Mental health service utilization and help seeking behaviours of adult Cambodians living in Western countries: A systematic scoping review

BACKGROUND

Health disparity and under-utilization of health services is prevalent among Asian refugees and migrants in Western countries and can profoundly impact health outcomes. Cambodians who survived extreme physical and emotional trauma during the genocides enacted by the Khmer Rouge regime in the 1970's are particularly vulnerable to poor mental health outcomes decades later. Understanding the experiences of help-seeking and service use by displaced Cambodians in Western countries may help to design more effective and culturally safe healthcare services.

AIMS

To identify characteristics or factors associated with help seeking behaviours and service utilization of displaced Cambodians with mental health issues living in Western countries.

METHODS

This review followed the Arksey & O'Malley methodological framework for scoping reviews. Articles for review were identified through searches of nine electronic databases and manual searches. Relevant articles were selected, and data was extracted and synthesized into key themes.

RESULTS

This review included 15 articles. Most of the studies were conducted in the USA (n = 13) with one each conducted in Canada and New Zealand. Seven studies used qualitative interviews, five used a cross-sectional survey approach, two used a mixed-methods approach and one was a narrative review and case series. Key findings highlighted the impact of Cambodian cultural beliefs about mental health (guilt, shame and help-seeking stigma) on service utilization and the disconnect between Western models of service provision and preferred Cambodian ways of receiving support.

CONCLUSION

Mental health services in Western countries are likely to be under-utilized by Cambodians due to a mismatch between health beliefs and Western models of care. Further investigation of the association between health beliefs and barriers to service utilization among adult Cambodian refugees is warranted.

Spirulina as a daily nutritional supplement of young pre-school Cambodian children of deprived settings: a single-blinded, placebo-controlled, cross-over trial

BACKGROUND

Spirulina (SP) is widely used as a nutritional supplement to enhance child nutrition in low-income countries. We assessed Spirulina's efficacy of the current dose supplied by institutions in Cambodia on improving growth and anemia in a cross-over randomized controlled trial in preschool underprivileged children from similar settings.

METHODS

Preschool children cared by a not-for-profit institution were randomly and blindly allocated (2 to 1) to spirulina or placebo: 100 g in total, given in 2 g per day. After 5 weeks of wash-out, participants were crossed-over to the other group. Anthropometric gain and selected hematological data (blood cell count, ferritin, and C-reactive protein) were assessed at each phase.

RESULTS

A total of 179 children completed the trial, 149 (83.2%) completed all the anthropometrics, and 99 (55.3%) all hematological measures. Mean BMI was 14.18 (95%CI: 14.00-14.37) and 31(20.8%) children had thinness. Mean blood hemoglobin was 11.9 g/dL (95%CI: 11.8-12.1). The weight gain of the SP group showed a modest higher trend compared to placebo (0.63 kg; 95%CI: 0.54-0.72 and 0.46 kg; 95%CI: 0.33-0.58, respectively; p = 0.07). Height increased similarly in both groups. The number of anemic children decreased by 6 (6.06%) and 11 (11.11%) on Placebo or SP, respectively (p = 0.004). Tolerance was good.

CONCLUSION

SP may be recommended to improve childhood anemia. The analysis of the usual daily dose (2 g) provided by organizations in Cambodia shows a tendency to improve weight gain in the group supplemented with SP very close to significance, but no trend in height. Increased doses and longer supplementation should be evaluated further.

TRIAL REGISTRATION

The study was retrospectively registered at ISRCTN under number 11696165 on 12/12/2018.

Self-reported outcomes of a randomized trial comparing three community health worker interventions for diabetes prevention among Cambodian Americans with depression

OBJECTIVE

Cambodian Americans have complex, interrelated and persistent medical and mental health problems stemming from genocide and the social determinants of health. We examined changes in multiple domains of self-reported health outcomes from a diabetes prevention trial.

METHODS

Cambodian Americans with depression and high risk for diabetes (n = 188) were randomized to one of three community health worker interventions: lifestyle vs lifestyle plus medication therapy management vs social services. Assessments were at baseline, 12- and 15-months.

RESULTS

The typical participant was 55 years old, female, earned below $20,000 annually, and had 7 years of education. About one-third were taking antidepressant medication and over half had elevated depressive symptoms. Relative to social services, lifestyle and lifestyle plus medication therapy management were both similarly effective at increasing diabetes knowledge, nutrition habits, sleep quality and decreasing pain; 2) lifestyle alone was superior to social services for self-reported health; and, 3) all three groups showed improved anxiety and insomnia. There were no effects on physical activity or physical functioning.

