Health Education & Behavior, 31(6), 684–697. Minkler, M. (Ed.). (2006). Community organizing and community building for health (2nd ed.). New Brunswick: Rutgers University Press. Minkler, M., Vasquez, V. B., Chang, C., & Miller, J. (2008). Promoting healthy public policy through community-based participatory research: Ten case studies. Berkeley: University of California, School of Public Health and Policy Link. Minkler, M., & Wallerstein, N. (Eds.). (2003). Community-based participatory research for health. San Francisco: Jossey-Bass. van Ryn, M., & Fu, S. S. (2003). Paved with good intentions: Do public health and human service providers contribute to racial/ ethnic disparities in health? American Journal of Public Health, 93(2), 248–255. Wallerstein, N. (2006). What is the evidence on effectiveness of empowerment to improve health? Copenhagen: World Health Organization. Wallerstein, N. B., & Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7(3), 312–323. Suggested Resources http://depts.washington.edu/ccph/commbas.html http://mailman2.u.washington.edu/mailman/listinfo/cbpr http://www.aapcho.org/site/aapcho/section.php?id=11295 http://www.cbprcurriculum.info/ C 483 Community-Oriented Primary Care KIMBERLY WILLIAMS1, BRAD WALSH2 1 School of Public Health, University of North Texas, Health Science Center at Fort Worth, Fort Worth, TX, USA 2 Population Medicine, Parkland Health & Hospital System, Dallas, TX, USA Community-Oriented Primary Care: Past and Present Background Community oriented primary care (COPC) is a defined systematic approach to health that brings the community into the primary care planning and health care delivery process. COPC aims to improve the health of the community, not just those receiving direct patient care services. Unlike traditional medicine, COPC is based on principles in the fields of epidemiology and public health in addition to primary medicine and preventive care. The team of health practitioners, health professionals, and community leaders comes together to address the specific health needs within diverse communities on a local and global level. COPC originated during the 1940s in South Africa through the efforts of Sidney and Emily Kark, two physicians that implemented a health delivery system in an impoverished, rural area of South Africa (Pholela, Natal). Appointed by the South African Government, Dr. Sidney Kark was given the task of developing a primary care system that focused on curing diseases as well as disease prevention. The framework he introduced centered around five basic questions to be investigated: (1) What is the community’s current state of health? (2) What are the factors that have contributed to this health state? (3) What is being done about it? (4) What more can be done and what is the expected outcome? and (5) What measures are needed to continue health surveillance of the community and to evaluate the effects of the existing programs? A population-based system, COPC requires: (1) a community-based, primary care practice; (2) an C 484 C Community-Oriented Primary Care identifiable population or community for which the practice assumes responsibility for effecting change in health status; and (3) a planning, monitoring, and evaluation process for identifying and resolving health problems. The central tenet is to treat the patient in the community context. As an example, the first proposal for the United States Office of Economic Opportunityfunded health centers in the United States notes that: “the need is not for the distribution of services to passive recipients, but for the active involvement of local populations in ways which will change their knowledge, attitudes and motivation.” The World Health Organization (WHO) and United Nations Educational, Scientific and Cultural Organization (UNESCO) endorsed the COPC model at the Alma-Ata Conference on Primary Care in 1978. In 1982, the Institute of Medicine in the United States convened a conference on expanding research into COPC. Following the conference, progress toward fuller implementation of COPC concepts in the United States and elsewhere were noted. COPC has continued to expand in the developed and developing world. COPC as an approach to specific clinical issues such as chronic heart disease management, application of COCP for pediatric populations and for migrant Muslim women in Germany, and evidence of COPC in Spain and Brazil underscore the expansion of COPC to vulnerable populations and communities globally. The COPC model combines applied epidemiology, collaboration with the community to prioritize health issues, and define the community interventions, evaluation, and monitoring. This model promotes collaboration and coordination among the community and health care professionals; creating an environment whereby trust is created among the community, the health system, and health care practitioners. These linkages tie together the needs assessments, interventions, and outcomes. Components of COPC COPC transforms the traditional, doctor–patient health model into a health care provider–community health model. Since the 1970s, the WHO has recognized the importance of community participation and its benefits. These benefits include increased health benefits, efficiency, equity, and self-managed care. Unlike the traditional clinical practice model, the COPC program model relies heavily on input from the surrounding community and then develops a health plan that will address the community’s specific needs. The COPC model contains three basic components: (1) a primary care practice providing accessible, comprehensive, coordinated, continuous, and accountable health care services; (2) a defined community for whose health the practice has assumed responsibility; (“Community” refers to either geographic or social communities, or a combination of both; groups that form within the workplace, church, or schools; or persons enrolled in a common health plan, but not made up of the active patients in a practice); and (3) a cyclical process that includes six important steps: Defining the Community Defining the community is an integral part of the COPC process, since the term “community” can be defined many different ways, and relies on presumptions about geography and patient populations. Inaccurate definition of the community can impede the COPC process by misdiagnosing the population and suggesting the wrong intervention. A clear understanding of the population that will be served and making community involvement easier throughout the process is essential for success. While the Karks’ initial work focused on a geographically defined community, communities can also be defined by sex or gender, race, or other demographic descriptors; by language, religion, or other cultural groupings; by employment status, immigration status, or other legal categories; or other characteristics. While quantitative data are essential to achieving an understanding of a community, qualitative data such as focus group findings, oral histories, or key informant interviews can also play a critical role in understanding what defines a community. Characterizing the Community Following the definition of the community, the next task is to describe the community. The characterization of a community, using parameters such as geographic or political boundaries, languages, ages, social norms, economics, and the environment can be compared to the general population and other peer communities to help sharpen an understanding of the specific characteristics of the community. Boundaries such as census tracts, health services areas, ZIP Codes, and even Community-Oriented Primary Care political jurisdictions are considered in characterizing the community profile. Birth and death data, health care utilization data, topographical characteristics, socioeconomic data, health attitudes survey data, and any other variables which influence an individual’s health can be incorporated. By gathering data on the community, a snapshot of health status will be formulated and health problems will be identified for intervention. Understanding and describing the community its groups and issues are essential before any planning occurs. Prioritizing Community Health Problems Identification of health problems for intervention includes weighing and prioritizing issues suggested from community leaders, health advisory boards, and needs assessments. Selecting the first among many issues to be addressed is a crucial step in the process. Community involvement plays a critical role in this part of the COPC process. Determining priority areas rely heavily on what the community views as their greatest concerns. Planners must weigh the views and perspectives and avoid prioritization schemes that favor one subgroup of the community over another. Community priorities are often directed at issues with a bearing on health status but seem to have little relationship to the medical care system. These issues can include such variables as: education, access to meaningful employment, teenage pregnancy, transportation, and safety. Clinicians who dismiss these issues as irrelevant to clinical care, or unchangeable, risk losing the support of the community stakeholders involved in the COPC process. These priorities reflect the determinants of health as defined by genetic endowment, social circumstances, environmental exposure, health care and behavioral patterns. Detailed Assessment of the Health Problem Health problems selected as priorities must be completely assessed by the planning team. Assessment of the problem requires the analyzing of available data whenever possible (disease incidence and prevalence data, survey results, mortality rates, etc.). However, data may not adequately describe the problems, especially in communities with lack of access to health care or where surveying the community is difficult. C Estimates and anecdotal data generated by those most familiar with the community may help make up for missing data. Community members and stakeholders included in the assessment process can bring their own perspectives to the issues. For example, the community members may be able to help the planning team understand how past health interventions have fallen short, or why community members have responded to a survey in a particular way. As the team examines each health problem, relationships between seemingly unrelated health problems may emerge, noting relationships specific to this community. Unexpected opportunities for synergy, coalition-building, or efficiencies may be uncovered while assessing prioritized health problems. Intervention After a complete assessment of the problem has been conducted, the intervention is developed. Several approaches may be identified; however, the COPC team will analyze and choose the most successful, practical, and feasible intervention for the population. The intervention will also be problem specific. Factors such as insurance status, available resources (equipment, staff, facilities, etc.), access to transportation, potential language barriers, as well as social and cultural norms are factors influencing the implementation of the most appropriate intervention. Interventions must be scientifically justifiable, evidence-based, and shown to be effective in practice. They must also be reviewed, accepted, and approved by community members to ensure feasibility. The provision of primary care clinical services such as adult health, pediatrics, or behavioral health are often the focus of a COPC intervention. However, especially for low-income communities or those with problems with access to health care, interventions may need to go beyond physician care to include access to prescription drugs, transportation to the site of healthcare services, help with language or cultural barriers, safety for patients, referrals for specialty or hospital care, nutritional assistance, chronic disease management education, or other health-related services. A COPC planning team that has done the work of involving the community throughout the process will be less likely to be surprised by barriers to achieving optimal health. 485 C 486 C Community-Oriented Primary Care Evaluation Evaluation of the intervention is a necessary component of the COPC process. By measuring specific outcomes, the COPC team can identify what components of the intervention worked, what components did not work, and why. Evaluation of the outcomes leads to a reassessment of the priorities and determines if the process merits continuation in the community Evaluation should be an aspect of the initial plan that accounts for the impacts of services and permits adjustment of services as needs change. The completion of the evaluation step includes outcomes that support the next cycle of the planning process, keeping community contacts engaged and other stakeholders available for the subsequent redefinition, and refocusing of assets and reevaluation of outcomes. COPC Today For over 25 years, the COPC model has been used in many types of health care environments in assessing disease risk factors, addressing previously unrecognized health problems, assessing the costeffectiveness of strategies, and identifying and targeting the skewed distribution of various diseases. Today, the COPC model has been applied in a wide variety of clinical settings, from the rural villages in South Africa, to urban clinics in the United States and Israel, to general practices in the United Kingdom. Below are two current examples: Hadassah Community Health Center: Kiryat HaYovel, Jerusalem Hadassah Community Health Center has used the COPC model since the 1960s and continues to demonstrate and teach the model. As a result, there has been a measurable reduction in a nemia due to pregnancy, hypertension, cardiovascular risk, an improvement in disparities in infant development between the privileged and unprivileged, and an increase in the use of family planning. Parkland Health and Hospital System: Dallas, TX Parkland is one of the largest public hospitals and health systems in the United States and falls under the jurisdiction of the Dallas County Hospital District, whose primary purpose is to provide medical aid and hospital care to the indigent and needy that live in Dallas County. Parkland’s outpatient clinic system utilized the COPC model from its inception in the 1980s and continues to do so. The system consists of 11 centers providing multiple primary care services (pediatrics, adult health, dental services, and adolescent health) as well as a robust homeless outreach division and a network of school-based clinics. The Parkland System has instituted clinics for refugee health, optometry, podiatry, and behavioral health care after analyzing demand for services. An annual review of outcomes and epidemiologic data is integral to the system. Demographic change in this fastgrowing county has driven shifts in resources and new center construction as patient populations follow jobs and affordable housing around the county. All Parkland COPC centers have standing community advisory boards that review service offerings and serve as liaisons to the community. These boards also include representatives from other stakeholders in the community, including health care providers, nonprofit organizations, schools, and civic groups. The Parkland COPC clinic system sees over 300,000 clinic visits per year, the majority of which are uninsured or on Medicaid. Conclusion COPC as a model of primary health care can provide primary care based on the needs of the community, whether that community consists of immigrants, specific ethnic groups, vulnerable populations, or a homogeneous group. The model focuses on including the community decision makers, providing prevention and health promotion as core competencies, and community and individual problem solving. Immigrants can benefit from a process that includes their contributions in designing services to suit their particular needs. COPC is designed to create a system of care that opens access and is designed to use the existing assets of a community. It should improve efficiency and effectiveness and as a worldwide model should be advantageous as a primary care model in any type of location, be it urban or rural, developing, or developed. Related Topics ▶ Community ▶ Health care ▶ Vulnerable populations Compadrazgo Suggested Readings Abramson, J. H. (1988). Community-oriented primary care – strategy, approaches, and practice: A review. Public Health Reviews, 16, 35–98. Connor, E., & Mullen, F. (Eds.). (1983). Community oriented primary care, new directions for health services delivery: Conference proceedings. Washington, DC: National Academy Press. Cuetro, M. (2004). The origins of primary health care and selective primary health care. American Journal of Public Health, 94(11), 1864–1874. Epstein, L., Gofin, J., Gofin, R., & Neumark, Y. (2002). The Jerusalem experience: Three decades of service, research, and training in community-oriented primary care. American Journal of Public Health, 92, 1717–1721. Geiger, H. J. (1993). Community-oriented primary care: The legacy of Sidney Kark. American Journal of Public Health, 83(7), 946–947. Longlett, S. K., Kruse, J. E., & Wesley, R. M. (2001). Communityoriented primary care: Historical perspective. The Journal of the American Board of Family Practice, 14, 54–63. Mullan, F., & Epstein, L. (2002). Community-oriented primary care: New relevance in the changing world. American Journal of Public Health, 92, 1748–1755. Nutting, P. A., Wood, M., & Moore, E. M. (1985). Communityoriented primary care in the United States: A status report. Journal of the American Medical Association, 253(12), 1763–1766. Pickens, S., Boumbulian, P., Anderson, R. J., Ross, S., & Phillips, S. (2002). Community-oriented primary care in action: A Dallas story. American Journal of Public Health, 92(11), 1728–1732. Wright, R. A. (1993). Community oriented primary care: The cornerstone to health reform. Journal of the American Medical Association, 269(19), 2544–2547. Suggested Resources Nevin, J. E. (1995). Community-oriented primary care. Health Policy Newsletter 8(2) Article 7. Retrieved June 16, 2010, from http:// jdc.jefferson.edu/hpn/vol8/iss2/7 Compadrazgo MAURA I. TORO-MORN Department of Sociology and Anthropology, Illinois State University, Normal, IL, USA The practice of compadrazgo (godparenting, ritual kinship) goes back to the colonization of the Americas by Spain and Portugal. Historically, compadrazgo (godparenting) has been (and still is) a cultural practice C connected to religious rituals through a person’s life: baptism, confirmation, first communion, and marriage. Through each of these rituals, padrinos (godparents) enter into social relations of obligation and close friendship with members of another family. Historians suggest that the practice of compadrazgo shaped social and cultural life during and after the colonization and settlement processes in Latin, Central America, and the Caribbean. Visiting comadres (godmothers) was an important social activity for women because it cemented gendered and family bonds between women of the same social class. The practice of compadrazgo extended family bonds beyond those of blood-related family members. Although the practice has been attributed to the Spanish and Portuguese colonizing elites, there is evidence to suggest that complex sponsorship ceremonies also existed among Aztec and Mayan Indians prior to colonization. After colonization, descendants of indigenous people have also adopted this cultural practice. Historians also maintain that the tradition of compadrazgo was embraced by Africans and their descendants in the Americas as a way to create bonds of obligation between people. The most popularly known form of compadrazgo is connected to a child’s baptism. At the time of the baptism, surrogate parents (padrinos) are named and introduced to the community through the baptism ceremony. The selected madrina (godmother) and padrino (godfather) become compadres (godparents) of the child’s parents. By accepting the role of padrinos, the couple promise to care for the child in the event that something happens to the biological parents. The most significant religious commitment is the promise to help raise the child according to Christian/religious values. Today, compadrazgo is both a religious and cultural practice that characterizes Latino families across the hemisphere. Researchers have conducted numerous studies about the practice of compadrazgo in Mexico. They have documented how the cultural significance of this practice extends beyond the relationship of responsibility to a godchild, but more importantly in the relationship between compadres, which become social ties between two families. Therefore, Hispanic/Latino families tend to be large and each child is entitled to padrino and madrina, thereby increasing the number of people an individual considers kin. A clear advantage 487 C 488 C Compadrazgo of compadrazgo is that it increases the social capital and resources of individuals and families. Anthropologists argue that underlying compadrazgo relations lie a complex structure of relations, hierarchy, and behavior that needs to be studied more systematically. Research conducted in Oaxaca, Mexico, for example, confirms that compadrazgo rituals continue to be connected to the religious rituals of baptism, confirmation, and first communion, but that the most prestigious and onerous is the ritual connected to the baptism ceremony. In Oaxaca, godparents pay for the child’s baptismal clothing and other needs. When the child marries, they pay for the wedding clothing, offer a large gift, and in some cases may sponsor a party for the newlyweds at their house. Confirmation godparents also incur some expenses in that they are also responsible for the child’s clothing and provide a chest or cabinet for when the child marries. First communion godparents are expected to give a godchild a large wedding present. In Oaxaca, the responsibilities and expectations of godparenting bind community members in deep and complex ways, including most principally the organization of production and labor relations. Godparents with social class status (merchants) recruit godchildren and compadres as workers. In US Hispanic/Latino communities, compadrazgo represents an important cultural institution. For some groups, migration entails the loss of supportive social relations as exemplified by compadrazgo ties. Among Puerto Ricans in the Northeast, for example, researchers have found that the loss of compadrazgo ties has led to poor evaluations of the quality of life and as a consequence poor health outcomes. In contrast, for Dominicans and Colombians, compadrazgo ties are used to facilitate migration. In many rural communities of the Dominican Republic and Colombia, everyone has a “compadre” in the USA. There is also evidence that among some Hispanic/Latino groups, small recreational clubs also offer immigrants an opportunity to facilitate compadrazgo bonds. There is evidence to suggest that compadrazgo ties play a major role in the settlement process as well. Compadres lend each other money, offer help in finding employment, may offer a place to stay in the process of migration, and/or secure business contacts. It is unclear, however, whether these compadrazgo ties function the same way for immigrant men and women. There is some anecdotal evidence to suggest that second-generation Latinos in the USA continue to practice godparenting rituals. Maria Hinojosa’s memoir of the birth of her son, Raul, includes an account of the baptism ritual they developed to maintain this family tradition. Although they felt strongly about the Catholic tradition of padrinos, they made a few adjustments. Raul had four sets of godparents, one for each element, fire, water, air, and earth. During the ceremony, the godparents formed a circle and each set of godparents stood on the four cardinal points. Each set of godparent gave the child a symbolic present for each element. There was drumming and singing and their friends were invited to say or give something to Raul. In the end, Maria Hinojosa writes that they “were creating a new kind of family for him. These people would be his familia now, his mentors and teachers and caretakers, the people who made up his days and nights, the people who may not have been tied by blood but instead by love, and to be frank, by the convenience of proximity.” Related Topics ▶ Family ▶ Hispanics ▶ Latinos ▶ Social capital Suggested Readings Chant, S., & Craske, N. (2003). Gender in Latin America. New Brunswick: Rutgers University Press. Ebaugh, H. R., & Curry, M. (2000). Fictive kin as social capital in new immigrant communities. Sociological Perspectives, 43(2), 189– 209. Griswold del Castillo, R. (1984). La familia: Chicano families in the urban Southwest, 1848 to the present. Notre Dame: University of Notre Dame Press. Socolow, S. M. (2000). The women of colonial Latin America. Cambridge: Cambridge University Press. Stephen, L. (2005). Zapotec women: Gender, class, and ethnicity in globalized Oaxaca. Durham: Duke University Press. Toro-Morn, M. (2008). Beyond gender dichotomies: Toward a new century of gendered scholarship in the Latina/o experience. In H. Rodriguez, R. Saenz, & C. Menjivar (Eds.), Latinas/os in the United States: Changing the face of America. New York: Springer. Zambrana, R. (1995). Understanding Latino families: Scholarship, policy, and practice. Thousand Oaks: Sage. Compliance Compliance MICHELE G. SHEDLIN College of Nursing, New York University, New York, NY, USA The term compliance is generally used to refer to consumer/patient acceptance of recommended health behaviors, and is often assessed by the extent to which a person’s behavior coincides with medical or health advice. It is frequently used in relation to the acceptance of specific required behaviors such as consistent and correct use of medicines or the following of dietary restrictions to correct or prevent a particular outcome or condition. Other terms for these phenomena are adherence, concordance, cooperation, and conformity. Since the term compliance can infer an asymmetric and hierarchical relationship between provider and patient, and the expectation implied is that a consumer/patient will accept provider instructions and will cooperate, there is a clear current preference for the term adherence. Adherence, in fact, implies a more informed and participatory decision by a consumer/patient to follow provider recommendations and/or protocols for medical treatment. Problems with compliance are seen as manifested in missed appointments, failure to take medications, lost prescriptions or medications, and medication misuse. Also, discontinuation of protocols and medications are equated with noncompliance, even when discussed in the light of such obstacles as responses to unwanted collateral effects of the recommended behavior/procedure/medication. Most research has focused on the factors influencing poor compliance and has examined patient characteristics, particular illnesses, or medications most associated with noncompliance. However predictive ability would seem to come from an understanding of psychosocial factors affecting compliance, especially health beliefs including perceptions of vulnerability, the meanings/implications of illness and disease, the perceived costs and benefits of complying, and the quality of the provider–patient relationship. Other factors which may influence compliance are trialability (ability to test out what is recommended), C comprehension (how well the behavior/procedure or medication required is understood), and cultural acceptability (how consonant it is with cultural values and a sense of well-being). The capacity of the consumer/patient to comply is another important consideration. Understanding the cultural acceptability of the required behaviors or health effects of a protocol or medication, while crucial to correct use and continuation, is not sufficient. Lifestyle issues, family influence and behavior, cost, convenience, risk of stigma, and accessibility are factors which may influence a patient’s ability to comply. Addiction, or even the occasional use of illicit drugs or abuse of alcohol, is another factor which may interfere with an individual’s ability to comply. Noncompliance by immigrants is usually attributed to a lack of understanding of the instructions because of language or educational levels, or the willful refusal or misunderstanding on the part of the individual or family. If these assumptions determine the provider/ patient interaction in a medical consult, they may limit communication and thus the resolution of erroneous assumptions, fears, and inadequate information which undermine recommended behaviors. This is especially true where self-administration and daily motivation are required. The effects of this type of consumer/ patient–provider relationship exist despite the fact that in many cultures this dynamic is an expected one, especially between male physicians and female patients. But culturally appropriate or not, the role/status of the provider and the expectations inherent in the term “compliance” can serve as barriers to the correct use and continuation of a medicine or medical protocol. Compliance is affected not only by the provider/patient communication, but such salient issues as the perceived roles and expected behaviors of provider and patient, the characteristics of patients and providers, the type of protocol or program involved, the criteria for compliance, and many other aspects of the context and quality of the health care encounter. Understanding compliance (and the behaviors, attitudes, knowledge, and motivation supporting it) must include identification of the social and cultural factors affecting behavioral decision making which vary with a complex array of factors in immigrant 489 C 490 C Compliance lives. An individual’s or family’s decision not to accept or to follow medical advice may be quite reasonable based upon their knowledge, experiences, or beliefs. Furthermore, continual exposure to controversies and contradictions, even in rural areas and traditional communities of sending countries, can foster fears and a lack of confidence in the alternatives being offered in a new country or community or type of provider. One of the problems in understanding “compliance” is that it is largely understood through outcomes. Except by the analysis of body fluids to determine the presence or absence or actual levels of a medication, for example, providers are usually unable to identify noncompliance until such outcomes as pregnancy, increased viral loads, or frank illness. Methods of assessment such as pill counts and self-report can only provide clues about compliance. There are various steps which can be taken by programs and providers to enhance compliance: Some of those which involve a consideration of specific immigrant needs are: 1. Encouragement of questions in the initial consultation and in follow-up visits when new issues and concerns may have emerged; obviously, a lack of questions does not necessarily indicate satisfaction or compliance, especially in traditional cultures. 2. Understanding of the patient’s level of comprehension of what is recommended. 3. Emphasis on the advantages and the attributes of what is recommended which are culturally acceptable; address the aspects of a medication or procedure which may have negative cultural interpretations. 4. Provision of information about health benefits and their meanings to the individual patient. 5. Direction of attention to media issues or local myths which may undermine required behaviors. 6. Assessment of patient characteristics which would act as barriers to their ability and desire to comply. 7. Assessment of the situational factors which might influence desire and ability to comply. 8. Satisfaction with patient–provider relationships and other aspects of the medical/family planning encounter can facilitate cooperation, understanding, and communication. 9. Referral to, or creation of, a culturally appropriate and accessible mechanism for patient support, especially for counseling and information regarding obstacles to compliance. Clearly, these recommendations place greater responsibilities on the provider. Especially difficult in some cases may be the responsibility to recognize and have some understanding of immigrant needs and the cultural factors which may affect a patients’ motivation and ability to comply. In multicultural settings, the challenge obviously includes a commitment to developing culturally informed and knowledgeable health care teams. Related Topics ▶ Adherence ▶ Barriers to care ▶ Communication barriers ▶ Physician–patient communication Suggested Readings Becker, M. H., & Maiman, L. A. (1980). Strategies for enhancing patient compliance. Journal of Community Health, 6(2), 113–135. Benagiano, G., & Shedlin, M. G. (1992). Cultural factors in oral contraceptive compliance. Advances in Contraception, 8(1), 47–56. Cook, N., Kobetz, E., Reis, I., Fleming, L., Loer-Martin, D., & Amofah, S. A. (2010). Role of patient race/ethnicity, insurance and age on Pap smear compliance across ten community health centers in Florida. Ethnicity & Diseases, 20(4), 321–326. Eraker, S. A., Kirscht, J. P., & Becker, M. H. (1984). Understanding and improving patient compliance. Annals of Internal Medicine, 100(2), 258–268. Jay, S., Litt, I. F., & Durant, R. H. (1984). Compliance with therapeutic regimens. Journal of Adolescent Health Care, 5(2), 124–136. Li, W. W., Stewart, A. L., Stotts, N. A., & Froelicher, E. S. (2005). Cultural factors and medication compliance in Chinese immigrants who are taking antihypertensive medications: Instrument development. Journal of Nursing Measurement, 13(3), 231–252. PubMed PMID:16605045. Roter, D. L., Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36(8), 1138–1161. Sherbourne, C. D., Hays, R. D., Ordway, L., DiMatteo, M. R., & Kravitz, R. L. (1992). Antecedents of adherence to medical recommendations: Results from the Medical Outcomes Study. Journal of Behavioral Medicine, 15(5), 447–468. Uitewaal, P., Hoes, A., & Thomas, S. (2005). Diabetes education on Turkish immigrant diabetics: Predictors of compliance. Patient Education and Counseling, 57(2), 151–161. Confianza Confianza PATRICIA DOCUMET Department of Behavioral & Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA In Spanish, confianza means “hope or firm belief in something or someone,” and also “familiarity.” Indeed, in the English language literature on Latinos, confianza is used for both “trust” and “familiarity,” not one or the other but together. Confianza is a necessity for any personal relationship that includes meaningful interactional behavior within the Latino culture. Confianza provides a comfortable, safe space, where the person can be himself or herself, with no need for false pretenses. A relationship with confianza is by definition personal, involves an informal way of relating that enables the formation of a special bond, and opens the possibility for sharing feelings and concerns at a deep level. Such a relationship also carries the understanding that the information being shared must be kept confidential and not disclosed to others who are not en confianza. Like other cultural characteristics, confianza has to be learned through socialization. The importance of relationships within the extended family in Latino culture could be at the root for the perceived need for confianza. Such intra-family relationships are expected to involve confianza and, in turn, are held as the ideal for all other meaningful relationships. The presence of confianza within a relationship enhances the quality and value of the interaction. This quality, in turn, gives credibility to the relationship. Confianza is closely related to two other integral characteristics of Latino culture: personalismo and respeto. Personalismo is the importance of personal relationships. Respeto is the use of appropriate deferential behavior toward others based on age, sex, social position, economic status, and authority. The exercise of personalismo and respeto in Latino culture engenders confianza. Interestingly, a Spanish version of the Therapeutic Collaboration Scale (TCS) is composed of 14 items that measure personalismo, respeto, and confianza because they are crucial constructs for Latinos’ daily C lives and for the development of a useful therapeutic relationship. Confianza develops under certain conditions that relate to personalismo and respeto: a caring attitude, mutuality, informal communication styles, and repeated contact. A caring attitude shows that the person matters to the other and is demonstrated by asking questions, listening attentively to what the person has to say, or showing interest in the person’s family. Mutuality refers to the sharing of information or experiences. It can also take other forms, from as simple as exchanging a few phrases in Spanish as a way of connecting, to talking about commonalities of food or family background. For example, many educators use their own youth experiences to communicate with students and foster confianza. The crucial aspect of these exchanges is the understanding that is established between the different parties, even if they have unequal power. The informal communication style, characteristic of confianza, helps in creating a connection. However, this informality should not be seen as a lack of respeto; a person could still maintain his or her position within the family/social hierarchy, while communicating informally with others who are older or younger or who hold more or less authority. Repeated contacts are also necessary, because a single contact can only demonstrate the potential for confianza. Confianza can only develop with time, and the investment of a valued resource, such as time, is a way of showing that one cares. Latinos use confianza to evaluate all relationships, including professional ones (e.g., service providers). In fact, some researchers have argued that confianza is the cornerstone for any supportive relationship, especially those that involve giving and receiving information and suggestions. Latinos tend to rate highly physicians who inquire about the patient personally, take time to explain a diagnosis or procedure, and relate some personal information, however small, during the encounter. These same physicians could also expect higher compliance from their Latino patients. The benefits of confianza have been demonstrated in breast-feeding promotion, cancer screening, domestic violence and social work services, education, and psychotherapy. For example, confianza in the doctor coupled with a comfortable communication style has been shown to decrease the embarrassment associated with Pap tests, while the lack of confianza resulted in higher 491 C 492 C Convention Against Torture embarrassment levels and doubts about the service or the tests. In general, Latinos feel that doctor–patient relationships in health care settings in the United States are often rushed and impersonal, and make it difficult to foster confianza. The bureaucratic infrastructure and the lack of continuity of health care have also been shown to hinder the development of confianza. Confianza can be purposively constructed and needs to be maintained. Cultivating confianza makes sense because it can help bring a great deal of cultural understanding into therapeutic or service relationships. Taking the time to develop confianza shows that the provider has the best interest of the patient, client, or student at heart. The same principle that we apply to personal relationships can be applied to organizational settings. Developing relationships with Latino organizations could foster “indirect confianza” for the provider and enhance its credibility. As with personal relationships, organizational relationships require sincerity and trust to establish a bond that can exist over an extended period of time, and are based on proof of positive and contributing actions. This approach could also be used for recruiting research participants. Community members who trust a Latino agency are more likely to trust the research institution that has taken the time to develop a relationship of confianza with the agency. Related Topics ▶ Hispanics ▶ Latinos ▶ Physician–patient communication ▶ Respeto Suggested Readings Belknap, R. A., & Sayeed, P. (2003). Te contaria mi vida: I would tell you my life, if you only asked. Health Care for Women International, 24(8), 723–737. Bracero, W. (1998). Intimidades: Confianza, gender, and hierarchy in the construction of Latino-Latina therapeutic relationships. Cultural Diversity and Mental Health, 4(4), 264–277. Delgado, M. (2007). Social work with Latinos: A cultural assets paradigm. Oxford, UK: Oxford University Press. Dyrness, A. (2007). ‘Confianza is where I can be myself ’: Latina mothers’ constructions of community in education reform. Ethnography and Education, 2(2), 257–271. Gallagher-Thompson, D., Singer, L. S., et al. (2004). Effective recruitment strategies for Latino and Caucasian dementia family caregivers in intervention research. The American Journal of Geriatric Psychiatry, 12(5), 484–490. Monzó, L. D., & Rueda, R. S. (2001). Sociocultural factors in social relationships: Examining Latino teachers’ and paraeducators’ interactions with Latino students (Research Report 9). Santa Cruz, CA: Center for Research on Education, Diversity, and Excellence. Paris, M., Bedregal, L., et al. (2004). Psychometric properties of the Spanish version of the therapeutic collaboration scale (TCS). Hispanic Journal of Behavioral Science, 26(3), 390–402. Convention Against Torture KATHRIN MAUTINO Mautino & Mautino, San Diego, CA, USA The Convention Against Torture (CAT) is the common name for Article 3 of the United Nations Convention Against Torture and Other Forms of Cruel, Inhuman or Degrading Treatment or Punishment. The CAT as enacted in the United States provides that an individual will not be returned to a country where there are substantial grounds to believe that the individual will be tortured. Torture is defined as any act by which severe pain or suffering, whether physical or mental is intentionally inflicted on a person. It does not include pain or suffering incidental to lawful sanctions, including the death penalty. However, the regulations state that lawful sanctions that “defeat the object and purpose” of the CAT can be considered torture. In other words, an individual can argue that some punishments for crime rise to the level of torture even if they are lawful punishments for crimes. An individual can receive CAT relief based upon past torture and the possibility of future torture. Health care professionals trained in recognizing the mental and physical signs of torture are priceless when it comes to developing a successful CAT application. Although some individuals may have obvious physical scars, some individuals inflicting torture have become more sophisticated in developing techniques such as water-boarding, that do not leave a physical sign. Mental health professionals who can write an authoritative statement as to whether, in their opinion, a victim has suffered past torture, are extremely important to the preparation of a good case. Convention on the Prevention and Punishment of the Crime of Genocide CAT relief differs considerably from asylum. In asylum, an individual must establish a well-founded fear of persecution based upon race, religion, nationality, political opinion, or social group. Well-founded fear is often described as a “reasonable person” standard – a reasonable person in that situation would be afraid. CAT relief requires establishing that it is “more likely than not” that an individual will be tortured – a higher standard than for asylum. In addition, CAT does not require showing that the torture is because of one of the five grounds for asylum. Individuals granted refugee or asylee status are eligible to apply for permanent resident status after being in the United States for 1 year. Individuals granted CAT relief are not eligible for permanent resident status. CAT relief maintains the person under the jurisdiction of the Executive Office for Immigration Review (Immigration Court), in a status known as withholding of removal. Individuals in such status cannot leave the United States except in rare circumstances, although they are eligible for work authorization. These individuals are deemed still to be in removal proceedings. Normally, individuals granted withholding of removal are not imprisoned or otherwise detained by the government. Individuals are ineligible for asylum if they are guilty of certain serious crimes, have themselves persecuted others, or are a security threat. However, such individuals remain eligible for deferral of removal pursuant to the CAT. Deferral of removal is more limited than withholding of removal discussed above. Under deferral of removal, the individual can be imprisoned in the United States. Most individuals who are ineligible for withholding of removal are subject to mandatory detention by the government. Such detained individuals are entitled only to have their detention reviewed at regular intervals to determine if the reason for detention remains. In effect, some applicants for CAT relief are accepting life imprisonment in the United States, rather than return to the country of citizenship. At any time, the government can move the Immigration Court to reopen a deferral of removal case based upon new evidence that the individual will not be tortured, including diplomatic assurances from the individual’s country of citizenship. The Immigration Judge is required to hold a de novo hearing, meaning C a review of all of the underlying facts and the relevant law, on whether or not the individual still qualifies for relief. The individual in question also can move to have the deferral of removal order terminated – he or she would then be deported to the country of citizenship. CAT relief is defensive in nature. The regulations provide that the Immigration Judge is the only person who can consider a claim for relief under CAT; unlike asylum, there is no administrative method to apply for CAT relief. Asylum applications generally must be filed within 1 year of an individual’s entry into the United States; however, there is no time limit for applying for CAT relief. Related Topics ▶ Asylum ▶ Detention ▶ Refugee ▶ Torture Suggested Resources United Nations website. http://untreaty.un.org/cod/avl/ha/catcidtp/ catcidtp.html Convention on the Prevention and Punishment of the Crime of Genocide CRISTINA CAZACU CHINOLE Center for Ethics and Public Policies, Bucharest and Iasi, Romania The Convention on the Prevention and Punishment of the Crime of Genocide was the first human rights treaty that was adopted by the General Assembly of the United Nations on December 9, 1948. The key provision of this Convention is that genocide is declared to be a crime under international law and is punishable regardless of whether it is committed in a time of peace or in a time of war. This distinction is important as genocide is seen as different from “crimes against humanity,” whose legal definition specifies wartime. Genocide (from Greek: genos, people or race; and Latin: caedere, to kill) is the systematic attempt to 493 C 494 C Convention on the Prevention and Punishment of the Crime of Genocide destroy and/or eradicate an ethnic, national, racial, or religious group. The term was used for the first time by the Polish writer Raphael Lemkin in 1944, in his work about the Nazi occupation of Eastern Europe. Lemkin, who fled from Germany during World War II to the USA, drafted the International Convention on the Prevention and Punishment of the Crime of Genocide. Yet, although the term “genocide” as such is new, the practice of extermination of entire groups or population is common throughout the entire history of mankind. It was the Holocaust, the systematic killing of Jews, Gypsies, Slavs, political opponents, and the socalled social deviants like homosexuals and the mentally disabled in the Nazi extermination camps that prompted the call for international legislation to prohibit and punish such deeds. The development of legal thinking and procedures after World War II, especially about war crimes and crimes against humanity, paved the way for the development and the adoption of the Genocide Convention. Even if the world was still in shock after the horrors of the Nazi regime, it took a while until the Convention was ratified by the necessary 20 States, and entered into force in January 1951. As of today, 140 States have ratified the Genocide Convention, a treaty that is in line with the priorities set by the United Nations and the modern human rights movement, aiming to eradicate racism and xenophobia. More importantly, it stresses the role of criminal justice