Integrating Latina/o ethnic determinants of health in research to promote population health and reduce health disparities.

OBJECTIVES: Social determinants of health (SDOH) such as environmental conditions and the nature of social settings have become highly influential in public health policy-making circles worldwide, yet they may not address clearly the role of ethnicity in health processes. METHOD: Drawing from the National Institutes of Health's disparity research frameworks, this papers illustrates a set of variables that are advanced as having a unique role in disparities experienced by ethnic populations and Latina/os, in particular. The proposed ethnic determinants of health tap environmental, community, and social-cognitive levels of analyses and are defined as variables that have discernable differences-relative to other subpopulations-in their levels or in the way that they impact health. RESULTS: Health process models illustrate that ethnic determinants such as racism, family cultural norms and cultural change, and ethnic identity can, for example, mediate ethnic health disparities or condition (moderate) the levels of impact that SDOH have on health outcomes. Qualitative research analyses also strengthen ethnic and SDOH research by diversifying researchers' a priori assumptions and methodological limitations imposed by quantitative approaches. CONCLUSIONS: The expected dividends of the proposed Latina/o ethnic determinants of health research agenda amount to the generation of research that clarifies the role of ethnicity in SDOH and population health processes that are highly influential in ongoing regional and national health agendas. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Family caregivers' narratives of mental health treatment usage processes by their Latino adult relatives with serious and persistent mental illness.

Family caregivers' views and experiences related to treatment usage processes by their adult relatives with serious and persistent mental illness (SPMI) were empirically examined in a sample of Latino caregivers (n = 17) who were users of services at the National Alliance on Mental Illness (NAMI) in a predominantly Latino- (80%) and Mexican-descent large city in the Southwest United States. We conducted a stability check of qualitative findings with a second sample of Latino caregivers with no exposure to NAMI (n = 15). Overall, the combined sample (N = 32) compared similarly with larger samples of Latino adults and caregivers in quantitative measures of acculturation, familism, caregiver stigma, and depression symptoms. Together, caregivers' stigma and cultural beliefs, such as vergüenza (shame), use of folk healers, and lack of insurance, were major reported barriers to service usage. Family support (and lack of) for treatment also weighed heavily as a facilitator (and a barrier) of service usage, thus highlighting the complexity of family relationship contexts. Substantial portions of caregivers reported that treatment initiation was prompted by psychiatric hospitalization (50%), and that positive experiences with service providers were influential in treatment retention (72%). Given the high levels of family involvement reported among Latino caregivers, the findings underscore the potential role of family caregivers in treatment engagement and retention. Future research is needed that examines family caregivers' role in treatment with models that consider the interplay between cultural background, family level relationships, and service system contexts.

Mental health care for latino immigrants in the U. S. A. and the quest for global health equities / Servicios de Salud Mental para los Inmigrantes Latinos en los Estados Unidos y la Lucha por una Igualdad en Salud Global

Currently, approximately 190 million immigrants world-wide live in host societies located incountries that have higher economic resources and political power than the countries of origin of immigrants. In this paper I use ecological and system theories (eco-systems) to frame the relationship between Latino immigrants and the host society in the U.S.A. The eco-system perspective highlights that policies and initiatives to address the mental health care of Latino immigrants must weigh dilemmas such as: (a)containing the costs of care while providing high quality (efficacious) care, and (b) the power inequity between immigrants and their host society. I posit that Social Justice/Public Health frameworks are needed to address these dilemmas because they are mindful of the receiving community needs, inclusive of immigrants, as well as of other marginalized populations. The framework is consistent with the proposed focus on Health Equity in public health in the U.S. (Braveman et al., 2011) and is relevant for the global phenomenon of immigration (AU)