CONCLUSION

Community health worker interventions have multiple benefits beyond delaying diabetes.

PRACTICE IMPLICATIONS

Health promotion programs that are designed and delivered appropriately can impact even hard to reach and hard to treat groups.

SNAP participation moderates the association between household food insecurity and HbA1c among Cambodian Americans with depression

OBJECTIVES

We tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) moderated the relation between household food insecurity and HbA1c among Cambodian Americans with depression enrolled in a diabetes prevention trial.

METHODS

Community health workers assessed household food insecurity and SNAP participation. HbA1c was ascertained using direct enzymatic assay.

RESULTS

Among the n = 189 respondents, 19% were food insecure, 41% received SNAP benefits, and mean HbA1c = 5.5%. There was a significant interaction between SNAP and food insecurity. HbA1c was highest among participants without SNAP who were food insecure. Simple effects analysis revealed a significant difference within the no SNAP group [Mean (SD): Secure = 5.38 (0.38), Insecure = 5.78 (0.36)] and no difference within the SNAP group [Secure = 5.61(0.44), Insecure = 5.61(0.55)]. Differences remained significant after controlling for demographic, socioeconomic, and clinical indicators.

CONCLUSIONS

SNAP may protect against the deleterious association between household food insecurity and HbA1c.

Psychological distress and health behaviours among Cambodian Americans at risk for developing diabetes

This paper reports secondary data analysis of associations between psychological distress and health behaviours among Cambodian Americans. Data are from baseline assessments from a diabetes prevention trial. All participants met stucriteria for depression and were free of diabetes. Participants (n = 191) completed surveys, a food frequency assessment, and wore sleep and physical activity actigraphy devices for 7 days. A factor analysis of symptoms of post-traumatic stress, baksbat (a Cambodian culture-bound syndrome), depression, and anxiety yielded a single factor named 'psychological distress'. Multivariate models controlling for psychotropic medications were run for the following outcomes: sleep actigraphy, self-reported sleep, physical activity actigraphy, self-reported physical activity, nutrition, and substance use. For actigraphy, higher distress was associated with lower moderate/vigorous physical activity and higher mean variability of 24 h total sleep time. Higher distress was also associated with worse self-reported sleep quality as indicated by standard, and culturally-specific, sleep indicators. Higher distress was also associated with lower use of food labels, lower carbohydrate consumption, and higher alcohol consumption as a coping mechanism. Interventions to mitigate diabetes risk in high-distress populations may benefit from strategies to decrease psychological distress. The sequelae of complex trauma may transcend discrete psychiatric diagnoses.

Auditory Hallucination Among Traumatized Cambodian Refugees: PTSD Association and Biocultural Shaping

At a psychiatric refugee clinic for survivors of the Khmer Rouge genocide, a survey revealed that 42% (38/90) had auditory hallucinations (AHs) in the last month. Of those with AHs, 87% (33/38) had PTSD, whereas of those without AHs, 31% (16/52) had PTSD, giving a chi square of 27.8, p < .001, odds ratio 14.8 (4.8-45). Most AHs were of a "ghost summoning" (khmaoch hao), considered an exhortation to go with a ghost (e.g., hearing "Please come with me, younger sister"), experienced by 73% percent of patients with AHs. The voices were always exterior and usually loud and clear. AHs were heard most often during hypnagogia (i.e., upon falling asleep or awakening), experienced by 72% of patients with AHs, whereas 42% of patients with AHs experienced AHs when fully awake. AHs were almost always attributed to a ghost, giving rise to great fear: of having the "soul" called away or of being frightened to death. AH episodes almost always triggered trauma recall. AHs caused patients to undertake certain actions to address acute episodes and to prevent further ones. To illustrate these processes, cases are provided. AH appears to be a key part of the Cambodian bioculturally shaped trauma subjectivity.

A randomized trial to decrease risk for diabetes among Cambodian Americans with depression: Intervention development, baseline characteristics and process outcomes

Background:

Depression and antidepressant medications are associated with increased risk for type 2 diabetes. It is not known if diabetes can be prevented in the setting of depression. Cambodian Americans have high rates of both depression and diabetes. This paper reports intervention development, experimental design, baseline characteristics, and process outcomes of diabetes prevention interventions for Cambodian Americans with depression, “Diabetes Risk Reduction through Eat, Walk, Sleep and Medication Therapy Management” (DREAM).