and accountability in the protection and promotion of human rights. The Convention is one of the important pillars of the framework of protection of national, racial, ethnic, and religious minorities from various threats to their very existence. Unlike other human rights treaties, there is no specific monitoring body or expert committee but it contains the provision that any Contracting Party may call upon the competent organs of the United Nations to act under the United Nations Charter in any way that may be suitable to prevent and suppress acts of genocide. The Convention is relatively brief, with just 19 short articles. The Preamble of the Convention affirms that genocide is contrary to the spirit and aims of the United Nations and is condemned by the civilized world, since genocide has inflicted great losses on humanity at all periods of history. It also stresses that international cooperation is necessary “to liberate mankind from such an odious scourge.” The first Article provides the important clarification that genocide can be committed “in time of peace or in time of war” and that it is a distinct crime from crimes against humanity. The crime of genocide is defined in the second Article, as any of a number of acts which are committed with the intent to destroy, either as a whole or in part, a national, ethnic, racial, or religious group, killing members of the group; causing serious bodily or mental harm to members of the group; deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part; imposing measures intended to prevent births within the group; and forcibly transferring children of the group to another group. According to the third Article, not only is genocide to be punished but also the conspiracy, the direct or indirect incitement, attempt or complicity to commit genocide. The fourth Article states that there should be no immunity since persons that commit genocide or any of the acts enumerated previously should be punished regardless, even if they are constitutionally responsible rulers, public officials, or private individuals. The fifth Article contains provisions about the legislation that Contracting Parties have to adopt in order to provide effective penalties for persons guilty of genocide, or any of the other acts enumerated in the third Article. The sixth Article of the Convention stipulates that any person charged with genocide shall be tried by a competent tribunal of the State in the territory in which the act was committed, or by an international penal tribunal that may have jurisdiction over the Contracting Parties. The next Article stipulates that genocide shall not be considered to be a political crime for the purpose of extradition and, in such cases, Contracting Parties pledge themselves to grant extradition. Pursuant to the eighth Article, any Contracting Party may call upon the competent organs of the United Nations to take such action under the Charter of the United Nations as they consider appropriate for Coping the prevention and suppression of acts of genocide or any of the other acts enumerated in the third Article. The following Article stipulates that any disputes between the Contracting Parties relating to the interpretation, application, or fulfillment of the Convention, including those relating to the responsibility of a State for genocide or for any of the other acts described previously, shall be submitted to the International Court of Justice at the request of any of the parties to the dispute. Although it is considered a pillar of the framework of international humanitarian rules, the Genocide Convention has been criticized for its limitations. Due to the vague and unclear definition of genocide, prevention and punishment of genocide is difficult. Moreover, Article XI requires that the members of the UN have to ratify the document, but there are many States which did not ratify it, for nearly 50 years. On the ground that the Convention violates sovereignty, the USA did not ratify the convention until 1988. At the time of its ratification, the US stipulated that the USA would not be subject to the jurisdiction of the International Court of Justice and that US laws would take precedence over the Convention. Nevertheless, in 1990, the US Congress passed the Immigration and Nationality Act (INA) (8 U.S.C.A. } 1182), that stipulates that aliens guilty of genocide are excluded from entry into the USA, or deported when discovered. Another flaw is that there is no committee or monitoring body for this Convention to ensure implementation and compliance, like the Convention on the Elimination of All Forms of Discrimination Against Women, International Covenant on Civil and Political Rights, and United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. After several requests for setting up a treaty body, by adopting an additional protocol to the Convention, or passing a resolution of the General Assembly, in 2004, the Secretary General of the United Nations established the high-level position of Special Adviser on the Prevention of Genocide. The limitations of the Genocide Convention are obvious since, in spite of its provisions that State Parties should “prevent and punish genocide,” millions C 495 of people still have died without intervention in Cambodia, the former Yugoslavia, the Democratic Republic of Congo, Sierra Leone, Rwanda, and Darfur. Related Topics ▶ Ethnic cleansing ▶ European Court of Human Rights ▶ Holocaust ▶ Human rights ▶ Torture Suggested Readings International Court of Justice. (1951). Reservations to the genocide convention, Advisory Opinion. I.C.J. Reports, p. 15. LeBlanc, L. J. (1991). The United States and the genocide convention. Durham: Duke University Press. Lemkin, R. (1944). Axis rule in occupied Europe. Washington: Carnegie Endowment for International Peace. Quigley, J. (2006). The genocide convention: An international law analysis. London: Ashgate. Weindling, P. J. (1980). Health, race and German politics between national unification and Nazism. Cambridge: Cambridge University Press. Suggested Resources Encyclopedia Britannica. (2004). Definition of genocide, from Encyclopedia Britannica. http://www.britannica.com/ EBchecked/topic/229236/genocide, United States of America, 9 September 2004, 2004/955 (Press release). Accessed May 10, 2010. Office of the High Commissioner for Human Rights. Convention on the prevention and punishment of the crime of genocide. http:// www.un.org/millennium/law/iv-1.htm. Accessed May 25, 2010. U.N.T.S.(United Nations Treaty Series), No. 1021, Vol. 78, p. 277. http://www.preventgenocide.org/law/convention/text. htm. Accessed May 19, 2010. World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance, 2001 Declaration. http://www.un. org/WCAR/durban.pdf. Accessed May 5, 2010. COPC ▶ Community-oriented primary care Coping ▶ Resilience C 496 C Cortisol Cortisol LUIS F. RAMIREZ Quality Outcomes Training, Brecksville, OH, USA Cortisol is a hormone produced by the zona fasciculata of the adrenal cortex. There are two adrenal glands, each of which weighs about 4 g, located on top of the kidneys. Each gland is composed of two distinct parts: the adrenal medulla and the adrenal cortex. The adrenal medulla secretes the hormones epinephrine and norepinephrine and the adrenal cortex secretes a group of hormones called the corticosteroids produced by three different layers of the medulla. The zona glomerulosa secretes aldosterone, the zona reticularis secretes adrenal androgens, and the zona fasciculata secretes the glucocorticoids cortisol and corticosterone. These hormones are synthesized from cholesterol and have similar formulas but different functions. Cortisol is referred as the “stress” hormone because it plays an important role in the stress response. Together with norepinephrine, cortisol is released during times of threat and is critical to survival. Cortisol aids in survival by redistributing energy when an individual is under attack. To do so it suppresses functions not needed for immediate survival, including reproduction, immune response, digestion, and pain. Cortisol promotes vital functions, including heart rate and blood pressure, while shunting energy to the brain and muscles to speed up thought processes and fight or flee. However, chronic high levels of cortisol cause gastric ulcers, thinning of the bones, and possibly brain damage. In animals, stress has produced a reduction of neurotrophins which in turn decreases the growth of new neurons in the hippocampus. These actions may affect memory and mood leading to depression and feelings of fatigue. Stress also impairs the immune system which can lead to an increase in infections and possibly increase rates of cancer. Stress also affects the cardiovascular system and patient suffering depression and heart disease have five times higher risk of sudden death than the patients without depression. Persons suffering posttraumatic stress disorders are also predisposed to cardiac problems. The disorder of hypercortisolism is called Cushing’s syndrome and the one causing hypocortisolism is known as Addisson’s disease. These are serious conditions that need immediate treatment. The main problems with Addisson’s disease are electrolyte imbalance, inability to regulate blood pressure, muscle weakness, inability to tolerate stress leading to cardiac problems, neurological problems, shock, and death. The Cushing’s syndrome is characterized by mobilization of fat from the lower part of the body with extra deposition of fat in the thoracic and upper abdominal regions. Also there is an edematous appearance of the face with acne and hirsutism. Persons suffering Cushing’s syndrome are feeling weak and are susceptible to infections. Increases in cortisol levels have been associated with the development of mental disorders, especially depression. The immigration process, legal or otherwise, is a stressful situation which will produce an increase in cortisol levels. The development of mental disorders is the final outcome of a complex series of events in which cortisol is part of the process and methods of reducing the levels of cortisol may be beneficial in the management of these disorders. Besides these disorders, there are different factors affecting cortisol levels. Among the ones increasing levels besides stress are ingestion of caffeine, sleep deprivation, anorexia nervosa, some oral contraceptives, and prolonged physical exercise. Factors reducing cortisol levels are music therapy, massage therapy, laughing and the experience of humor, and in general relaxation exercises. The ingestion of omega-3 fatty acids can also lower levels of cortisol. Related Topics ▶ Job stress ▶ Posttraumatic stress disorder ▶ Social stress ▶ Somatic symptoms ▶ Stress Suggested Readings Bremner, J. D. (2002). Does stress damage the brain? Understanding trauma related disorders from a mind-body perspective. New York: W.W. Norton. Cross-Cultural Health Guyton, A. C., & Hall, J. E. (2000). Textbook of medical physiology. Philadelphia: W.B. Saunders. Sapolsky, R. M. (2004). Why zebras don’t get ulcers (3rd ed.). New York: Owl Books. Council for International Organizations of Medical Sciences SANA LOUE Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH, USA The Council for International Organizations of Medical Sciences (CIOMS) was formed in 1949 by the World Health Organization (WHO) and the United Nations Scientific and Cultural Organization (UNESCO). CIOMS strives to facilitate and promote international activities in the biomedical sciences. In furtherance of this goal, CIOMS has issued International Guidelines for Biomedical Research Involving Human Subjects and International Guidelines for Ethical Review of Epidemiological Studies. Each of these documents addresses issues relating to informed consent, risks and benefits, vulnerable populations, and ethical review. Several of the guidelines in each of these CIOMS’ documents are relevant to the conduct of research with immigrant populations. For example, Guideline 13 of the International Guidelines for Biomedical Research Involving Human Subjects advises that special justification is required for inviting vulnerable individuals to participate in research and that their rights and welfare must be protected. Refugees and displaced persons are explicitly recognized as vulnerable in the context of conducting research in the commentary to this guideline. Individuals who are politically powerless are also identified as vulnerable; this could encompass individuals who are illegally present in a country and individuals who have recently immigrated to a country and are unfamiliar with its culture or systems. Similar provisions exist in the International Guidelines for Ethical Review of Epidemiological Studies. Although other Guidelines in each of these documents do not refer specifically to immigrants, they are C clearly relevant to the conduct of research with immigrants. These relevant provisions include the proscription against undue inducement to participate in research, the provision of information to prospective participants in language that is understandable, and the need to balance the risks and benefits of participation. Depending upon the focus of the study and the immigration status of an individual, the balance of risks and benefits for immigrants may be significantly different from that for native-born individuals. For example, a breach of confidentiality in the context of a USbased questionnaire study relating to drug use could potentially lead to jail or imprisonment for some participants, but to deportation for only noncitizen immigrant participants. Related Topics ▶ Ethical issues in research with immigrants and refugees ▶ Helsinki Declaration ▶ Informed consent ▶ Nuremberg Code Suggested Readings Council for International Organizations of Medical Sciences. (2002a). International guidelines for biomedical research involving human subjects. Geneva: Author. Council for International Organizations of Medical Sciences. (2002b). International guidelines for ethical review of epidemiological studies. Geneva: Author. Suggested Resources Council for International Organizations of Medical Sciences. http:// www.cioms.org Cross-Cultural Health RIKA SUZUKI1, IQBAL AHMED1,2 Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA 2 Department of Psychiatry, Tripler Army Medical Center, Honolulu, HI, USA 1 Culture is defined by a group’s distinct values, norms, and beliefs, including understanding of life and death. 497 C 498 C Cross-Cultural Health It is shared among individuals who identify themselves similarly. Culture is passed down from generation to generation, and is a core part of every individual. Communication style, spirituality, familial roles, sense of autonomy versus collectivism, and behavioral and social norms are among the many factors that comprise one’s identified culture. These factors help to shape one’s understanding of health, what causes illness, what appropriate responses to illness are, and how illness should be treated. Thus, culture can profoundly impact how one approaches health care, from individual interactions with providers and staff to the larger exchange with health care systems and organizations. What Is Cross-Cultural Health? Cross-cultural health can be defined as an approach to health care that attempts to reconcile differing cultural values, behaviors, and practices about health. In this way, it strives to accomplish effective health care across different cultures. For its providers, cross-cultural health care involves both an awareness of one’s own attitudes and beliefs, and an awareness of others’ attitudes and beliefs, about health and illness. Crosscultural health at an individual level entails everything from how a provider and patient interact; how they negotiate screening, diagnostic, and treatment interventions; how education is communicated; and how long-term relations are maintained between them. At the systems level, cross-cultural health encompasses issues at the community, public health, and organizational level. Pertinent tasks include management of illness but also health promotion, and screening and education for illness prevention, including administering preventive medications to varied population groups. Examples include cultural attitudes toward blood pressure screenings and administration of the H1N1 (influenza) vaccine to those at risk. Also included in cross-cultural health at the systems level are the various strategies health organizations undertake to promote better relations with their culturally diverse patient populations. This includes education of providers and other care team members as well as outreach to patient groups. A necessary task in effective crosscultural health care is the examination of those factors that pose barriers to care across cultures. Much of the literature to date focuses on the negative health impacts of cultural differences. Relatively less literature exists about how different cultural beliefs (which may deviate from biomedical models) may be protective in terms of health. What Is the Relevance of CrossCultural Health? In the USA, as well as in almost every country in the globe, the population is becoming increasingly diverse. For example, by the year 2030, the ethnic minority population in the USA (African Americans, Hispanics, Asian/Pacific Islanders, Native Americans, and Alaskan Natives) will grow from 28% to over 40% of the population. In the decade of 1990–2000, the number of people in the USA speaking a language other than English at home increased from 31.8 million to 47.0 million. Currently, 21 million Americans are limited in English proficiency. Linguistic differences, however, are just one facet of cross-cultural health care. Beliefs and attitudes, including religious, have been shown to have a large impact on an individual’s health behaviors, according to studies on cross-cultural health care. In his formative anthropologic work on culture, illness, and care, Kleinman states that “70 to 90 percent of all self-recognized episodes of sickness are managed exclusively outside the perimeter of the formal health care system.” This suggests that, with the steady increase in the minority populations in the USA in the past 30 years, many more individuals than ever before may seek out culturally based resources (family/friends, religious authorities, traditional healers, self-help groups, etc.) prior to seeking help from formal health care providers. In part, this may be due to a desire to avoid encounters that could potentially be costly, difficult, uncomfortable, or frustrating, and in the worst cases, offensive. Where Do We See Cross-Cultural Health Care Today? Cross-cultural health is carried out in a wide variety of settings today – outpatient community clinics, private health clinics, local hospitals (emergency room, inpatient units), offices of social work and other health care staff, disease prevention clinics (tuberculosis, sexually transmitted disease clinics), community health screenings, and specialized settings (substance abuse clinics, domestic violence shelters, homeless shelters, nursing homes, hospices, and rehabilitation clinics). Cross-Cultural Health Cross-cultural health care also takes place in pharmacies, where patients are often educated by pharmacists just prior to receiving their medications. Challenges of Cross-Cultural Health Care Cross-cultural health care at its best will work towards decreasing the prejudices, misunderstandings, and assumptions between providers and their patients to enable care that is both meaningful and effective. Imagine the scenario of a newly immigrated young Chinese woman with reproductive difficulties presenting to a Los Angeles community clinic. One can imagine the possible frustration she and her family may be experiencing in the couple’s futile attempts to conceive a child. Childbearing, across all cultures, is indeed a valued life task. However, this woman’s distress may be more profound than we might imagine given her cultural context. Traditionally, in some Chinese subcultures, the ability to bear a male child is highly valued. It becomes clear that the initial interface between a provider and this patient and family will be critical in addressing their distress and concerns, and in clarifying their understanding of a possible physical problem. They may not accept, if in fact she is infertile, that she cannot have a child, much less a male child. Frustration, grief, understanding, and support will need to be skillfully managed in the context of what infertility means to the patient and family in their Chinese subculture. How Do We Know We Are Achieving Cross-Cultural Health Care? Cross-cultural health care, at its best, is a candid exploration and negotiation of culturally based beliefs about health and illness, which leads to a reconciliation of attitudes about how best to achieve good health outcome. It can thus be viewed as happening on a continuum. Reaching the goal would be defined by achieving optimal screening, detection, and management of a patient’s illness and preventing future illness. It would also be defined by an enduring relationship built on trust, increased understanding of differences, and mutual respect. Differing views about health and illness will not be compromised but rather enhanced in an ongoing dialogue between health care provider and patient, or between a health care system and patient C population. A critical component of cross-cultural health is cultural competence – defined as the ability of a provider or health care system to deliver care that is culturally appropriate, well informed, and tailored for the recipient of the care. There are a variety of ways to conceptualize crosscultural health. Structurally, it can be considered at both an individual level and at a systems level. As the individual level is discussed in detail in a separate chapter on cross-cultural medicine in this encyclopedia, it will be discussed only briefly here. Cross-Cultural Health at an Individual Level At the individual level, cross-cultural health is the approach to care in which a provider or other health care member engages with a patient in an exploratory, nonjudgmental way so as to elicit the patient’s understanding of his/her health concern. This involves learning about the factors that affect the patient’s presentation, including cultural and social factors. This is best accomplished by structured questions targeted at eliciting the patient’s views about his/her illness, treatment options, and prognoses (the patient’s explanatory model for illness) as well as the patient’s fears and concerns. Economics, ethnicity and acculturation, spiritual beliefs/practices, family and personal dynamics (gender role, parental roles, individualism, collectivism), and academic or occupational demands all may impact health-seeking behaviors and attitudes toward health care. Culturally based gender roles in a family, for example, may be instrumental in defining how health discussions take place and how rapport is built with the provider. Cultural health beliefs (“folk beliefs”) may also help or hinder one’s health-related behaviors, including treatment adherence. Thus, providers of cross-cultural health care must listen and demonstrate self-awareness to open the door to a genuine discussion between himself/herself and a patient. Cross-Cultural Health at a Systems Level At a systems level, cross-cultural health care works at a larger scale and targets populations and communities. Whether in private or public health organizations, aims are to identify and negotiate potential barriers to 499 C 500 C Cross-Cultural Health care by examining trends among various groups in their health-related behaviors. Linguistic and cultural differences are bridged via written or oral communication aids, such as brochures, community screenings/ education, and liaison persons such as translators or interpreters. Disparities in health care for US ethnic minority populations persist not only as increasing disease burden by minority populations but also in the level of satisfaction expressed by minority patients. The systems-based approach is particularly important because it is often the case that minority patients from immigrant populations are first seen in larger community or private hospitals rather than in smaller scale clinics. Because cultural factors impacting health care are multidimensional, cross-cultural health strategies at a systems level must aim to negotiate