En la actualidad, aproximadamente 190 millones de inmigrantes de todo el mundo viven en sociedades de acogida situadas en países con mayores recursos económicos y mayor poder político que los países de origen de los inmigrantes. En este artículo utilizo las teorías ecológicas y de sistemas (ecosistemas) para analizar la relación entre los inmigrantes latinos y la sociedad de acogida en los EEUU. El enfoque de ecosistemas pone de relieve que las políticas e iniciativas para abordar la asistencia sanitaria de los inmigrantes latinos deben sopesar dilemas como: (a) la contención de costes sanitarios al tiempo que se proporciona una atención de alta calidad (eficaz), y (b) la desigualdad de poder entre los inmigrantes y su sociedad de acogida. Postulo que el marco de la Justicia Social/Salud Pública es necesario para abordar estos dilemas, porque toma en consideración las necesidades de la comunidad receptora, así como de los inmigrantes y de otras poblaciones marginadas. Dicho marco concuerda con el enfoque propuesto basado en la Igualdad Sanitaria del sistema de salud de los EEUU (Braveman et al., 2011) y es relevante para el fenómeno global de la inmigración (AU)

"Hay que ponerse en los zapatos del joven": adaptive parenting of adolescent children among Mexican-American parents residing in a dangerous neighborhood.

We examined parenting of adolescents with Consensual Qualitative Research analyses of five 90-minute focus groups with 45 Mexican immigrant parents residing in a high-crime and low-income neighborhood. Parents identified gangs as their major challenge in parenting. Relatedly, they endorsed control-oriented practices to ensure the safety of their adolescents. In addition, parents used practices that aimed to build strong, trusting relationships with their adolescents. The co-occurrence of parenting strategies that promote strong parent-adolescent bonds along with strict monitoring highlights the need to conceptualize parenting with both controlling as well as supportive dimensions. Moreover, the parents' narratives pertaining to the dangers in their neighborhood suggest that interventions for Latino families should be not only consistent with their cultural heritage, but also grounded in the families' local neighborhood contexts.

Family caregivers' monitoring of medication usage: a qualitative study of Mexican-origin families with serious mental illness.

Despite the high level of involvement of many family caregivers of adults with serious mental illness such as schizophrenia, little is known about their experiences with and beliefs about monitoring the psychiatric medication usage of their relatives. We used consensual qualitative research methods to analyze narratives on this topic by 12 Mexican-descent caregivers (160 pages of transcripts). The caregivers predominantly represented parent (mother) caregivers with levels of psychological distress and burden that were similar to those of larger samples of Mexican-descent caregivers. They represented equally high and low Expressed Emotion. We found that (a) caregivers' high knowledge (awareness) of medication usage was either tied to a hands-on monitoring approach or inferred by either the absence or the presence of their relatives' symptoms, (b) caregivers struggled with reconciling the symptom stabilization benefits of medication with the medications' side effects and limitations, and (c) most caregivers received little to no assistance from other available family members. Theory development and possible interventions involving family-assisted support of psychiatric medication usage should assess and possibly address caregivers' struggles with medications' side effects and low levels of support from available family.

Culture and community psychology: toward a renewed and reimagined vision.

Interest is growing in community psychology to look more closely at culture. Culture has resided in community psychology in its emphasis on context, ecology, and diversity, however we believe that the field will benefit from a more explicit focus on culture. We suggest a cultural approach that values the community's points of view and an understanding of shared and divergent meanings, goals, and norms within a theory of empowerment. Furthermore, we posit the importance of pluralistic, multi-method programs of research and action encompassing both idiographic and nomothetic approaches, and critical reflexivity of our roles and agendas. Culture can be further incorporated into all the branches and fibers of community psychology.

The family as mediator of the impact of parent-youth acculturation/enculturation and inner-city stressors on Mexican American youth substance use.