Methods:

Participants were aged 35–75, Khmer speaking, at high risk for developing diabetes, and met criteria for likely depression by either a) antidepressant medication and/or b) elevated depressive symptoms at two time-points during a study eligibility period. Treatment arms were: 1) community health educator (CHE) delivered lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus pharmacist/CHE-delivered medication therapy management (EWS + MTM), and, 3) social services (SS; control).

Results:

188 participants were randomized. Treatment fidelity was high (98% checklist adherence) and on a scale from 0 to 3, participants reported high EWS treatment satisfaction (M = 2.9, SD = 0.2), group cohesion (M = 2.9, SD = 0.3), and therapeutic alliance to CHEs (M = 2.9, SD = 0.2) and to pharmacists (2.9, SD = 0.3). Attendance was challenging but highly successful; in EWS, 99% attended ≥ one session and 86% completed ≥ 24 sessions, M = 27.3 (SD = 3.7) sessions. Of those randomized to EWS + MTM, 98% attended at least one MTM session and 77%) completed ≥ 4 sessions. Retention was high, 95% at 12-month and 96% at 15-month assessments.

Conclusions:

The interventions were successfully implemented. Lessons learned and suggestions for future trials are offered.

ClinicalTrials.gov identifier: NCT02502929

Social disconnection and metabolic syndrome score among Cambodian Americans with depression

AIMS

Migrants experience social disconnection and also have high risk for metabolic syndrome (MetS). This study explored associations of social alienation, social isolation, and social support with MetS among Cambodian Americans.

METHODS

We conducted secondary data analysis on baseline assessments from a diabetes prevention trial for Cambodian Americans with depression and high risk for diabetes. Participants were aged 35-75, Cambodian or Cambodian-American, Khmer speaking, lived in Cambodia during the Pol Pot regime, lived in the northeastern U.S. at the time of study, endorsed elevated risk factors for diabetes and met criteria for depression by medication for depression and/or elevated depressive symptoms. They completed surveys and provided anthropometric and blood pressure measurements and fasting blood samples.

RESULTS

In multiple linear regressions, greater social alienation was associated with increased risk for MetS. The social alienation-MetS association was stronger in men than women. Associations were not better accounted for by crude indicators of social isolation such as marital status, living alone, and number of people in the household. Social support was not associated with MetS and did not buffer the deleterious association between social alienation and MetS.

CONCLUSIONS

Decreasing social alienation may mitigate risk for MetS among migrant populations.

COVID-19 Medical Vulnerability Indicators: A Predictive, Local Data Model for Equity in Public Health Decision Making

This article reports the outcome of a project to develop and assess a predictive model of vulnerability indicators for COVID-19 infection in Los Angeles County. Multiple data sources were used to construct four indicators for zip code tabulation areas: (1) pre-existing health condition, (2) barriers to accessing health care, (3) built environment risk, and (4) the CDC's social vulnerability. The assessment of the indicators finds that the most vulnerable neighborhoods are characterized by significant clustering of racial minorities. An overwhelming 73% of Blacks reside in the neighborhoods with the two highest levels of pre-existing health conditions. For the barriers to accessing health care indicator, 40% of Latinx reside in the highest vulnerability places. The built environment indicator finds that selected Asian ethnic groups (63%), Latinx (55%), and Blacks (53%) reside in the neighborhoods designated as high or the highest vulnerability. The social vulnerability indicator finds 42% of Blacks and Latinx and 38% of selected Asian ethnic group residing in neighborhoods of high vulnerability. The vulnerability indicators can be adopted nationally to respond to COVID-19. The metrics can be utilized in data-driven decision making of re-openings or resource distribution such as testing, vaccine distribution and other pandemic-related resources to ensure equity for the most vulnerable.

An outbreak of Paragonimus westermani infection among Cambodian technical intern trainees in Japan, exhibiting various extrapulmonary lesions

We encountered an outbreak of paragonimiasis among Cambodian technical intern trainees (TITs) at a food-processing factory in Fukuoka, Japan. The patients were 20-28 years old, seven females and two males, who had been in Japan for one to four years. All of them had consumed raw or undercooked Japanese mitten crab they purchased at a local grocery store near their training place. CT images showed multiple lesions not only in the lungs but in the extrapulmonary organs as well, such as subcutaneous tissues, abdominal muscles, and mesentery, in most of the patients. Their medical records indicated that all of them acquired infection in Japan, not in Cambodia. Diagnosis was made serologically and the patients were treated with praziquantel successfully. Foreign workers and TITs are increasing in Japan so rapidly, that food borne-infections, including paragonimiasis, should be considered in people from developing countries who have exotic dietary habits.