potential barriers in multiple ways. Strategies for Systems-Based Approach to Cross-Cultural Health Care Some of the ways that health care institutions and organizations can exercise cross-cultural health care involve application of tasks applied at the individual level. However, at a systems level, strategies can optimize ways to reach the masses by understanding group identity and shared thinking processes. By appealing to common characteristics among larger groups of people, important health information can be disseminated and health behaviors impacted. The strategies can target primary, secondary, and tertiary prevention and thus are a potential means to impact health care globally. Examples of several strategies that can be employed at a systems level are: ● Mandated training of health care providers, employees, and trainees in cultural competence ● Specific outreach strategies for the prevention and treatment of illness, which include: – Peripheral strategies to educate and appeal to specific cultural groups – Evidential strategies to enhance a cultural group’s perception of the relevance of specific health issues – Constituent-involving strategies drawing on the experience of particular group members ● Linguistic strategies to make health care more accessible and effective ● Sociocultural strategies that address health issues in the context of larger social and cultural considerations Strategies for a Systems-Based Approach: Mandated Training in Cultural Competence Within larger health organizations, a tendency can develop for providers, staff, and management to generalize about behaviors of minorities. These tendencies are often reinforced through repeated experiences with similar presentations. For example, health employees might assume Hispanic or Asian patients manifest psychiatric complaints as physical ones, or that Asian male patients underreport pain symptoms. They may not fully appreciate expressed complaints if they perceive that some patients overreport symptoms. Understanding the meaning of an illness to the patient in his/her cultural context requires that providers and staff not make assumptions based on stereotypes. To achieve effective cross-cultural care, it is imperative to understand common cultural trends but also to approach each patient as a unique individual. Part of this task entails differentiating subculture from culture. An older African American man from a rural town in Georgia may hold different beliefs about health care than a young African American man living in Los Angeles, California. Also, an African American and a Vietnamese American may hold similar views about health issues by virtue of being longtime residents in the same community. Because it is not possible to know about every culture and subculture, the best strategy is to keep an open mind and explore belief systems by nonjudgmental inquiry. The methods of such an inquiry and the appreciation for this kind of exploration can be taught early in professional training. Hiring minority faculty/teachers with firsthand knowledge and experience, implementing core requirements in cultural competency (didactics, clinical experiences), and evaluating standards for meeting requirements are some of the ways cross-cultural health practices can be taught. For large health care organizations, similarly structured employment training in cultural competence can be implemented. Hiring of multiethnic staff and Cross-Cultural Health experiential workshops with routine evaluation of effectiveness are additional ways to standardize competency in cross-cultural health care. Such training can be overseen by formal committees with clear competency guidelines and reassessments as necessary. The focus of the training should be multidirectional and not unidirectional. There is an interaction of different cultural beliefs of the providers and the recipients of health care. The providers’ culture includes the medical culture with its own belief system about the doctor–patient relationship, attitudes about other systems of care, and adherence to treatment. In addition, providers bring to the table their own family cultural background. Cross-cultural health care at a systems level should strive toward a meeting of minds. It is a negotiation of the belief systems and explanatory models of patient/family and provider, but also of the health care system at large. Specific Outreach Strategies: Peripheral, Evidential, and Constituent-Involving Strategies Kreuter, Lukwago, Bucholtz, Clark, and SandersThompson discuss specific strategies to promote health care in cross-cultural settings using culturally informed tactics. These strategies can be applied to many different cultures. As such, they are a compelling means to enable outreach to immigrant and other minority populations. 1. Peripheral strategies use design in a deliberate way to create and distribute materials and promote health programs that will appeal to specific groups. As an example, to communicate the importance of early detection of breast cancer to a Mexican immigrant population, the use of bright primary colors with bold messages and images may be more effective than utilizing the light pink signature ribbon symbol. Information delivered this way would likely appeal to the Mexican cultural aesthetic of colorful schemes and patterns. Bold, clear messages may be more consistent with cultures expressing higher emotive affect. For cultures whose family hierarchy is matriarchal, patients may respond best to brochures with images depicting older women educating younger family members. Peripheral strategies thus utilize specific images, C themes, designs, lettering, and color schemes to appeal to cultural aesthetics as well as belief systems. In essence, it is the use of marketing to achieve a cross-cultural health goal. 2. Evidential strategies enhance a cultural group’s understanding of the relevance of a particular health issue. These strategies work at a systems level by highlighting health epidemiology, that is, diseases specific to a given cultural group. By presenting information about the prevalence of high blood pressure in African Americans or the prevalence of strokes in Japanese Americans, the intent is that the statements will raise the level of concern and perception of individual vulnerability to the health problem. Kreuter references Weinstein’s precaution adoption model – the notion that perceiving others like you have this problem can stimulate one’s own decision to act to prevent the problem for oneself. 3. Constituent-involving strategies draw on the experiences or insights of specific members of a group being targeted for health education. These individuals serve as a liaison between other group members and the health care organization or system. They may be cultural leaders, folk healers, or trained paraprofessionals. As a member of the target group, they help to contextualize health care in culturally specific ways for both other group members and for the health care organization. By enhancing communication bidirectionally, these individuals can promote trust and understanding in health care discussions. They can offer insights into preferred strategies, communication styles, family dynamics, and other factors that may influence the patient’s or target group’s approach to health care. Finally, they may bridge overt language gaps. Linguistic Strategies to Make Health Education More Accessible and Effective Rogler et al. in 1987 appropriately called linguistic accessibility “the lowest common denominator of cultural sensitivity.” Language-related strategies in crosscultural health may seem obvious and fundamental but can be complex because they must be carefully integrated with sociocultural context. Also, current 501 C 502 C Cross-Cultural Health strategies are still contending with problems regarding consistency and standardization of quality. In an overview of strategies to overcome barriers, Sherry Riddick discusses several important ways that health care organizations and systems can address language and cultural barriers. She describes the use of bilingual/bicultural providers, bilingual/bicultural health workers, employee language banks, professional interpreters, and written translation materials as key strategies. However, there are many subtle challenges entailed in the use of these resources. Bilingual/bicultural providers: Riddick points out that even when providers and health care workers speak the patient’s language, issues of credibility and trust arise. Linguistic skills of the provider or health care worker do not equate to competency of communicating health information in a culturally appropriate manner. There is a need for standardized evaluation of linguistic skills, competency in health knowledge, and cultural appropriateness. Bilingual/bicultural health workers: With bilingual workers, their utility is multifold – they have the potential to provide outreach, to promote community participation in the health care system, and to educate providers about cultural awareness. Their role in the system is limited however if they are not situated with primary providers or larger organizations. Often, they work in parallel with the system but in a different setting, that is, at an external case managing agency. This can lead to a breakdown in communication, which may negatively impact patient care and perception of care. Employee language banks: Language banks are inhouse employees used for interpreting or translating, in addition to their regular work duties. This strategy has potential economic and health benefits. However, such an arrangement is prone to abuse of employees, who may be pulled from their usual duties to provide interpreting services. These individuals may lack formal language training, which can lead to dangerous miscommunication about a health problem, diagnosis, or treatment. Successful use of language banks would require that systems formalize the use of such employees by providing the appropriate training, job descriptions, and compensation. Professional interpreters: In his systematic review of the impact of medical interpreting on quality of health care, Flores concluded that the most rigorous studies on patient satisfaction have shown highest satisfaction with bilingual providers and trained telephone interpreters. Ad hoc interpreters (family, friends, nonmedical or untrained staff) resulted in significantly lower patient satisfaction. Patients who need but do not get interpreters have the lowest satisfaction. Thus, a key determinant in the success of cross-cultural health care will be improvements in linguistic accessibility. Sociocultural Strategies, Considering Health Issues in a Social and Cultural Context These strategies may best be described as culturally specific approaches to health care. Horky and Becker define cultural competence as possessing the set of values, beliefs, and practices that enables effective work across cultures. In this, they stress the importance of having the ability to honor the beliefs, language, interaction styles, and behaviors of patients but also the staff providing the care. Cross-cultural health care is therefore a process. It is a dynamic, ongoing relationship between patients, providers/staff, and the health care system at large. Sociocultural strategies are categorically very broad. Social factors can include but are not limited to a patient’s family and social supports, insurance status, occupational status, economic status (including access to resources such as transportation), health and nutritional status, and recreational life. Cultural factors include acculturation, spiritual beliefs, interpersonal dynamics, and beliefs about health, illness, and mortality. Sociocultural strategies would incorporate all of these factors into health care discussions to help bridge communication and understanding between the patients and the health care teams. Example: Applying Sociocultural Strategies to a Minority Group In order to conceptualize how these strategies can be effective, it may be useful to focus on a specific cultural group. The African American population is a diverse group. Every geographic region has unique subcultures with variability in practices and beliefs, particularly if religious affiliations influence beliefs. In applying Cross-Cultural Health sociocultural strategies at the systems level, however, the focus should be on identifying key similarities that may be generalizable across a majority of the African American population. Literature on the African American population has shown consistent findings about the larger culture among patient populations – strong emotional impacts of a history of slavery and the Tuskagee study, a history of racial disparity in health services and economic opportunities, poor health literacy, a tendency to advocate home remedies, and the strong role of religion and faith in beliefs about health and illness. An understanding of the key influences in a cultural group’s history and evolution in their country of residence allows providers and organizations to tailor approaches to care. For example, for the African American patient population, providers can be trained to inquire sensitively about nonbiological beliefs about illness (folk treatments) and attitudes rooted in spirituality and church affiliation. They can also explore for any negative health encounters in the past, which may impact the patient’s approach to health care today. This would include but is not limited to past exposure to prejudicial treatment. At a systems level, health care organizations can formalize alliances with community churches to promote health screening and educational seminars. Clergy, for example, may be key members of the health care team for an African American patient admitted with end stage kidney disease. Clergy may be instrumental in the patient’s and family’s coping with decisions about dialysis and need for long-term care. There are numerous ways in which organizations can practice and improve cross-cultural health care by taking the time to learn the history and belief systems of different cultural groups in their community. Ongoing epidemiologic research will continue to be a vital way for health care organizations, particularly managed care, to allocate resources so that quality health care is ensured to minority populations in ways that respect their culture and beliefs. Conclusion Cross-cultural health presents a rich arena for improvements in overall health care. Furthering the community’s understanding of what it is and how much it can impact the well-being of all our populations is a key task for the future. C In many US health professional training programs, cross-cultural curriculums are already implemented and being evaluated for their efficacy. Providers and health care systems will face the challenge of keeping up with the diverse populations whom they serve, as minority populations increase exponentially in the next half century. No longer will it be enough to acquire biomedically based understandings about health and illness (medical competence). Cultural and nonbiomedical understanding about health and illness (cross-cultural competence) will play an increasing role in health care competency. Related Topics ▶ Barriers to care ▶ Communication barriers ▶ Cross-cultural medicine ▶ Cultural competence ▶ Cultural humility ▶ Culture-specific diagnoses ▶ Explanatory model of illness ▶ Health beliefs ▶ Multiculturalism ▶ Physician–patient communication ▶ Public health Suggested Readings Bates, M., Rankin-Hill, L., & Sanchez-Ayendez, M. (1997). The effects of the cultural context of health care on treatment of and response to chronic pain and illness. Social Science and Medicine, 45(9), 1433–1447. Betancourt, J., Green, A., & Carrillo, J. E. (2009). The challenges of cross-cultural healthcare – Diversity, ethics, and the medical encounter. Bioethics Forum, 16(3), 27–32. Eiser, A., & Ellis, G. (2007). Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education. Academic Medicine, 82(2), 176–183. Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review, 62(3), 255–299. Kagawa-Singer, M., & Kassim-Lakha, S. (2003). A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Academic Medicine, 78(6), 577–587. Kleinman, A., Eisenberg, L., & Good, B. (2006). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. FOCUS: The Journal of Lifelong Learning in Psychiatry, 4(1), 140–149 (reprinted from Annals of Internal Medicine 1978; 88, 251–258). 503 C 504 C Cross-Cultural Medicine Kreuter, M., Lukwago, S., Bucholtz, D., Clark, E., & Sanders-Thompson, V. (2002). Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Education and Behavior, 30(2), 133–146. Lavizzo-Mourey, R., MD, M. B. A., & Mackenzie, E. (1996). Cultural competence: Essential measurements of quality for managed care organizations. Annals of Internal Medicine, 124, 919–921. Rogler, L. H., Malgady, R. G., Costantino, G., & Blumenthal, R. (1987). What do culturally sensitive mental health services mean? The case of hispanics. American Psychologist, 42(6), 565–570. Tseng, W. S., & Streltzer, J. (Eds.). (2001). Culture and psychotherapy: A guide for clinical practice. Washington, DC: American Psychiatric Press. Suggested Resources Horky, S., & Becker, C. (2009). Cross cultural health care – Case studies [Online]. support.mchtraining.net/national_ccce/. Accessed July, 2010. Riddick, S. (2003). Overview of models and strategies for overcoming linguistic and cultural barriers to health care [Online]. www. diversityrx.org/html/MOVERAhtm. Accessed July, 2010. Yeo, G. (Ed.) (2001). Stanford ethnogeriatrics curriculum [Online]. http://www.stanford.edu/group/ethnoger/. Accessed July, 2010. Cross-Cultural Medicine JULIENNE ONG AULWES1, IQBAL AHMED2 1 Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA 2 Department of Psychiatry, Tripler Army Medical Center, Honolulu, HI, USA Culture is commonly defined as shared beliefs and attitudes of a group. In the diverse world we live in, currently, culture undoubtedly shapes ideas of disease causation and what is considered to be acceptable treatment in accordance with a person’s worldviews and religious beliefs. Many patients find comfort in their worldviews which are internally consistent. The clinical encounter will vary depending upon cultural understanding of health and illness. The expectations of the roles physicians play in one’s life also differ depending on what culture you are from. Lastly, culture and ethnicity affect the prescribing practices of physicians’ and patients’ acceptance of medications. Culture and Concepts of Health and Illness Each culture has beliefs about how bodies function normally and abnormally. Gaining insight into a patient’s understanding of what constitutes disease and the illness process is the first step in appreciating the patient and developing a therapeutic alliance. For example, the traditional Han Chinese system conceives of human beings as being part of the universe that is regulated by the opposing forces of yin and yang (male/ female, hot/cold, wet/dry, dark/light, earth/heaven) which are always changing. Good health and wellbeing are maintained by finding a balance between yin and yang and diseases are treated by restoring this balance. Asian cultures believe that foods have “hot” and “cold” properties and associate these with the nutritional qualities, medicinal value, and healing power of most foods. This concept of health exists in other Asian and Latino health belief systems as well. Traditional Mexican beliefs of health include the importance of balancing hot/cold and wet/dry concepts that were probably influenced by traditional concepts of native peoples, such as the Mayans and Aztecs, and by the colonialist Spaniards whose New World concepts originated with Hippocrates’ theory of disease and the four humors. The traditional holistic system of healing in India, ayurveda (“science of life”),was built on the ancient knowledge in the Atharaveda text about the three humors: Vita, Pitta and Kapha more than 3,000 years ago. Each person’s prescribed lifestyle of diet, exercise, and meditation is designed to maintain his or her specific balance between the three humors. The focus is on establishing and maintaining balance of the life energies within the individual, rather than focusing on particular symptoms. Ayurvedic medicine recognizes that each individual has a unique constitution and thus, treatment and prevention is based on the individual, not on illness, disease, or symptomatology. This system of healing has influenced other Asian systems, such as the Thais. Every healing system has beliefs about how the natural realm is connected to the social and supernatural aspects of life and how these beliefs relate to health, illness, and healing. The natural realm reflects the connections between people and the earth, such as soil, plants, water, air, and animals. The social realm refers to the connections between people of different ages, Cross-Cultural Medicine genders, lineages, and ethnic groups. The supernatural realm is characterized by the connections between the human world and the spiritual world and includes religious beliefs about birth, death, and the afterlife. Religion and spiritual beliefs are some of the strongest influences on health systems. For example, Chinese medicine is interwoven with and influenced by Taoism, Ayurvedic medicine by Hinduism, and Tibetan medicine by Buddhism. People’s religious beliefs are intertwined with their interpretations and experiences of health and disease. Many African American women, for example, across all socioeconomic levels, believe in the power of prayer and God’s healing power to treat and cope with breast cancer. This belief can often lead to a delay in seeking professional health care despite being an important source of emotional support for many African Americans. In trying to understand how the patient views a particular illness, the physician should ask the patient what the illness means to him/her and what treatments the patient is currently undergoing. It is important to elicit pertinent history by inquiring about what alternative therapies the patient has already tried and what providers he/she has already seen. There is often a “hierarchy of care” in many cultures, where patients would first try home remedies, prior to seeking care from the folk sector (traditional healers or religious leaders), and lastly approaching the professional sector (such as a physician) only when all other therapies have failed. In the popular or lay sector of healers, treatments are usually provided by family members or by the patient and may include practices such as massage, coining, cupping, burning, incantations, medicines, or wound dressings. The folk sector of healers usually consists of priests, shamans, herbalists, or bonesetters. Treatments are usually culturally integrated and congruent and require some sort of payment usually in the form of gifts which may be monetary, material items, or involve exchange. The professional sector of healers includes conventionally trained allopathic medical personnel (physicians, nurses, dentists, pharmacists) and those trained in complementary and alternative medicine (acupuncturists, homeopaths, Ayurvedic and Chinese medicine specialists, etc.). Formal education and licensing are required and an apprenticeship may be involved. C Monetary payment is standard, usually paid by thirdparty insurance or in the form of cash payments. Healers from each sector may refer, ignore, or compete with each other. In many countries, various folk healers exist in parallel providing specialized or generalized services. Arthur Kleinman, a prominent American psychiatrist and one of the world’s leading medical anthropologists, calls people’s ideas about an illness their explanatory model. Explanatory models consist of five components: (1) timing and onset of symptoms, (2) pathophysiological processes, (3) the etiology of the condition, (4) natural history and severity of illness, and (5) appropriate treatments. The ill person, family members, medical providers, and social networks have their own explanatory models about the illness, which may be complementary or contradictory. The more the agreement that exists between explanatory models of all parties involved, the less likely there is conflict. Kleinman et al. designed eight questions to elicit patients’ explanatory models: (1) What do you call the illness? (2) What do you think