Youth substance use was investigated in a sample of Mexican-origin mothers and youth (93 dyads totaling 186 individuals). We tested the hypotheses that both acculturation and inner-city risk factors impact substance use largely because they undermine family relationships. Mothers and youth completed self-report measures of acculturation and enculturation. Youth completed questionnaires of family relationships, inner-city risk factors, and substance use. Youth substance use was measured with an index of lifetime alcohol, tobacco, and marijuana use based on the Youth Risk Behavior Survey. As predicted, mother-youth (dyadic) acculturation/enculturation, as well as exposure to violence, were significantly associated with substance use. Family cohesion mediated the impact of violence exposure on substance use. However, both cohesion and violence had unique and significant associations with substance use. Furthermore, family relationships did not mediate the link between substance use and mother-youth acculturation or mother-youth enculturation. Results underscore the need to develop and test hypotheses that link Latino youth substance use with both acculturation and inner-city contexts that do not solely rely on family relationships as mediators.

The role of familism in the relation between parent-child discord and psychological distress among emerging adults of Mexican descent.

Although parent-child discord is a predictor of distress among emerging adults, little is known about this important link among Mexican-descent populations. This is an important gap, given Mexican Americans' high risk for psychological distress and their expected high value placed on close family ties. This topic was studied in a sample of 392 college students from El Paso, TX (n = 193) and from Ciudad Juárez, México (n = 199). The authors tested a stress-appraisal model with self-report measures of familism, parent-child discord, threat appraisals of parent-child discord, and psychological distress. As predicted, threat appraisals partially mediated the relation between parent-child discord and psychological distress. Moreover, the relation between parent-child discord and threat appraisals was stronger at higher than at lower levels of familism. Study findings highlight the need to consider that, under certain conditions, familism may increase risk of distress among emerging adults.

Cultural variability in the manifestation of expressed emotion.

We examined the distribution of expressed emotion (EE) and its indices in a sample of 224 family caregivers of individuals with schizophrenia pooled from 5 studies, 3 reflecting a contemporary sample of Mexican Americans (MA 2000, N = 126), 1 of an earlier study of Mexican Americans (MA 1980, N = 44), and the other of an earlier study of Anglo Americans (AA, N = 54). Chi-square and path analyses revealed no significant differences between the 2 MA samples in rates of high EE, critical comments, hostility, and emotional over-involvement (EOI). Only caregiver warmth differed for the 2 MA samples; MA 1980 had higher warmth than MA 2000. Significant differences were consistently found between the combined MA samples and the AA sample; AAs had higher rates of high EE, more critical comments, less warmth, less EOI, and a high EE profile comprised more of criticism/hostility. We also examined the relationship of proxy measures of acculturation among the MA 2000 sample. The findings support and extend Jenkins' earlier observations regarding the cultural variability of EE for Mexican Americans. Implications are discussed regarding the cross-cultural measurement of EE and the focus of family interventions.

Mexican American caregivers' coping efficacy: associations with caregivers' distress and positivity to their relatives with schizophrenia.

BACKGROUND: Coping styles utilized by family caregivers of persons with schizophrenia have been implicated in the mental health of those caregivers and in the course of schizophrenia. We tested the relation between caregivers' coping efficacy, defined as the caregiver's perceptions of how successful they were in modifying their relative's behavior, and caregiver's psychological distress as well as criticisms and positivity toward their relatives diagnosed with schizophrenia. METHOD: We sampled 31 dyads of Mexican American caregivers and their relative with schizophrenia or schizoaffective disorder and used multiple methods of measurement including caregiver interviews, interactions between caregivers and their relatives, and clinician interviews with patients. RESULTS: Coping efficacy accounted for significant variance beyond patient symptoms and caregiver burden to: (a) caregiver psychological distress (beta=-0.35, P<0.05), and (b) caregiver positivity, that is, caregivers' expressions of praise, approval or affection toward their ill relatives (beta=0.47 P<0.01). CONCLUSIONS: Caregivers' coping efficacy has heuristic value for research on the alleviation of caregiver psychological distress and the promotion of family caregiver behaviors associated with a benign course of illness.

Acceptance and expressed emotion in Mexican American caregivers of relatives with schizophrenia.