Healthcare-Experience Survey Assessment in the Rhode Island Cambodian Community

The Cambodian community is the largest Southeast Asian cultural identity in Rhode Island (RI) with high poverty rates and limited healthcare access. Investigators conducted a cross-sectional observational survey study from 2016 to 2017 on eligible Cambodians to better understand their healthcare experiences. Questions were reviewed by the RI Cambodian Society for cultural sensitivity. 123 surveys were collected; 98 respondents had medical providers. Respondents with providers reported difficulty understanding of their providers (59%) and limited access to medical interpreters (50%). The non-provider group were less likely to have medical insurance (54.2% vs. 88.8%, p = .0001) and more likely to visit the emergency department (47.1% vs. 15.3%; p < .0001). Language barrier and lack of medical interpreters and healthcare insurance were the major barriers to healthcare for surveyed Cambodians. Future studies are needed to assess whether native-language specific community healthcare resources can positively affect their access to care.

Cambodian Remarried Women Are at Risk for Domestic Violence

Divorce rates continue to rise, especially in urban centers, which in turn contributes to increasing numbers of women who remarry. While remarriage is one of the only options for survival for divorced women, especially those from low socioeconomic status, remarriage also brings with it increased stressors of financial strain and the strain of blended families. This study tested the hypothesis that remarried women compared with first-time married and divorced women are at increased risk for domestic violence. The sample was drawn from the Cambodia Demographic and Health Survey, consisting of 1,560 women with the average age of 31.64. Results showed that 20% of women reported emotional violence and 14%, physical violence. Based on hierarchical multiple regressions, this study found that remarried women were more likely to experience physical and emotional abuse than women in their first marriage or women who remain divorced/not in union. Further interaction analyses showed that domestic violence varies depending on place of residence, number of children younger than 5 years, partners' education, and wealth index. Rural residents who were in poorest and poorer groups and urban residents in their poorer and middle groups of their wealth index showed high risk of domestic violence. Remarried women with two or three children younger than 5 years showed highest risk of domestic violence. Additional three-way interaction analysis revealed that remarried women residing in rural/urban areas with a spouse having no education and/or primary level of education were at highest risk of domestic violence. The study lends support to the structural role of the power of male dominance on women's social and emotional well-being. This study suggested that to reduce men's perceived domination, structural intervention that includes implementing gender-responsive curriculum in formal education, as well as strengthening domestic violence law enforcement would help reduce domestic violence against women.

Social Disconnection as a Risk Factor for Health among Cambodian Refugees and Their Offspring in the United States

Studies of relatively recently resettled refugees have noted social disconnection, linked to various physical and mental health outcomes, as a concern. Limited studies have examined whether social disconnection and its effects persists within refugee populations resettled more than 3 decades prior. The relationship between social disconnection and self-reported health was explored in a secondary analysis of a cross-sectional needs assessment survey with a snowball sample of 100 Cambodian refugees residing in Connecticut. Social disconnectedness and comorbid health conditions were prevalent. Lack of religious and community engagement were associated with poor health outcomes, while individuals with a lack of ethnic engagement reported better overall health. This study underscores the importance of understanding the specific risks that social disconnection poses to refugees who have resettled many years before and their offspring that may assist in better serving currently settling refugees within the United States.

Hepatitis C Is Poorly Associated With Drug Use in Cambodian Americans in Lowell, Massachusetts

Background. Hepatitis C (HCV) is the most common chronic blood-borne infection in the United States and affects Asian and non-Asian Americans comparably. Injection drug use, the most common national transmission risk, is not as prevalent in Asian-Americans, but prior studies do not include many Cambodian Americans. Lowell, Massachusetts has the second largest population of Cambodian Americans, allowing a direct comparison of HCV-infected Cambodian and non-Cambodian Americans not previously done. Improving our understanding of HCV risks in this unique community may improve their linkage to care.

Methods. In this cross-sectional study, medical data were collected regarding HCV risk factors for HCV-infected Cambodian and non-Cambodian Americans seen at Lowell Community Health Center from 2009 to 2012.