has caused the illness? (3) Why do you think the illness started when it did? (4) What problems do you think the illness causes? How does it work? (5) How severe is the illness? Will it have a long or short course? (6) What kind of treatment do you think is necessary? What are the most important results you hope to receive from this treatment? (7) What are the main problems the illness has caused you? (8) What do you fear most about the illness? Cross-Cultural Care Patient role is influenced by culture, especially in relating to the clinician and adhering to treatment recommendations. There might be unique feelings toward the clinician related to the perceived cultural orientation of the clinician based on racial and power differentials. Patient role and feelings, in turn, affect the beliefs and expectations about the therapeutic alliance and the treatments prescribed by the clinician. Clinicians may also be affected by their perceptions of a patient’s illness based on racial or ethnic characteristics, which can influence their diagnosis of the illness and beliefs about likely treatment response. They might perceive patients from certain ethnic backgrounds as having more psychopathology, as being more likely to need 505 C 506 C Cross-Cultural Medicine medications, as needing more “potent” medications, and as having a worse prognosis for their illness. Clinicians have been found to overpathologize symptoms found in African Americans and Hispanics, and possibly to minimize symptoms in Caucasians. Culhane-Pera and Borkan recommend six fundamentals to assist healthcare professionals in providing quality cross-cultural care. Health care providers must know themselves as cultural beings, know their patients as cultural beings, have attitudes that express respect and engender trust, develop communication skills that facilitate mutual understanding, apply a culturally appropriate interview model during the clinical encounter, and develop cross-cultural negotiation skills that build therapeutic relationships. The goal is to provide medically, linguistically, and culturally appropriate health care interactions irrespective of the cultural background of the patient and provider, in order to deliver excellent health care service with optimal outcomes. Culture is something that all humans possess and being aware of one’s own cultural beliefs, values, and assumptions is extremely important in providing quality health care that is culturally sensitive. Adverse effects on health care delivery can occur when interacting with people of different cultural beliefs, values, and ethics because of one’s own biases and unchallenged assumptions. Thus, self-awareness and identification of sensitivities, reactions, biases, and centrisms are key to providing culturally competent care. Health care professionals should strive to familiarize themselves with their predominant patient population’s traditional lifestyles, religions, social structure, histories, and prior experiences with health care, ranging from lay and traditional healing systems to Western biomedicine. Identifying similarities and differences between the patient’s traditional health care system and Western biomedicine can be helpful in delivering excellent health care. Expectations of the patient–provider relationship should also be explored in order to identify areas of congruence and incongruence. Patients in general respond best to health care providers who can express respect and engender trust across cultural gaps in their behaviors with their patients, families, and communities. Respect is a cross-cultural concept that is demonstrated and experienced in different ways. As a health care provider, being culturally humble can facilitate the clinical encounter when dealing with patients of different cultural backgrounds. One needs to commit to selfevaluation and self-critique, to rectify the power imbalances in the patient–physician relationship and to develop nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations. Different cultural milieus dictate what a phrase, a word, or gesture may mean. When working with different groups, it is recommended that one be familiar with differences in nonverbal and verbal communication for these groups, including eye contact, personal space, gestures, greetings, touching, and body parts. Verbal communication differences must also be addressed. It is important to learn basic greetings and medical words and become proficient in working with interpreters. Generally, it is preferable to work with trained interpreters rather than children, adult family members, or untrained individuals who happen to know the language. It is important to choose interpreters that are acceptable to patients and their families in terms of their sex and ethnic group, and who can translate in the first-person singular style “word for word” rather than phrasing or summarizing. In addition to providing linguistic interpretation, it is helpful if the interpreter can also serve as a cultural broker. There are several different cross-cultural communication models that can be applied to clinical encounters when interacting with a diverse patient population. The patient-centered model encourages health care providers to explore both the patient’s disease perspective and illness experience. One should also strive to understand the whole person in the context of individual development, the family life cycle, and the larger socioeconomic and cultural context of people’s lives. It is important to find common ground in the clinical encounter with good patient communication skills that lead to mutual decisions. One can incorporate prevention and health promotion, and enhance the patient– clinician relationships, while being realistic about the realities of clinical medicine. Lastly, it is important for health care providers to develop cross-cultural negotiation skills. Difficulties may arise from different patient and provider health beliefs, expectations of life-cycle events, desires for Cross-Cultural Medicine treatment, moral values, or ethical principles. If providers have objections to requests from patients or their families for care or refusals of care, they have to decide if they are objecting based on challenges to their personal moral beliefs, personal preferences, or professional integrity. Health care professionals must negotiate treatment alternatives with the patient, family, and possibly community members as well. If negotiation is unsuccessful, the provider must either accommodate the patient or transfer the care to another provider. Challenges to personal integrity may be resolved by utilizing an ethics committee that has community input. To avoid harmful consequences of unintentional biases, physicians must (1) be aware that disparities exist in health care, (2) be aware of their own assumptions and preferences, and (3) take actions so that their biases do not negatively impact care. The cross-cultural interview is one that requires time and patience. Cultural dynamics such as cultural norms, communication styles, and family dynamics all influence the clinical encounter. A person’s concept of time and punctuality, facial expressions, body language, and personal space and touch issues are all relevant factors when interviewing a patient. For example, persons from Latino or African American culture may have a more relaxed sense of time, and schedules are considered less important than personal relationships. Non-Western cultures tend to view time as flexible as compared to Western cultures where time is equivalent to efficiency and considered an important entity. One can explain the importance of punctuality in the Western medical setting if a patient is late. In the Latino culture, “small talk” can contribute to establishing trust (confianza in Spanish) between the patient and the clinician. Patients may frequently nod in agreement or say they understand something even if they do not comprehend. They may avoid asking questions due to embarrassment or respect. In such cases, it is helpful to have patients repeat the instructions in order to verify their understanding. Nodding vigorously may signify respectful attention but not necessarily agreement or understanding. In Western cultures, eye contact signifies respect and attentiveness; however, in many non-Western cultures, direct eye contact may indicate disrespect of authority and/or sexual interest, and thus, patients may sometimes avoid eye contact with physicians out C of respect, especially if they are of a different sex or social status. Clinicians should speak slowly and simply to the patient using concise sentences and a normal tone of voice. They should also address patients by their formal name if they are uncertain of how to address them. In many non-Western cultures, using one’s first name as a greeting denotes disrespect, as compared to Western culture, where greeting on a first name basis helps to build rapport and denotes informality. If an interpreter is present, the clinician should speak directly to the patient. Personal space and the degree of physical touch also differ among various cultures. Western cultures view personal distance as denoting professionalism and objectivity. Latinos may interpret Westerners as being distant while conversing because they prefer more personal space. Some cultures such as Orthodox Jews and people from Islamic sects do not allow opposite sex touching, not even hand shaking. It is helpful for clinicians to explain what they will be doing when working with low-touch societies (e.g., Asians). The physical examination should be conducted in a culturally sensitive manner, noting specific male–female dynamics particular to the patient’s background. For example, in some cultures, a chaperone of the same sex must be in the room for a physical exam if the provider and patient are of opposite sex, while in some cultures only a clinician of the same sex as the patient is permitted to conduct a physical exam. Physical gestures also differ among cultures. The “thumbs up” sign may be interpreted as a profane gesture in Iran. The “okay” sign in North America may be considered obscene in Latin America. Many Asian cultures consider patting a child on its head, exposing the sole of the foot, or pointing with the foot an insult. In many countries of Asia and South America, using the index finger to point or beckon someone is considered rude and disrespectful. Rather, beckoning is done with the palm faced down and all fingers are waved inward. Many cultures consider the left hand “unclean” because it is often used for personal hygiene. Thus, prescriptions and samples should not be given with this hand. Culture and Medication Response Ethnicity has been reported to affect medication response due to genetic differences among the different 507 C 508 C Cross-Cultural Medicine groups affecting drug metabolism and cellular differences in organs such as the brain. The focus discussed here will be on the effect of culture on medication response in nonbiological aspects of medication response such as in the degree of patient adherence, placebo effects of medications, and other behaviors affecting drug interactions including dietary habits and other alternative treatments such as herbal remedies. Variables involved with these nonbiological effects are related to the patient, the clinician, and their relationship; cultural beliefs about illness and medication; and the actual process of giving and receiving medications. Culture influences personality and behavior patterns; perception of stress and coping style, including manner of utilization of social support; and interaction, including transference, with the clinicians. These variables influence the process and outcome of medical treatment, including medication response. It has been suggested that individuals from cultures that emphasize independence, struggle, and action (typically Western cultures) are likely to require more medication than patients whose personalities are shaped by cultures that emphasize interdependence and social adaptation (typically Asian cultures). How one reacts to stress and utilizes social support are both thought to be important factors affecting medication response (needing different dosages and levels of medications) and prognosis of psychiatric illness. For example, in families of patients with schizophrenia with higher levels of “expressed emotion” (frequent criticism, hostility, and emotional overinvolvement), there is a poorer response to medications. There appears to be differing levels of expressed emotions in different cultural groups: Anglo-American families have been reported to have higher levels of expressed emotions than British families, who, in turn, have higher levels of expressed emotions than Hispanic families. Culture also influences the role of the clinician in terms of one’s prescribing habits and decision-making process in regards to the clinician’s role and “healing power,” the desire to please the patient, feelings about the patient including biases about race and ethnicity, and professional norms and values. Even when there is no indication for medications to be prescribed, the clinician may do so in order to comply with patient demands and thus placate the patient. Certain cultures may objectify healing through medicines which serve to facilitate particular social and symbolic processes. This may be considered the “symbolic” effect of medication as compared with the pharmacological or “instrumental” effect. The symbolic effect includes characteristics such as “life” or “healing power” of a drug, and the attribution of value. Patients may experience and associate certain emotions with the use of certain medications. Some characteristics of medicines may have cultural meaning, including their form or consistency, the sensation experienced after taking the medicine, the source of the medicine, the packaging of the medicine, and the mode of administration of the medicine. Form or consistency of medicine refers to the physical characteristics of the medicine: tablet, capsule, liquid, color, size, amount, and even the name of the medicine. The color of the capsule has been reported to affect placebo response differentially in different ethnic groups. For example, white capsules are often viewed by non-Hispanic Whites as analgesics whereas African Americans may view them as stimulants. On the other hand, black capsules are often viewed by non-Hispanic Whites as stimulants and by African Americans as analgesics. Yellow pills are often viewed as appropriate treatment for depression in Europe, and red capsules are perceived as suitable for strengthening the blood in Sierra Leone. Culture may also affect the amount of medicines purchased by patients. In El Salvador, patients buy medicines in multiples of four, since the number has ritual significance. The sensation experienced after taking medicine refers to the reaction that occurs including the taste, such as bitter or sweet. Some cultures believe bitter medications to be more potent and effective. Certain types of aftertastes are considered to be indicative of the effect of the medication, either therapeutic or adverse, in some folk systems of medicine. The source of the medicine (whether from plants, derived from animals, or is synthetic) can have a psychological impact on medication response. For example, many Muslims do not use alcohol-containing medications because of religious reasons, and they along with orthodox Jews may not use medications containing porcine products. Other concerns related Cross-Cultural Medicine to sources of medication include whether the manufacture is foreign or domestic, and the degree of difficulty in obtaining the medication. Western medicines may be viewed as more potent, faster, and superior for acute illnesses, whereas herbal medicines are seen as milder, slower, and better for chronic illnesses. The presentation and packaging of the medication and location of distribution can influence the patient’s perception of its value and perceived efficacy. The traditional belief in Eastern herbal medicines, which consist of several herbs, has accustomed Asians to polypharmacy. Many physicians in Japan, Korea, China, and Taiwan often use polypharmacy as standard practice and frequently do not disclose the contents of medicines to the patients. This contributes to the mystery of the contents which gives more therapeutic power to the treatment. Asian patients widely accept polypharmacy and view a good doctor as being skillful in combining different kinds of drugs. The mode of administration of a medication has significant meaning to patients’ perception of treatment efficacy. Injectable agents are frequently believed to be more potent than oral medications. The experience of pain from the injection may contribute to this perception. After a clinical encounter, one should be aware that in many cultures, it is required to demonstrate one’s gratitude with a gift and its refusal may cause offense. Gifts are frequently offered to ensure the best possible care for the patient (a “soft” bribe for the caregiver). Gifts may come in the form of food, animals, small trinkets, or money. If the gift is culturally inappropriate (e.g., money), one can suggest an alternative such as food that could be shared with the rest of the staff. The conveyance of bad news or a negative prognosis also varies among cultures. In the United States, it is customary to only inform the patient in accordance to Health Insurance Portability and Accountability Act (HIPAA) regulations. However, in many other cultures, the family is informed first and then they decide if and when the patient should be informed. This violates HIPAA regulations if one is practicing in the United States. The patient or family may become angry at the health care provider if this custom is not followed because it is felt that giving someone a bad prognosis removes hope and becomes a self-fulfilling prophecy. Physicians should ask patients how they would like C their family to be involved and then explain to the family that informing the patient first is the standard US medical practice. Some benefits of possessing cross-cultural skills include better patient outcomes with greater patient adherence, improved access to care, reduction in health care disparities, and an awareness of the hazards and benefits facing the patient from traditional caregivers. One should be aware what aspects of traditional care can be adapted to a Western biomedical setting and know what aspects need to be rejected due to danger to either the patient’s spiritual or physical health. It is imperative that health care providers learn about the ethnic populations they serve in order to provide efficient, effective, patient-centered, quality care. Providers should also know themselves and their patients as cultural beings, have attitudes that express respect and engender trust, develop communication skills that facilitate mutual understanding, be able to apply these knowledge, attitudes, and skills in clinical encounters, and develop cross-cultural negotiation skills. Related Topics ▶ Assimilation ▶ Cross-cultural health ▶ Cultural competence ▶ Cultural humility ▶ Explanatory model of illness ▶ Health beliefs Suggested Readings Ahmed, I. (2001). Psychological aspects of giving and receiving medications. In W. S. Tseng & J. Streltzer (Eds.), Culture and psychotherapy: A guide to clinical practice (pp. 123–124). Washington, DC: American Psychiatric Press. Berlin, E. A., & Fowkes, W. C., Jr. (1983). A teaching framework for cross-cultural health care – Application in family practice. The Western Journal of Medicine, 139(6), 934–938. Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2000). The challenges of cross-cultural healthcare – Diversity, ethics, and the medical encounter. Bioethics Forum, 16(3), 27–32. Bigby, J. A. (Ed.). (2003). Cross-cultural medicine. Philadelphia: American College of Physicians. Carrillo, J. E., Green, A. R., & Betancourt, J. R. (1999). Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine, 130, 829–834. Culhane-Pera, K. A., & Borkan, J. M. (2007). Multicultural medicine. In P. F. Walker & E. Barnett (Eds.), Immigrant health (pp. 69–82). Philadelphia: Elsevier. 509 C 510 C Cuba Juckett, G. (2005). Cross-cultural medicine. American Family Physician, 72, 2267–2274. Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251–258. Puchalski, C. M., Epstein, L. C., Johnston, M. A., et al. (1999). Task force report: Spirituality, cultural issues, and end of life care. In Association of American Medical Colleges (Ed.), Contemporary issues in medicine: Communication in medicine (pp. 24–29). Medical School Objectives Project Report III. Washington, DC: Association of American Medical Colleges. Suggested Resources Center for Cross-Cultural Health. www.crosshealth.com Ethnomed. www.ethnomed.org National Center for Cultural Competence. http://nccc.georgetown. edu National Council on Interpretation in Health Care. www.diversityrx. org Cuba ▶ Hispanics ▶ Latinos Cultural Adaptation Resources KEN CRANE1, SUZANNE MALLERY2 1 Department of History, Politics, Society, La Sierra University, Riverside, CA, USA 2 Department of Psychology, La Sierra University, Riverside, CA, USA Many factors affect the well-being of immigrants as they enter a new society. Particularly significant is the mode of incorporation, that is, how they are received by the host community and the strategies they develop in response. This is often shaped by background factors such as language proficiency, socioeconomic status, race/ethnicity, and legal status. The mode of incorporation is key to an immigrant’s access to crucial resources, including health care, education, and employment. Host Community Integration/ Incorporation First of all, the way in which a government recognizes or refuses to recognize the status of immigrants is significant to adaptation. Immigrants’ legal status can determine whether they have access to resources necessary for successful integration. For example, Iraqis fleeing war and sectarian violence by going to Jordan are granted only temporary protection by the Jordanian government, with the condition that they will be resettled in another country in 6 months. They are not allowed to work and receive only minimal aid through the United Nations High Commissioner for Refugees (UNHCR), forcing them to find support among other Iraqis and in the informal economy. Fortunately the official position does not restrict the movements of those given the status of “asylum seekers,” and they are allowed to attend school and receive medical care at government hospitals. However, their marginal, transitory status provides little motivation to become part of Jordanian society. It should be noted that cultural adaptation to a new society might begin before individuals arrive in their country of destination. A study of Sudanese refugees by Chrostowsky showed that those who had lived in Cairo before being resettled in the USA had an easier transition than those who had lived in Eritrea or Kenya. The reason is that many of the women worked as domestics during their transitional stay in Cairo where they had fewer language barriers (some Sudanese speak Arabic, albeit a different dialect), and gained familiarity with electricity and household appliances. Because they had an easier time finding work than Sudanese men, the women assumed more of the breadwinner role in family, anticipating the radically different constructions of gender roles to be encountered in the USA. There are a number of assumptions about immigrant adaptation. The first is that immigrants naturally, for the better, assimilate or acculturate, that is, blend in with the host community, and the faster they do so the better for their own good. The second assumption is more recent and takes the opposite view, that immigrants are following a pattern of resistance to assimilation, refusing to learn the host country language and fit in with the dominant culture. Both assumptions are faulty and not supported by research. Cultural Adaptation Resources In the USA, scholars of immigration such as Alejandro Portes and Ruben Rumbaut found that acculturation occurs along a continuum. Near one end is a more “selective” mode of acculturation, often involving conscious strategies by parents to socialize children into the culture of the ethnic community. Within this mode of adjustment parents and children in immigrant families tend to