The relation between Expressed Emotion (EE) and caregiver acceptance was tested with the use of video-recorded interactions between 31 Mexican American family caregivers and their relatives with schizophrenia. Borrowing the concept from Integrative Behavioral Couple Therapy, acceptance was defined as caregiver's engagement with the ill relative along with low levels of expectations for behavioral change. Three aspects of caregiver acceptance were measured: global acceptance of the patient, unified detachment (i.e., nonblaming but engaged problem discussion), and low aversive responses to patient behavior (e.g., criticisms and demanding change). Relative to high EE caregivers, low EE caregivers were consistently more accepting of their ill relatives across the three measures of acceptance. Unified detachment was negatively associated with emotional overinvolvement and aversive responses were positively related to criticism. Warmth was not related to acceptance. The findings suggest that the study of acceptance in family caregivers is a heuristic avenue for future research due to its potential to shed light on specifically what family members do in caring for their ill relatives with schizophrenia.

Mothers' parenting dimensions and adolescent externalizing and internalizing behaviors in a low-income, urban Mexican American sample.

The relation between adolescent-reported parenting behaviors and mother-reported youth externalizing and internalizing behaviors was examined among 91 Mexican American mother-adolescent (ages 13-17) dyads recruited from an immigrant enclave in a large midwestern metropolitan area. Two major dimensions of mothers' parenting emerged: supportive parenting and harsh parental control. Gender moderation analyses revealed that lower levels of externalizing behaviors were linked with mothers' higher levels of supportive parenting among girls but not among boys. Higher levels of youth-reported depression were linked with mothers' higher levels of harsh parental control among boys but not among girls. The findings highlight the importance of supportive parenting and of gender in the study of Mexican American families and youth mental health.

Psychological distress among latino family caregivers of adults with schizophrenia: the roles of burden and stigma.

OBJECTIVE: Little research has focused on the mental health of Latino caregivers with a relative with schizophrenia, despite data showing that up to three-quarters of Latino persons with schizophrenia live with their families. This study examined the relation between caregivers' mental health and perceived burden and stigma and characteristics of the patient and caregiver. METHODS: Interviews were conducted in the language of preference (Spanish or English) in Wisconsin, California, and Texas with 85 Latinos caring for an adult with schizophrenia. Measures included the Center for Epidemiologic Studies-Depression Scale, the Zarit Burden Scale, and the Greenley Stigma Scale. RESULTS: General population studies of Mexican Americans have found that between 12% and 18% meet the cutoff for being at risk of depression; however, 40% of the sample met this criterion. Younger caregiver age, lower levels of caregivers' education, and higher levels of the patients' mental illness symptoms were predictive of higher levels of caregivers' depressive symptoms. Caregivers' perceived burden mediated the relation between patients' psychiatric symptoms and caregivers' depression. Caregivers' perceived stigma was significantly related to caregivers' depressive symptoms, even when the analyses statistically adjusted for psychiatric symptoms and demographic variables. CONCLUSIONS: The high rates of depressive symptoms among Latino families caring for a relative with schizophrenia suggest that interventions should include attention to the mental health and recovery of family caregivers in addition to the patient's recovery. Younger Latino caregivers and those with lower levels of education are particularly at risk of depression.

Family support predicts psychiatric medication usage among Mexican American individuals with schizophrenia.

BACKGROUND: Support provided by family caregivers to persons with schizophrenia is a viable intervention focus to improve psychiatric medication usage. However, little is known about the relation between medication usage and family support as well as other key caregiving factors. METHOD: Family support and Expressed Emotion (EE) dimensions were tested as predictors of medication usage during a 9-month period following psychiatric hospital discharge in a sample of 30 individuals of Mexican descent with schizophrenia. RESULTS: Family instrumental support predicted higher medication usage (Odds Ratio = 4.8) in multivariate analyses that statistically adjusted for the impact of emotional support, family EE, and psychiatric status (e.g., positive symptoms) on medication usage. CONCLUSIONS: Findings suggest that efforts to improve medication usage among Mexican American individuals with schizophrenia should take into account social supportive factors such as instrumental or directive, hands-on assistance from family caregivers.