Results. Cambodian Americans (n = 128) were older (mean age 53 vs 43 years old) and less likely to be male (41% vs 67%, P < .001) compared with non-Cambodians (n = 541). Cambodians had lower rates of injection drug use (1.6% vs 33.6%, P < .001) and any drug use (2.3% vs 82.1%, P < .001). More Cambodians were born between 1945 and 1965 (66.4% vs 44.5%). Within this birth cohort, more Cambodians had no other risk factor (82% vs 69%, P = .02). Fewer Cambodians had chronic HCV (53% vs 74%, P < .001).

Conclusions. Birth between 1945 and 1965 was the major HCV risk factor for Cambodian Americans. Cambodians had lower rates of injection drug use or any drug use history. Risk behavior screening fails to describe HCV transmission for Cambodian Americans and creates a barrier to their linkage to care.

Khmer American Mothers' Knowledge about HPV and HBV Infection and Their Perceptions of Parenting: My English Speaking Daughter Knows More

PURPOSE

The purpose of this study is to explore and describe Khmer mothers' understanding of HBV and HPV prevention as well as their perception of parenting on health and health education of their daughters in the US.

METHODS

The qualitative pilot study guided by the revised Network Episode Model and informed by ethnographic analysis and community-based purposive sampling method were used. Face-to-face audiotaped interviews with eight Khmer mothers were conducted by bilingual female middle-aged community health leaders who spoke Khmer.

RESULTS

The findings revealed that Khmer mothers clearly lacked knowledge about HBV and HPV infection prevention and had difficulty understanding and educating their daughters about health behavior, especially on sex-related topics. The findings showed that histo-sociocultural factors are integrated with the individual factor, and these factors influenced the HBV and HPV knowledge and perspective of Khmer mothers' parenting.

CONCLUSIONS

The study suggests that situation-specific conceptual and methodological approaches that take into account the uniqueness of the sociocultural context of CAs is a novel method for identifying factors that are significant in shaping the perception of Khmer mothers' health education related to HBV and HPV prevention among their daughters. The communication between mother and daughter about sex and the risk involved in contracting HBV and HPV has been limited, partly because it is seen as a "taboo subject" and partly because mothers think that schools educate their children regarding sexuality and health.

Colorectal Cancer Screening among Chinese, Cambodian, and Vietnamese Immigrants in Chicago

Asian Americans are now the most rapidly growing minority group in the USA. Over 60 % of Asian Americans in the USA are immigrants. Cancer has been the leading cause of death among Asian Americans since 1980. Understanding the barriers to screening is essential to reduce the unnecessary burden of cancer. Little is known about colorectal cancer screening behavior among foreign-born Asian Americans and how socio-demographic factors may influence the behavior. Even less is known about disaggregated Asian subgroups. Using data from the Chicago Asian Community Survey, a local health assessment survey of three Asian subgroups in Chicago, Chinese, Cambodian, and Vietnamese, this study found that the colorectal cancer screening rate were much lower among foreign-born Asian Americans in Chicago (30 %) than the national rate for the general population (59 %). Furthermore, we studied disaggregated data to determine colorectal cancer screening differences between communities. Findings from this study provide a critical evidence base to inform future research and intervention designs.

Hepatitis B screening compliance and non-compliance among Chinese, Koreans, Vietnamese and Cambodians

Objective:

The purpose of this community-based study was to determine factors associated with hepatitis B virus (HBV) screening compliance and non-compliance among Chinese, Korean, Vietnamese and Cambodian adults with varying levels of English language proficiency.

Methods:

A cross-sectional design was used consisting of a sample of 1,603 Asian adult men and women.

Results:

Overall, 71.4% of the sample reported having never been screened and 28.6% reported being screened for HBV. Demographic, acculturation, and barrier factors were differentially associated with screening rates among the subgroups. Demographic factors associated with never-screened were: lower education, younger age, being male, and no insurance for Chinese; lower education, lower income and no insurance for Cambodians; younger age and unmarried for Koreans; and no health insurance for Vietnamese; Acculturation factors associated with never-screened were: not speaking English for Chinese; not speaking English, not reading newspapers in English, and watching TV in one’s native language for Cambodians; not speaking English for Koreans; while no significant factors were found for Vietnamese. All barriers were associated with never-screened for Cambodians and Chinese. Those who lacked knowledge about HBV and had language and transportation barrier were more likely to be never-screened for Koreans. There were no significant relationships between the barriers and the screening status for Vietnamese.

Conclusions:

High incidence of HBV and liver cancer in Asian Americans mandates a more vigorous and more culturally and linguistically appropriate educational effort to increase screening and vaccination for HBV in these underserved and mostly uninsured populations.