acculturate in similar directions and retain more traditional values and language. Parents and children tend to be highly involved in ethnic institutions (e.g., religious congregations), further keeping both generations acculturating in roughly similar directions. This pattern does not, as is often assumed, preclude the acquisition of English language ability and cultural competency in the wider American community. Studies of immigrant children reveal an ability to acquire bicultural/bilingual skills within constantly evolving frames of ethnic identity. On the other side of the continuum is where children indeed acculturate rapidly, but parents lag behind, their lack of language skills making them dependent on their children to deal with the outside world. Thus, “generational dissonance” occurs as parents have difficulty guiding a highly acculturated second generation. This pattern is associated with such negative dynamics as the loss of parental authority and children’s rejection of the parents’ culture. The mode of incorporation is shaped by many factors, including the type of community where immigrants live. Immigrants who settle in an urban enclave of co-ethnics, full of shops, churches, and people who speak the same language and share similar cultural norms, will experience a mode of incorporation different than those living in a more isolated suburban neighborhood. It should be stressed that immigrants are proactive in the process of adaptation; it is not something that is done for them or to them. The rapidity by which immigrants establish networks, clubs, and organizations such as churches, is an example. Crane and Millard observed that the rapid creation of viable social institutions, such as religious congregations, demonstrated that new immigrant Latinos in the Midwest could create organizations that significantly benefit their constituencies and represent them in their new hometowns. Therefore, it should be acknowledged that cultural adaptation among immigrants is typically C a process negotiated by immigrants themselves via the mechanism of entrepreneurial activity, education, mutual assistance organizations, and religious institutions as well as via other expressions of human agency. This does not rule out the important role of individuals, organizations, and governmental institutions external to immigrant groups. Ultimately, success in American society requires resources beyond what private organizations can supply, particularly for language acquisition, education, health care, and financial capital. Another factor that has led to new types of organizations involved in cultural adaptation is mutual group suspicion among new immigrants, various immigrant groups, and the host community. This leads to newcomer immigrants maintaining separate social networks. Their reasons are understandable – particularly if they have experienced suspicion and hostility from the host community. As Godziak and Melia observe, ethnic communities serve to “cushion the impact of cultural change and protect immigrants from outside prejudice. . .” The anthropologists Grey and Woodrick identified a “20-60-20” pattern in Iowa, where roughly 20% of the Anglo community sees the influx of Latino newcomers as basically positive, 20% react negatively, and 60% adopt a “wait and see” attitude. Because of mutual suspicion and the marginal status occupied by many new immigrants, public interaction between groups is more difficult, even if most individuals on both sides desire to get along. The fear that this engenders among immigrant populations produces additional barriers to finding an established place in a new community and to getting the necessary resources. Fortunately, many concerned nonimmigrant citizens have proactively formed organizations to mitigate negative sentiment and constructively address the acceptance of new immigrants and bridge the gap between cultures. These organizations, an example being Heart and Hands, Inc., of Plymouth, Indiana, or TODEC in Perris, California, provide services to the new immigrant community, such as English language classes, job training, citizenship preparation, and translation and referral to other essential services, such as health care. In communities where immigrant communities are not well established, it is common that service organizations emerge that serve “all” immigrant newcomers. 511 C 512 C Cultural Adaptation Resources As immigrant communities grow and become better established, they commonly create their own organizational structures to provide services to a specific language, nationality, or ethnic group. The advantage in this practice is that immigrant communities can mobilize mutual assistance resources faster in a more appropriate fashion to particular culturally defined needs, bypassing the more cumbersome mechanisms of public services. The risk associated with strong ethnic organizations is that they may further serve to isolate immigrants culturally and socially. This can present a further barrier to gaining English language proficiency. Language Acquisition In most cases, acquisition of the host country language is essential for overall success, to avoid exploitation, for upward mobility, and to retain control over and connection with children who are rapidly losing the mother tongue. Most immigrants to the USA enter an environment in which English is dominant, although some regions and communities may have significant bilingual populations. It is not unusual that immigrants will encounter expectations that “they need to learn English,” and “they need to adapt to our ways.” Local fears of immigrants “not integrating” into “our way of doing things” are common reactions. Fennely found that lack of English ability is interpreted by the host community as choosing not to “assimilate” and as rejecting American culture and “creating their own isolation.” The 2000 census revealed that four out of five immigrant families spoke a language other than English at home. For people who see their place in American society as only temporary, there may not be an incentive to learn English. Even for those who intend to become citizens, the English language requirement is minimal. Furthermore, the demands of family and work schedules make it difficult to take advantage of classes. Nevertheless, as Gozdziak and Melia point out, most immigrants recognize the value of learning English and seek out ESL (English as a Second Language) programs. Their research also describes the many types of ESL or ENL (English as a New Language) programs created to accommodate the needs of immigrants. These include public and alternative schools with day and evening schedules, public library programs, and nonprofit organizations that offer low cost classes, often allowing the whole family to attend and providing childcare. Often immigrants must draw on resources within their own community organizations for help in language barriers. The UNHCR reports that Albanian refugees from Kosovo resettled in Spain had to create their own Albanian-Spanish dictionary with key words and phrases that could be used by new arrivals and Spanish settlement workers. Economic Self-Sufficiency A crucial area of cultural adaption concerns economic self-sufficiency through employment or entrepreneurial initiative. With the exception of immigrants who are highly skilled professionals, new arrivals often find work in niche-markets and informal economies of ethnic communities. While this may work in the short term, it may not be a long-term, permanent option, and immigrants moving into the mainstream job market may face many barriers in the job market related to culture and language. Many countries have created specific programs to increase the changes of economic success for immigrants. For example, in Germany, refugees seeking help in finding employment work with a separate agency, the AWO, which works specifically with refugees to provide job assessment and placement support. In the Australian state of Victoria, refugees are provided with similar services within the same mainstream employment service, but through government workers who are provided special training to deal the immigrant populations. Mentoring programs have also emerged, whereby immigrants who have achieved successful careers provide mentoring services to new arrivals. In the UK, a program developed by doctors who had been refugees now provides coaching, placements, and qualifying exams to qualified immigrants. Many immigrants contribute greatly to host country economies through creation of new business. Family and ethnic networks may be sources of otherwise difficult to find start-up capital. The challenge of finding adequate start-up capital for entrepreneurial immigrants has led to an increasing number of microenterprise programs worldwide targeting immigrants and refugees. The UNHCR reports that refugees from Ireland to Burkina Faso have taken advantage of Cultural Adaptation Resources grants and easy term loans programs to assist small business. Personnel and organizations working with immigrants also play a role in educating employers about the culture and religious needs of immigrant workers, for example, taking into consideration time for religious observance, prohibitions against handling certain food items, and gender role restrictions. The UNHCR advises that agency staff need to be careful not to inflate the skills or exaggerate the needs of refugees. Rather they should be seen as “normal people in extraordinary circumstances.” Accessing Culturally Appropriate Health Care Immigrants worldwide often face significant obstacles to accessing health care that is culturally and linguistically appropriate and affordable. Even in places like New York City, which has a long history of dealing with diverse immigrant populations, barriers persist. The following description of these difficulties in New York and elsewhere in the USA has parallels in many other countries. A recent report from the New York City Department of Health and Mental Hygiene noted that foreign-born adults are less likely than native-born adults to have a primary care provider; have Medicaid or health insurance; or receive regular preventive health measures such as colon cancer screenings, pap smears, or cholesterol screening. This difficulty accessing medical care is especially pronounced for recent arrivals and those who lack adequate proficiency in English (Low English Proficiency or LEP). Many undocumented immigrants actively avoid encounters with health care systems for fear of being turned over to immigration officials and deported. As a result, they may not have access to preventive care, routine screenings, or early treatment, seeking medical assistance only once potentially treatable conditions have progressed to the point of being severe. Health care costs can be a significant barrier to accessing care for immigrants. Department of Homeland Security statistics indicate that one third of foreign-born individuals in the USA were uninsured in 2007, compared to less than 15% of those who were born in the USA. A Pew Hispanic Center report found C that almost 60% of undocumented adults lacked health insurance coverage. The Personal Responsibility and Work Reconciliation Act of 1996 (PWORA) barred states from using federal funds for Medicaid or the Children’s Health Insurance Program (CHIP) for most undocumented immigrants and recent immigrants (within 5 years of arrival, regardless of immigration status), but allowed funds for some emergency Medicaid services. The result is a lack of preventive care. The 2009 CHIP reauthorization law, CHIPRA, changed regulations to allow states to use federal funds to provide Medicaid or CHIP to legal immigrant pregnant women and children, but not to other groups. Immigrants are also less likely than native-born citizens to have health care benefits provided by their employer. Even immigrants who have insurance have less access to and lower use of medical care than do native-born individuals. Both linguistic and cultural barriers contribute significantly to making health care systems relatively inaccessible to many immigrants. The U.S. Department of Health and Human Services Office of Minority Health issued National Standards for Culturally and Linguistically Appropriate Services in Health Care. Four of these standards mandate language access in health care in any medical facility that is a recipient of federal funds. These standards require facilities to offer competent language assistance services such as interpreters and bilingual staff to any patient who needs those services. Despite these standards, often no qualified interpreter is available to the patient, leaving LEP patients to rely on family members, friends, other patients, or strangers to translate for them, resulting in a loss of privacy and accuracy. Reliance on children poses particular problems, as it causes role reversals in the family structure, and children often lack the vocabulary and understanding of complex issues to translate accurately. Additionally, children may wish to avoid sensitive topics, which can slant the information given. Bureaucratic, large, and impersonal health care systems are often extremely difficult for immigrants to navigate, and cultural insensitivity can be enough to drive them away from seeking care or make receiving care a negative experience. Birth and death are particularly difficult times, with health regulations, safety rules, and hospital practices often interfering with the practice 513 C 514 C Cultural Appropriateness of cultural and religious rituals such as burying a newborn’s placenta, touching the lips of a baby with honey or preparing the dying for passage into the next life. Physicians and patients may also have differing ideas about the causes and treatment of illness, which can cause misunderstandings and conflict. Patients may be using traditional, complementary, or alternative medicine in addition to the medical treatment offered by an MD, but unless both parties are able to communicate and know what to ask, this information may not be available to the physician. Patients may not volunteer information for fear ridicule or rejection if they reveal alternative treatments. In general, immigrants’ access to key resources can be facilitated or hindered by their mode of acculturation and by the availability of others in the community who can assist in making this transition. Communitybased private organizations can provide an important bridge between immigrant families and participation in the wider society, connecting them to programs that provide resources for education and advocacy. Ultimately, nonimmigrants and a variety of immigrant groups need to cooperate together for a truly successful and diverse society to emerge. Fennelly, K. (2008). Prejudice toward immigrants in the Midwest. In D. S. Massey (Ed.), New faces in new places: The changing geography of American immigration (pp. 151–178). New York: Russell Sage Foundation. Gozdziak, E. M., & Melia, M. J. (2005). Promising practices for immigration integration. In E. M. Gozdziak & S. F. Martin (Eds.), Beyond the gateway: Immigrants in a changing America (pp. 241–276). Lanham: Lexington Books. Grey, M. A., & Woodrick, A. C. (2002). Unofficial sister cities: Meatpacking labor migration between Villachuato, Mexico, and Marshalltown, Iowa. Human Organization, 61(4), 364–376. Kim, M., Van Wye, G., Kerker, B., Thorpe, L., & Frieden, T. R. (2006). The health of immigrants in New York city. New York: New York City Department of Health and Mental Hygiene. Portes, A., & Rumbaut, R. G. (2006). Immigrant America: A portrait (3rd ed.). Berkeley: University of California Press. U.S. Department of Health and Human Services, OPHS Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care. Washington DC: U.S. Department of Health and Human Services. Suggested Resources UNHCR Refugee Resettlement: An international handbook to guide reception and integration. 2002. Retrieved October 3, 2010, from http://www.unhcr.org/4a2cfe336.html. Cultural Appropriateness Related Topics ▶ Acculturation ▶ Barriers to care ▶ Cultural competence ▶ Culture shock ▶ Culture-specific diagnoses ▶ English as a Second Language ▶ Ethnic enclave ▶ Immigration processes and health in the U.S.: A brief history ▶ Language acculturation ▶ Limited English proficiency ▶ Social integration Suggested Readings Chrostowsky, M. B. (2010). The role of asylum location on refugee adjustment strategies: The case of Sudanese in San Diego, California. Practicing Anthropology, 32(1), 38–42. Crane, K., & Millard, A. (2004). ‘To be with my people’: Latino churches in the rural Midwest. In A. V. Millard & J. Chapa (Eds.), Apple pie and enchiladas: Latino newcomers in the rural Midwest (pp. 172–195). Austin: University of Texas Press. ▶ Cultural competence ▶ Cultural humility Cultural Background CĂTĂLIN JAN IOV University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania The number of immigrants worldwide has almost doubled during the past 50 years. It is now estimated that there are 191 million immigrants worldwide, 115 million of whom live in developed countries. In fact, 75% of immigrants live in just 28 countries. One-third of all immigrants have made their new home in Europe, and another fifth have settled in the United States. All of these immigrants carry with them their habits, beliefs, and lifestyle from the countries of their Cultural Background births to their new host countries. In short, they carry with them their cultures, which are the sum of all beliefs, attitudes, models, templates, living style, and any other characteristics that promote relationships among the group members. The concept of culture also includes codes of manners, dressing style, language, religion, rituals, and systems of beliefs. These elements often identify immigrants as a distinct group in the host country. The culture frames individuals’ social lives and actions and differentiates the groups. The differences between cultures may not be obvious unless individuals from different groups occupy the same space or contiguous spaces. It is critical that the host cultures adapt to the new incoming cultures, particularly in view of increasing globalization and increased diversity. Host Culture Attitude The entry of any culture into a different one will always generate reactions. Scholars have suggested that the level of hostility directed to the newcomers by individuals in the host country depends on the degree of similarity between the new host culture and the immigrants’ original culture; it is hypothesized that the more similar the cultures, the less the level of hostility or antagonism. A common way of understanding a culture and the extent to which cultures are similar or different is by reference to four elements: values, norms, institutions, and artifacts. Values refer to what is important for the society, what is important for the family, what is important in general in life. Norms consist of all behaviors that are judged by the culture to be appropriate in dealing with different situations. The institutions are those structures that are governed by the values and norms. The values and norms within a society derive from unwritten law (common sense) and written law (such as punishing all those that are breaching the norms and values). The artifacts are the products of a cultural history. Attitudes toward cultural diversity as a result of immigration have been found by researchers to be associated with individuals’ age, sex, and race. For example, some groups, such as Algerians and some other North African French persons, may continue to be stigmatized, marginalized, and discriminated based on racial reasons despite their legal status as citizens. C 515 Young educated females have been found to be more open to exposure to new cultures than older men. Cultural Background and Health Care In the health care context, five issues relating to individuals’ cultural background are of primary importance: the style of communication, the existence and extent of mistrust and prejudice, decision making and family dynamics, traditions and spirituality, and sexual and gender-based issues. Cultural background may affect doctor–patient communication and, accordingly, the doctor–patient relationship. For example, a medical team trying to provide medical treatment may find that the treatment conflicts with the patient’s beliefs. Such dilemmas may be amplified when the patient’s language differs from the provider’s language. Differences in the cultural background between the provider and the patient may also bring different expectations. For example, the Western concept of health delivery stresses a collaborative model of communication between the health care provider and the patient. However, in many cultures, medical decision making requires the involvement of the family and not only the individual patient. In yet other cultures, individuals are accustomed to a more paternalistic model of relationship between the doctor and the patient. In many Eastern Europe cultures, for example, the doctor–patient relationship is one of trusting the doctor without asking too many questions about the treatment. The cross-cultural care model proposed by Betancourt and Cervantes requires consideration of the patients’ cultural background. Successful cross-cultural medical education would assist health care providers to develop the skills necessary to provide care to individuals of diverse backgrounds. Religious beliefs may also affect provider–patient communication and the patient’s willingness to agree to particular treatments. For example, some immigrant groups may favor the use of prayer, meditation, or traditional preparations to treat an illness, rather than Western medicine. Provider sensitivity to and accommodation of these varying beliefs to the extent possible are critical to the development of a successful provider– patient relationship and open lines of communication. Culture-based norms relating to sex and gender are also important in the health care context. Kopp, Réthy, C 516 C Cultural Competence and Chapuis reported on the case of a woman who presented to an emergency room for a gynecological problem. The patient and her husband initially rejected care from the male physician on duty based on their religious beliefs. However, they later agreed that the male physician could care for the woman after a religious authority explained that the religion did not prohibit the examination by a male physician because it was a medical emergency. Accordingly, it is critical that health care providers consider in each particular case all of the factors that define an individual, including the person’s attitudes, understandings of health and illness, language, and religious beliefs. A primary goal should be the development of a good relationship with the patient and smooth communication. Harmsen, H., Bernsen, R., Bruijnzeels, M., & Meeuwesen, L. (2008). Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers? Patient Education and Counseling, 72, 155–162. Kopp, N., Réthy, M. P., & Chapuis, F. (2006). Éthique médicale et interculturelle. Ethique & Santé, 3, 115–120. Lucassen, L., & Laarman, C. (2009). Immigration, intermarriage and the changing face of Europe in the post war period. History of the Family, 14, 52–68. Man, G. (2004). Gender, work and migration: Deskilling Chinese immigrant women in Canada. Women’s Studies International Forum, 27, 135–148. Martikainen, T. (2009). Religious diversity beyond the cosmopolis: Immigration and the religious field in the City of Turku, Finland. Religion, 39, 176–181. Qureshi, A., Collazos, F., Ramos, M., & Casas, M. (2008). Cultural competency training in psychiatry. European Psychiatry, 23, S49–S58. Related Topics ▶ Acculturation ▶ Communication barriers ▶ Cross-cultural health ▶ Cross-cultural medicine ▶ Culture shock ▶ Culture-specific diagnoses ▶ Cultural competence ▶ Cultural humility ▶ Health beliefs ▶ Physician–patient communication Suggested Readings Alaggia, R., Regehr, C., & Rishchynski, G. (2009). Intimate partner violence and immigration laws in Canada: How far have we come? International Journal of Law and Psychiatry, 32, 335–341. Asanin, J., & Wilson, K. (2008). “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga. Ontario, Canada, Social Science & Medicine, 66, 1271–1283. Betancourt, J. R., & Cervantes, M. C. (2009). Cross-cultural medical education in the United States: Key principles and experiences. Kaohsiung Journal of Medical Science, 25(9), 471–478. Carroll, J., Epstein, R., Fiscella, K., Gipson, T., Volpe, E., & JeanPierre, P. (2007). Caring for Somali women: Implications for clinician–patient communication. Patient Education and Counseling, 66, 337–345. Dandy, J., & Pe-Pua, R. (2010). Attitudes to multiculturalism, immigration and cultural diversity: Comparison of dominant and non-dominant groups in three Australian states. International Journal of Intercultural Relations, 34, 34–46. Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, & Giroux. Cultural Competence LINDA S. MARTINEZ1, FLAVIA C. PERÉA2 1 School of Arts and Sciences, Community Health Program, Tufts University, Medford, MA, USA 2 Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA Driven largely by immigration, the USA, like Europe and Canada, is becoming ever more diverse. For example, it is anticipated that the country will have a minority-majority population by the year 2042, largely the result of immigration from Latin America and the Caribbean, as well as both Africa and Asia. This underscores the importance of understanding different cultural experiences in the health care realm. These demographic shifts have exaggerated an already present cultural distance between the medical community, which is predominantly upper middle class and White, and the general population. As such, health care organizations are grappling with ways in which to both understand and meet the needs of diverse communities that are not always reflective of their employees and/or providers. Cultural competence has been proposed as a mechanism by which to bridge the cultural distance between patients and health care providers. Cultural Competence Cultural competence is a component of patientcentered care. In 2001, 7 years after being charged by Congress with improving the ability of health care providers to deliver culturally competent care, the United States Office of Minority Health published National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. The overall aim of the CLAS standards is to address health care disparities through the delivery of culturally and linguistically competent care in health care services. As such, culturally competent health care organizations provide treatment services that effectively meet the needs of their patients, while considering the cultural, linguistic, and/ or socio-environmental context of patients. Similarly, culturally competent providers bridge sociocultural divides, allowing them to recognize and understand the needs of diverse patient populations with varying cultural beliefs and behaviors. Cultural Competence and Inequity in the Delivery of Care The modern day health care system is founded on traditional beliefs of Western biomedicine, thereby forming its own unique culture built on a distinct cultural orientation and perspective, inclusive of distinct assumptions and beliefs about patients, providers, and the nature of health care. Cultural competence involves understanding the ways in which individual and community level practices and beliefs influence health, and the delivery of health care. Both patients and providers bring with them into the health care exchange a set of beliefs, experiences, and practices that shape their behavior and interactions. Unequal Treatment, a report commissioned by the Institute of Medicine, brought a new dimension to our understanding of cultural distance and the contributions of providers to health care inequality. The report found that systemic, provider, and patient level factors take away from the overall quality of care. More specifically, patient race and ethnicity are primary predictors of health care quality. Culture also contributes to the divide between patients, providers, and the health care system. Culture, although often confounded with race and ethnicity, is more than race and/or it influences behavior, including health practices and interactions. Culture can be influenced by social constructs such as race and C ethnicity, but additional factors such as religious beliefs, family structure, class, place, and time coupled with socio-environmental and sociopolitical context also contribute to cultural variation. Such variation can result in cultural distance as well as disconnects both between and within groups. For example, how patients describe their relationship to the biomedical system may vary dependent on the cultural context of the patient. The same can be said for providers describing their cultural distance from patients, and patients describing their cultural distance from providers. Cultural distance contributes to poor quality care for racial and ethnic minorities including new immigrants. Cultural distance is a by-product of social, economic, political, and historical factors, which result in divergent health beliefs, communication barriers, mistrust, and bias. Socioeconomic and racial segregation – both associated with the social hierarchy in the USA – isolate individuals geographically, socially, and culturally. Isolation and unfamiliarity leave individuals vulnerable to the effects of bias and stereotypes. That which is unknown is more easily understood when grouped or categorized. Social cognition is the unconscious process by which we categorize or group individuals – how our minds make the unfamiliar familiar. For example, providers, when interacting with patients of a background that is foreign to them, draw upon past experiences, perceptions, and stereotypes to make sense of that which is unknown, which can lead to health care disparities. Thus initiatives that promote cultural competence are important as they encourage providers to (1) meet patients where they are at, (2) avoid using mental shortcuts and stereotypes, and (3) broaden their worldview to assure understanding of patient cultural context, thereby engaging patients in treatment as opposed to maintaining cultural distance. Cultural Competence as a Market Strategy Beyond addressing health care inequity, cultural competence by some has been described as a market strategy in addition to a means by which to reduce racial and ethnic disparities in health care. Researchers have found that experts from managed care, academia, and government describe cultural competence as a mechanism by which to improve access to quality 517 C 518 C Cultural Competence care for diverse, new immigrant communities. In addition, it has been described as a way for health care provider and payer organizations to increase their market share in a rapidly changing world demographic. This is significant; it represents a paradigm shift solely viewing cultural competence as the right thing to do in addressing disparities to a focus on good business practices in a shifting market. By providing culturally competent care, care that seeks to meet patients where they are at both culturally and linguistically, health care organizations can differentiate themselves from their competitors, increasing their market share. Four interconnected financial reasons for organizations to provide culturally competent care have been outlined in the literature. The first being clear, appeal to minority consumers. With the growing proportion of minority consumers in the market many businesses, including the health care sector, seek to reach the minorities. Cultural competence in this sense would provide organizations the tools needed to differentiate their services in the market. The next two reasons are based on the same premise, to compete for purchaser business. Brach and Fraser report that providing culturally competent care allows health care organizations to compete for private purchaser business and to respond to public purchaser demands. They explain this in that cultural competence will increase performance quality scores, increasing their appeal to private purchasers, while at the same time facilitating compliance with public purchaser rules and regulations. Finally, it has been identified as a means to improve cost-effectiveness. As providers who confront barriers in communications are likely to order additional diagnostic tests and thus incurring greater costs, cultural competent organizations would have the linguistic capability to better capture medical history and reducing the need for unnecessary testing. Conclusions Cultural competence has the potential to reduce care health disparities, by increasing patient access to quality health care though a respectful patient provider relationship. In addition, culturally competent health care makes good business sense. The hope is that diverse populations plus cultural competence leads to better communication, increased trust, better assessment, more appropriate diagnostic services, improved outcomes, and over time the reduction of racial and ethnic disparities in health. Related Topics ▶ Cross-cultural health ▶ Cross-cultural medicine ▶ Cultural humility ▶ Health barriers ▶ Health beliefs ▶ Interpreter services ▶ Transcultural psychiatry ▶ Vulnerable population Suggested Readings Bernstein, R., & Edwards, T. (2008). An older and more diverse nation by midcentury. U.S. Census Bureau News. Betancourt, J., Green, A. R., & Carrillo, J. E. (2002). Cultural competence in healthcare: Emerging frameworks and practical approaches. New York: The Commonwealth Fund. Bollini, P. (1992). Health policies for immigrant populations in the 1990’s. A comparative study in seven receiving countries. International Migration, 30, 103–112. Brach, C., & Fraser, I. (2002a). Reducing disparities through culturally competent health care: An analysis of the business case. Quality Management in Health Care, 10(4), 15–28. Brach, C., & Fraser, I. (2002). Reducing disparities through culturally competent health care: An analysis of the business case. (Need for US health care industry to be more inclusive of minorities triggers discussion of cultural competence training.) Quality Management in Health Care, 10(4), 15(14), 15–28. Department of Health and Human Services. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: OMH. Dogra, N., Betancourt, J., Park, E., & Martinez, L. (2009). The relationship between drivers and policy in the implementation of cultural competency training in health care. Journal of the National Medical Association, 101(2), 127–133. Laveist, T. (2005). Minority health and populations: An introduction to health disparities in the United States. San Fransisco: Jossey-Bass. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press. van Ryn, M. (2002). Research on the provider contribution to race/ ethnicity disparities in medical care. Medical Care, 40(1), 140–151. van Ryn, M., & Fu, S. S. (2003). Paved with good intentions: Do public health and human service providers contribute to racial/ ethnic disparities in health? American Journal of Public Health, 93(2), 248–255. Cultural Humility Suggested Resources http://www.hrsa.gov/culturalcompetence/ http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf http://nccc.georgetown.edu/index.html Cultural Humility ANDREW J. S. HOWIE Mental Health and Drug and Alcohol Services, Far West Local Health Network, Broken Hill, NSW, Australia In the context of health care, the term “cultural humility” denotes an attitude of appropriate respect by a health professional toward the culture of her clients or patients, where this differs from her own. As an attitude, rather than knowledge of a body of facts about other cultures, or a set of acquired relevant cultural skills, cultural humility is a necessary condition of the combined task of gaining relevant knowledge of other cultures, developing a set of skills necessary to apply this knowledge in theoretical clinical situations, actually applying the knowledge in complex real life situations, and accurately monitoring the outcomes in terms of patient and client satisfaction, and other beneficial or detrimental effects. The term therefore is used in contrast to other similar terms such as “cultural competence,” “cultural safety,” “cultural sensitivity,” and “cultural proficiency,” all of which emphasize appropriate cultural knowledge and skills brought to the clinical encounter. In the modern health care discussion the term “cultural humility” was coined by Tervalon and Murray-Garcia, who describe it as incorporating “a life-long commitment to self evaluation and self critique, to redressing the power imbalances in the patient physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.” Hunt characterizes it as “not. . . an examination of the patient’s belief system, but [a] careful consideration by healthcare providers of the assumptions and beliefs C that are embedded in their own understandings and goals in the clinical encounter.” Described in this way, the concept of cultural humility is brought very close to the generic philosophical virtue of humility, and embraces the multidisciplinary nature of clinical work, emphasizing ethical commitment to continual professional improvement, and professional egalitarianism applied in the context of the multidisciplinary study of individuals in communities. Tervalon and Garcia use the term in the context of medical education, emphasizing (1) patient-focused interviewing and care where, for example, patientinitiated questions and agendas are tolerated, as the physician relinquishes the role of expert in recognition of the fact that the patient is uniquely qualified to help the physician understand the complex intersection of the elements of a patient’s cultural identity; (2) community based care and advocacy, where maintaining the client’s cultural context as much as practicable is intended to be empowering; and (3) institutional consistency, where care is taken to ensure that polices are formulated and consistently applied so as to minimize the disadvantage, wherever practicable, to clients from minority cultures. Subsequent literature has addressed areas as diverse as the assessment and diagnosis of illness and dysfunction, management of disability, and psycho-education in physical and mental health, including programs for families of children with special needs, psychiatry and psychotherapy, substance abuse, midwifery, gynecology and neonatal care, cancer care, public health, the measurement of quality for managed care organizations, the indigenous practitioner, and cultural practices with health consequences. Clearly there is scope for more research. A strength of the concept of cultural humility is that as it emphasizes attitudes and habits of mind rather than specific domains of knowledge and skill, a clinician is readily able to bring cultural humility to unfamiliar situations, where knowledge and skill may be lacking, and seek to develop these as the relationship with her patients deepens. A possible weakness of the concept is that it can be unclear what the scope and limits of cultural humility are, as unseemly haste to avoid “the hegemony of one culture over another” may lead to a de facto cultural 519 C 520 C Culture relativism. However the practice of health care assumes that suffering and failure of function are what characterize an illness or disability, and in the extreme case a society or culture cannot tolerate or approve of these among its members and remain consistent with other values it embraces. Practically speaking, a person dealing with a health professional of another culture, who was showing appropriate cultural humility, would expect to have her values respected, to experience receptiveness to her questions, and to receive questions asking for further information regarding her cultural values, roles, and expectations, all of which may enhance the value of the clinical encounter. Acknowledging that cultural humility (where present) may not always be fully expressed, a failure to experience this may indicate a lack of cultural humility on the part of a clinician. A remedy for this could then be found by a complaint or appeal to the authorities of the institution, the ethical base of which will express principles based on respect for autonomy, beneficence, nonmaleficence, justice, and professional integrity, all of which also find expression in the notion of cultural humility. The notion of cultural humility is fundamental to other cultural competencies, and is well supported from the perspectives of many related disciplines in health care. Increasing work on the concept of cultural humility in future academic and clinical discussion would be welcomed. Related Topics ▶ Cultural competence Suggested Readings Foster, J. (2009). Cultural humility and the importance of long-term relationships in international partnerships. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38(1), 100–107. Hunt, M. (2001). Beyond cultural competence. Park Ridge Centre Bulletin, December 2001. Levi, A. (2009). The ethics of nursing student international clinical experiences. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38(1), 94–99. Pratt, G. (2007). Reflections of an indigenous counsellor: sharing the journey–therapist and person? Australasian Psychiatry, 15 (Suppl. 1), S54–S57. Surbone, A. (2008). Cultural aspects of communication in cancer care. Supportive Care in Cancer, 16(3), 235–240. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Undeserved, 9(2), 117–125. Wear, D. (2008). On outcomes and humility. Academic Medicine, 83(7), 625–626. Suggested Resources Carme, B. (2009). Malaria or kalimbe: how to choose? Malaria Journal 8, 280. http://www.malariajournal.com/content/8/1/280 Culture ▶ Cultural background Culture Shock SANA LOUE Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH, USA The term “culture shock” was introduced by Kalvero Oberg in 1954 to refer to an “abrupt loss of the familiar” or the “shock of the new.” Culture shock is caused by the anxiety that is associated with the loss of familiar signs and symbols that permeated one’s life before reaching the new environment. Culture shock occurs in various stages or phases, which have been variously termed incubation, crisis, recovery, and full recovery; elation, depression, recovery, and acculturation; and contact, disintegration, reintegration, autonomy, and independence. The first phase of culture shock is often referred to as the “honeymoon phase” because the individual feels excitement about the many new things that he or she is experiencing. This phase may last for hours, days, weeks, or months. The feeling of excitement that is experienced during the first phase of culture shock gradually diminishes as the individual begins to be aware of the differences that exist between his or her previous and current environments. This second phase is often characterized by the Culture Shock experience of many practical problems, an increase in misunderstandings, feelings of frustration, a sense of loneliness and uneasiness, and a decrease in self-confidence. This second stage often lasts about 6 months, but its exact length depends on the individual and his or her specific circumstances. Many people also experience physical symptoms of culture shock during these stages. These can include lethargy, headache, difficulties sleeping, a loss of appetite, and digestive irregularities. During the third stage of culture shock, the individual will begin to adjust to the new environment or reject his or her new situation, blaming others and adopting negative coping mechanisms, such as substance use and self-isolation. During the final stage, the individual gradually adjusts and adapts to the new environment and experiences an increased sense of control and belonging. Immigrant children may have a particularly difficult time adjusting to their new country and may experience severe culture shock. They may feel embarrassed because they do not speak the same language as their classmates or because they or their families look “different.” They may be unable to verbalize their feelings and may act out in frustration; accordingly, it is important that teachers have patience. They may also experience difficulties with their parents. The parents may want to continue the use of their primary language and the observation of their usual traditions, but the children may want to discard both their native language and their traditions in favor of those of their new country. Immigrants may experience a greater degree of culture shock if specific practices classified as common social behaviors in their countries of origin are considered to be abusive and criminal acts in their new host countries. As an example, some countries might consider beating one’s wife to be an acceptable response to her challenge of her husband’s authority, but in the United States, this could be considered partner violence and could result in criminal prosecution. The extent to which an immigrant experiences culture shock, and the rapidity with which he or she adjusts to the new environment is highly dependent on his or her personal experiences. Individuals who immigrate to a new country with their families are less likely to experience intense feelings of culture shock and/or may move through the various stages more quickly, because they have the support of their C family members. Immigrants whose language is the same as that of their host country, and whose culture in their country of origin is similar to that of their new host country, may also be less likely to experience culture shock. The extent to which an immigrant experiences culture shock also depends on individual factors. Individuals who are very resilient to change are less likely to experience difficulties in their new environments. A variety of interventions have been suggested to help immigrants adjust to their new country and minimize their experience of culture shock. This includes the development of leisure activities that include physical exercise; enrolling for language classes to learn the language of the host country; and volunteering in the new community, which provides a mechanism for meeting new people and becoming integrated into the community. It is important that the immigrant try to keep an open mind about his or her experiences and not interpret everything through the cultural lens of his or her country of origin, since a behavior or saying may have a very different meaning in the new culture. A sense of humor may also help to alleviate the feelings of frustration, anxiety, and confusion that are part of culture shock. Immigrants who return to their country of origin, for example, to visit family or friends, may find that they experience culture shock when they arrive in their country of origin. The immigrant may find that their family members and friends have changed during this time, and that their previous place of residence has also changed. Related Topics ▶ Acculturation ▶ Acculturative stress ▶ Anxiety ▶ Assimilation ▶ Language acculturation ▶ Resilience ▶ Stress Suggested Readings Adler, P. S. (1975). The transitional experience: An alternative view of culture shock. Journal of Humanistic Psychology, 15(4), 13–23. Oberg, K. (1960). Culture shock: Adjustment to new cultural environments. Practical Anthropology, 7, 177–182. 521 C 522 C Culture-Bound Syndromes Suggested Resources Oberg, K. (1954). Culture shock. (Bobbs-Merrill Reprint Series in the Social Sciences, A-329). Indianapolis: Bobbs-Merrill. Retrieved March 7, 2009, from http://www.smcm.edu/academics/internationaled/Pdf/cultureshockarticle.pdf Culture-Bound Syndromes ▶ Culture-specific diagnoses Cupping KRISTIN BRIGHT Department of Sociology & Anthropology, Carleton University, Ottawa, ON, Canada in the form of cattle horns for the draining of pustules, boils, and carbuncles. During the Qing Dynasty, Zhao Xuemin (1719–1805) included an extensive chapter in his materia medica on huoquan qi or “fire cupping”: the use of bamboo or pottery cups to treat headache, dizziness, abdominal pain, and snakebite. In the 1950s, cupping was established as an official therapy throughout China; and today there are numerous Traditional Chinese Medicine (TCM) research institutes with ongoing clinical trials in cupping therapy (see below). In South Asia, cupping is a common therapeutic practice in Unani-tibb or Greco-Islamic medicine. Based on the principles of Hippocrates, Avicenna, al-Majusi and others, Unani-tibb advises the use of cupping (al-hijamah) to draw inflammation toward the surface of the body; divert inflammation from an important organ to a less important one; dispel humors from an affected organ; and alleviate pain. Unani physicians or hakims, like their TCM counterparts, use cupping to treat a number of muscular, circulatory, and neurological disorders. Origins of Cupping Cupping therapy (huoquan qi in Chinese; and alhijamah in Arabic) is a practice whereby glass or bamboo cups are applied to the surface of the skin and through suction and negative pressure, the skin and superficial muscle are gently drawn into and held in the cups. Based on the holistic principle that the body relies on a balance of energies to function properly, cupping is used to remove accumulated stress, tension, and cold channels from the body; promote blood flow and healing; and restore balance. Widely practiced in China, Taiwan, India, Pakistan, Iran, Saudi Arabia, the Gulf States and parts of Africa and the Middle East, cupping is commonly used in immigrant communities (e.g., Asian, Arab, Mediterranean) in the USA, Canada, Europe, Australia, and New Zealand. The earliest recorded use of cupping is in the Ebers Papyrus of ancient Egypt (1550 BCE) where cupping was indicated for the removal of foreign matter from the body. Hippocrates (ca. 460–370 BCE) and Galen (ca. 129–200 CE) also described cupping as an effective remedy for numerous disorders and a means to evacuate toxins, reduce inflammation, arrest fevers, and restore humoral balance. One of the first records of cupping in China is by Taoist alchemist and herbalist Ge Hong (281–341 CE) who prescribed the use of cups Current Use of Cupping In most parts of Asia and the Middle East, cupping is administered by medical practitioners, usually TCM doctors or Unani hakims. In the USA and other Western countries, cupping was historically introduced and practiced by immigrants from the Mediterranean and Asia in the 1800s and then spread to many parts of the USA flourishing as late as the 1930s in immigrant sections of large cities. On the Lower East Side of New York, cupping shifted from the domain of family doctors to barber shops, and one could see sign boards reading “cups for colds” on barber shop windows. Today, in rural parts of the Mediterranean, cupping is still practiced at home by families who put a set of cups in their first aid boxes or simply use a set of jam jars. In the USA, Canada, Europe, Australia, and New Zealand, where there are sizable Asian communities (and hence an availability of trained practitioners) cupping is used alone or in tandem with other traditional therapies such as acupuncture, herbal medicine, massage, medicated steam, hydrotherapy, nutritional therapy, and in combination with biomedical treatments, such as pharmaceutical analgesics, nonsteroidal anti-inflammatory medications, orthopedic surgery, and physical and rehabilitative therapies. Cupping For patients with arthritis, fibromyalgia, carpal tunnel syndrome, chronic back pain, chronic headache, and joint injuries, the appeal of cupping therapy is its use of low-tech equipment, its low cost, and its lack of side effects that might otherwise be experienced with analgesics. In the past decade, cupping has seen renewed popularity in the USA in the domain of complementary and alternative medicine (CAM) and health spas, with growing numbers of the general public using cupping, and more TCM and CAM practitioners training in the use of this therapy. New versions of “cellulite trimming” and “stress relief ” cupping have cropped up on the menu of health spas in cities like New York and Los Angeles, creating an interesting contrast with the no-frills offerings found in Asian neighborhoods in Chicago, Los Angeles, New York, San Francisco, Toronto, Vancouver, and other cities, where cupping is still practiced in much the same way it has been for decades. Differences in technique and cultural milieu are reflected in cost: while a 30–40 min session with a holistic practitioner or spa technician can cost anywhere from $30 to $100, a session with a TCM practitioner in New York’s Chinatown is closer to $10–$20. By contrast, in China the average cost of a session is 12 Yuan ($1.60) compared with an average 56 Yuan ($7.30) for herbal therapy. The Procedure and Outcome There are two primary types of cupping: dry and wet. In dry cupping, glasses are applied to the skin and either a gentle vacuum pump or flame heat is used to purge air from the cup. As the glass cup cools on the skin and a seal is formed, pressure within the cup declines, sucking the skin into the cup. Cupping glasses are typically applied for 10–15 min to the back, neck, hips, legs, knees, or arms. Wet cupping involves minor scarification of the skin so that a small amount of blood is drawn. Today, wet cupping serves as a modern substitute for venesection, in which larger quantities of blood were let out. Two other classifications exist in cupping as well: stationary cupping, where each glass cup is left in position on the skin and the cup is not moved; and massage cupping, where the glass cups are moved around the skin in a massage-like technique. In regard to clinical evidence for the efficacy of cupping, a 2010 meta-review of the clinical literature conducted by Huisstede and colleagues found no C evidence of long-term results of cupping in the treatment of carpal tunnel syndrome, but did find evidence for short-term benefit and relief of symptoms. The combination of acupuncture and cupping has been found to be of greater benefit in the reduction of pain and inflammation associated with acute arthritis and the reduction of pain associated with fibromyalgia, compared to the use of either cupping or pharmacotherapy alone. Cupping has also been found to be effective in the treatment of acute arthritis when combined with herbal medicine; in the treatment of fibrositis; and in the treatment of intractable migraine, when combined with acupuncture. From a sociocultural standpoint, qualitative studies of cupping therapy and its rich historical and contemporary uses in immigrant communities are seriously needed. Such studies will enable public health and medical providers to understand the range of therapeutic applications of cupping in TCM, Unani, CAM, and biomedical contexts and the cultural meanings of cupping in widely diverse immigrant communities (e.g., African, Asian, Arab, Mediterranean). Importantly, as the number of individuals seeking cupping therapy increases in Western countries, providers should also be familiar with this practice so as to prevent any social and legal conflicts that may emerge from mistaken diagnosis, such as when cupping welts are misinterpreted as signs of violence or abuse as has been the case in Europe and in the USA. Related Topics ▶ Acupuncture ▶ Alternative and complementary medicine ▶ Chinese ▶ Chronic pain ▶ Cross-cultural medicine ▶ Islam ▶ Muslim ▶ South Asians ▶ Traditional Chinese medicine Suggested Readings Ahmadi, A., Schwebel, D. C., & Rezaei, M. (2008). The efficacy of wetcupping in the treatment of tension and migraine headache. The American Journal of Chinese Medicine, 36(1), 37–44. Bright, K. (1998). The traveling tonic: Tradition, commodity, and the body in Unani (Greco-Arab) medicine in India. Ph.D. dissertation, University of California, Santa Cruz, USA. Retrieved March 523 C 524 C Curandero 7, 2011, from Dissertations & Theses: Full Text. (Publication No. AAT 9913732). Cao, H., Liu, J., & Lewith, G. T. (2010). Traditional Chinese medicine for treatment of fibromyalgia: A systematic review of randomized controlled trials. Journal of Alternative and Complementary Medicine, 16(4), 397–409. Chirali, I. Z. (1999). Traditional Chinese medicine: Cupping therapy. Philadelphia, PA: Churchill Livingstone. Hameed, H. A. (1977). Arab medicine and its relevance to modern medicine. New Delhi: Institute of the History of Medicine and Medical Research, Jamia Hamdard University. Huisstede, B. M., Hoogvliet, P., Randsdorp, M. S., Glerum, S., van Middelkoop, M., & Koes, B. W. (2010). Carpal tunnel syndrome. Part I: Effectiveness of nonsurgical treatments – a systematic review. Archives of Physical Medicine and Rehabilitation, 91(7), 981–1004. Rahman, H. S. Z. (2001). Unani Medicine in India: Its origin and fundamental concepts. In Subbarayappa, B. V. (Ed.), History of science, philosophy and culture in Indian civilization (Vol. IV Part 2, pp. 298–325). New Delhi: Centre for Studies in Civilizations. Sherman, K. J., Cherkin, D. C., Deyo, R. A., Erro, J. H., Hrbek, A., Davis, R. B., et al. (2006). The diagnosis and treatment of chronic back pain by acupuncturists, chiropractors, and massage therapists. The Clinical Journal of Pain, 22(3), 227–234. Ullmann, M. (1997). Islamic medicine. Edinburgh: Edinburgh University Press. Curandero KONANE M. MARTINEZ Department of Anthropology, California State University San Marcos, San Marcos, CA, USA Curandero is a Spanish term meaning “healer.” Curanderos (male healers) and Curanderas (female healers) are important community-based “folk” healers held in high regard within Latin American and Latino immigrant and transnational communities. Contemporary curanderos’ medical knowledge, beliefs, and practices are generally a mixture of pre-Hispanic medical cultures with Spanish and Catholic symbols and beliefs. The term curandero is a broad term that refers to a whole set of healers who utilize diverse methods in their practice. Each specialty has specific methods and a title that accompany it, and some curanderos specialize in more than one method. A yerbero/a is a herbalist who utilizes herbs to address health issues. A Sobador/a is a healer who utilizes massage to help alleviate pain or help a client recover from an illness or trauma. A Huesero/a is a bonesetter who manipulates injured bones, tendons, and muscles to alleviate pain and facilitate recovery from an injury. A espiritisto/a is a psychic medium who channels spirit beings and/or utilizes prayer to rid clients of physical, psychological, spiritual, and even social problems. A partera is a midwife who cares for pregnant women providing prenatal care as well as assistance with the birth of the child. Utilization of parteras in Latin America is widespread. For example, in some Mexican communities, parteras oversee a significant percentage, if not the majority, of births. Curanderos often hear a “calling” to their profession and view this calling as a gift from God or other supernatural beings. Curanderos undergo an intense period of training during which their practical and spiritual knowledge is tested and affirmed. Generally, curanderos have a vast and specialized knowledge of the physical and supernatural worlds and employ this knowledge in their practice. Some curanderos/as are shamans who communicate directly with the supernatural through trance to heal. Curanderos attend to an individual’s physical, psychological, spiritual, and social wellbeing. This holistic approach to health is why many Latino immigrant communities seek out curanderos/as instead of, or in addition to, conventional medical care. Individuals and families seek out care from curanderos for diverse health issues that could range from cold relief to cancer. Certain curanderos can also address stresses associated with psychological or social states. For example, it is not out of the ordinary for an individual to approach a curandero for a limpia – cleansing with the goal of ridding themselves of a rash of bad luck that they are experiencing. A curandero is able to not only cleanse the person of the bad luck but provide for them an explanation of why they had the bad luck in the first place. Curanderos are the only source of care for common ethnospecific illnesses among Latino immigrant communities such as susto – fright, mal de ojo – the evil eye, or coraje – anger. Curanderos have the knowledge necessary to diagnose and treat these illnesses which historically have been dismissed by conventional medicine. There is, however, a growing set of research studies examining these types of ethnospecific illnesses and how they parallel the symptoms of conditions readily diagnosed in conventional medicine. Curandero Utilization of curanderos among Mexican American and Latino immigrants has been a topic of research and inquiry among social scientists. Anthropologists in the 1960s argued that underutilization of conventional medical care by Mexican Americans and Latino Immigrants was a result of their continued use of curanderos. Most recent research, however, has revealed that socioeconomic issues and structural issues such as lack of health insurance, high cost of health care, undocumented status of many immigrants, and lack of culturally and linguistically appropriate health care services tend to play a larger role in limited utilization of conventional medical care for this community. Research has revealed that continued utilization and reliance on curanderos may actually be as a result to these larger socioeconomic and structural barriers. Curanderos provide easily accessible, affordable, and culturally and linguistically appropriate health care to Latino immigrant individuals and families. Curanderos share the same medical culture (world view, religion, views on the body, and beliefs about the causes of illness) as their clients, thereby facilitating communication, confidence in the provider, and adherence to treatment. Latino immigrant and transnational communities often have curanderos as members of their social networks who can be accessed either in the United States or in their community of origin. In the United States, curanderos are active members of Latino immigrant communities and are an important source of medical care. Curanderos are only a part of a complex system of community-based healing strategies and resources that also include home remedies and therapies, as well as “botanicas,” which are small community stores that sell medicinal herbs, religious amulets, and products used in healing. Research shows that a large percentage of those patients who report complementing their medical care with these complementary and alternative medical practices often do not discuss them with their medical doctor. This withholding of information has the potential to impact patient-provider communication, as well as conflict with the treatment regimen prescribed by the medical doctor. Medical doctors should approach this issue in a culturally sensitive and competent manner as a way to gain the confidence of the patient to allow disclosure of information related to this topic. C Historically, there has been negative stigma attached to utilization of Latino complementary and alternative medicine (CAM) such as home remedies and curanderos among medical professionals. There has been, however, an increase of professionals who recognize the positive contribution of these communitybased healers and resources. Health care professionals in some regions of Latin America and the United States have begun to collaborate and partner with curanderos in local communities as a way to meet the health care needs of residents in a more comprehensive and culturally sensitive way. Working in partnership with curanderos has also been successfully integrated into several health promotion interventions and awareness campaigns. Working in collaboration with CAM resources in the community as well as modifying the delivery of conventional medical care to mirror the way care is delivered in these community-based systems has been proposed by researchers as an effective way to reduce barriers to care, and improve the quality of health care delivered to Latino immigrants in the United States. Related Topics ▶ Access to care ▶ Alternative and complementary medicine ▶ Communication barriers ▶ Cultural competence ▶ Culture-specific diagnoses ▶ Mal de ojo ▶ Transnational community Suggested Readings Avila, E. (1999). Woman who glows in the dark: A curandera reveals traditional Aztec secrets of physical and spiritual health. New York: Penguin Putnam. Clark, L., Bunik, M., & Johnson, S. L. (2010). Research opportunities with curanderos to address childhood overweight in Latino families. Qualitative Health Research, 20, 4–14. Gomez-Beloz, A., & Chavez, N. (2001). The Botánica as a culturally appropriate health care option for Latinos. The Journal of Alternative and Complementary Medicine, 7, 537–546. Perrone, B., Stockel, H. H., & Krueger, V. (1989). Medicine women, curanderas, and women doctors. Norman: University of New Mexico Press. Portilla, E. (2007). They all want magic: Curanderas and folk healing. College Station: Texas A&M University Press. Torres, E. (2005). Curandero: A life in Mexican folk healing. Albuquerque: University of New Mexico Press. Trotter, R. (1997). Curanderismo: Mexican American folk healing. Athens: University of Georgia Press. 525 C 526 C Customary Marriage Customary Marriage LAILA PRAGER Institute of Ethnology, University of Münster, Münster, Germany The term is usually applied to refer to various types of marriage or patterns of spouse selection, which in the widest sense can be classified as conforming to specific localized sociocultural traditions. “Tradition” in this respect can involve certain culturally or religiously established forms of performing the marriage ceremony or it can refer to the different types of normative marriage rules prevalent among various ethnic or religious groups. Generally, the term “customary marriage” is applied to denote marital relations which are considered to differ culturally from the US, Canadian, or West-European types of marriage, partly involving marriage patterns practiced among immigrant communities that many of the host societies declare as illegal, such as polygamy or first-cousin marriage. Customary marriages may be based on rules by which the circle of marriageable persons is limited to a large extent, as in the case of caste-like social systems, or other social communities whose marriage laws prescribe various forms of social, ethnic, or religious endogamy (the latter can apply likewise to Muslims, Christians, and other religious affiliations). Among immigrant communities such types of customary marriage can differ from each other to a large extent, depending on the regional origin of the immigrants, and the respective marriage patterns may also combine several of the above mentioned features (i.e., Pakistani immigrants in the UK often upheld ethnic and religious endogamy and marry first cousins). Moreover, in immigrant communities customary marriages may take the form of arranged or forced marriages, often implemented by the elder generations who are concerned about the potential loss of their children’s “cultural identity” due to the influences exerted by the host society. Customary marriages may entail several health problems, depending on the marital pattern. Polygamous marriages among immigrant communities, for instance, call forward the problem that in the Western host societies only the first wife is secured by her husband’s health insurance whereas his other wives are excluded since they have no legal status as spouses. Customary marriages may also be accompanied by mental health problems, particularly in case of forced marriages when pressure has been put on the couple by the parents and/or the wider social framework. Forced marriages may lead to the mental depression of one or both marriage partners, or to physical injuries in case of domestic violence. Mental depressions resulting from trans-generational conflicts may also occur among the generation of the parents if their children refuse to obey to the established patterns of traditional marriage rules, thereby challenging their parents’ authority and sometimes giving rise to irresolvable conflicts which may lead to the complete disruption of parent/child relations. Among various immigrant communities, particularly from the Middle East, nonconformance to customary marriage rules can entail several forms of honor-based violence or honor killing attempts, usually exerted upon women and frequently resulting in severe physical and mental health problems suffered by the victims. Some societies or immigrant communities foster the idea that nonconformance to customary marriage rules is likely to entail physical or mental illness among the persons involved, particularly among the children who are supposed to suffer from disabilities or mental disorders inflicted by spiritual beings, the ancestors, or other cosmic forces. Customary marriages based on marital relations between cousins have received the highest degree of attention in the Western host societies. Though cousin marriages are practiced by around 20% of the world’s population, they were largely tabooed in the USA where already in the nineteenth century many of the states decided to establish public laws in order to prohibit such types of marriage (Kansas 1858; 1860s: Nevada, North Dakota, South Dakota, Washington, New Hampshire, Ohio, and Wyoming). Cousin marriages during this period were often practiced among European immigrants and the respective laws were also intended to work against the migrants’ potential seclusion from their host society. Recently, in some European countries (UK, Germany), there have been public debates as well whether to prohibit such types of marriages given the Customary Marriage influx of migrants from the Middle East. Meanwhile, in France and Turkey, cousins have to present a medical health certificate before they are declared eligible to marry. Such laws are predicated on twentieth century Western biomedical assumptions according to which cousin marriages are supposed to entail a higher risk of hereditary diseases. Recent bio-genetic research, however, suggests that the risk of hereditary diseases resulting from such marital unions has been largely overestimated. According to a comprehensive survey undertaken by the National Society of Genetic Counsellors (NSGC), the risk of congenital defects resulting from first-cousin unions ranges from 1.7 to 2% above the background risk of 4.4% for pre-reproductive mortality, thus making any special preconception testing unnecessary. Other researchers, roughly averaging the statistics for birth defects and pre-reproductive mortality, noted that first-cousin marriage “only” increases the risk of adverse events by about 3%, which means that instead of 3–4% there can be a risk of genetic damage of up to 7%. Whereas some authors consider this increase of genetic risk as marginal, other commentators point to the fact that it nevertheless amounts to a doubling of potential genetic damage, thereby rendering the risk of first-cousin marriage highly significant. Furthermore, one has to differentiate whether a cousin marriage is conducted only once or repeatedly in every generation as practiced among various societies in the Middle East, Asia, Africa, Oceania, and South America. Whereas in the first case, the grandparents of the marriage partners are genetically unrelated, in the second case they are related due to preceding cousin marriages, thus increasing the risk of genetic disorders among the offspring. However, there exist hundreds of C different recessive genetic disorders, many associated with severe disabilities and sometimes early death, and each caused by a different variant gene. One should thus bear in mind that not every society displays the same recessive genetic features, so that immigrant communities deriving from differing populations are subject to varying genetic risks. Related Topics ▶ Eugenics ▶ Honor killing ▶ Marriage Suggested Readings Bennett, R. L., Hudgins, L., Smith, C. O., & Motulsky, A. G. (1999). Inconsistencies in genetic counselling and screening for consanguineous couples and their offspring: The need for practice guidelines. Genetics in Medicine, 1, 286–292. Dumont, L. (1983). Affinity as a value. Chicago: University of Chicago Press. Levi-Strauss, C. (1969). The elementary structures of kinship. London: Eyre & Spottiswoode. Ottenheimer, M. (1996). Forbidden relatives: The American myth of cousin marriage. Urbana: University of Chicago Press. Shaw, A. (2005). Attitudes to genetic diagnosis and to the use of medical technologies in pregnancy: Some British Pakistani perspectives. In M. Unnithan-Kumar (Ed.), Reproductive agency, medicine and the state: Cultural transformations in childbearing (pp. 25–42). Oxford: Berghahn Books. Suggested Resources Human Genetic Commission. http://www.hgc.gov.uk/client/Content.asp?ContentId=741 Paul, D. B., & Spencer, H. G. (2008). “It’s ok, we’re not cousins by blood”: The cousin marriage controversy in historical perspective. PLoS Biology, 6(12). http://www.plosbiology.org/article/ info:doi/10.1371/journal.pbio.0060320 527 C