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1.  Toxicity of Gutkha, a Smokeless Tobacco Product Gone Global: Is There More to the Toxicity than Nicotine? 
The popularity of smokeless tobacco (ST) is growing rapidly and its prevalence of use is rising globally. Consumption of Gutkha, an addictive form of ST, is particularly common amongst South Asian communities throughout the World. This includes within the US, following large-scale immigration into the country. However, there exists a lack of knowledge concerning these alternative tobacco products. To this end, a study was carried out to determine the toxicity of gutkha, and what role, if any, nicotine contributes to the effects. Adult male mice were treated daily for 3-week (5 day/week, once/day), via the oral mucosa, with equal volumes (50 μL) of either sterile water (control), a solution of nicotine dissolved in water (0.24 mg of nicotine), or a solution of lyophilized guthka dissolved in water (21 mg lyophilized gutkha). Serum cotinine, measured weekly, was 36 and 48 ng/mL in gutkha- and nicotine-treated mice, respectively. Results demonstrated that exposure to nicotine and gutkha reduced heart weight, while exposure to gutkha, but not nicotine, decreased liver weight, body weight, and serum testosterone levels (compared to controls). These findings suggest that short-term guhtka use adversely impacts growth and circulating testosterone levels, and that gutkha toxicity may be driven by components other than nicotine. As use of guthka increases worldwide, future studies are needed to further delineate toxicological implications such that appropriate policy decisions can be made.
doi:10.3390/ijerph110100919
PMCID: PMC3924482  PMID: 24413704
smokeless tobacco; gutkha; nicotine; testosterone; systemic toxicity
2.  Onset of Posttraumatic Stress Disorder and Major Depression Among Refugees and Voluntary Migrants to the United States 
Journal of traumatic stress  2012;25(6):705-712.
Although refugees are generally thought to be at increased risk for posttraumatic stress disorder (PTSD) and major depressive episode (MDE), few studies have compared onset of PTSD and MDE between refugees and voluntary migrants. Given differences in migration histories, onset should differ pre- and postmigration. The National Latino and Asian American Survey (NLAAS) is a national representative, complex dataset measuring psychiatric morbidity, mental health service use, and migration history among Latino and Asian immigrants to the United States. Of the 3,260 foreign-born participants, 660 were refugees (a weighted proportion of 9.52%). Refugees were more likely to report a history of war-related trauma, but reports of other traumatic events were similar. Premigration onset of PTSD was statistically higher for refugees than voluntary migrants, odds ratio (OR) = 4.86, 95% confidence interval (CI) [2.01, 11.76], where postmigration onset for PTSD was not, OR = 0.61, 95% CI [0.29, 1.28]; a similar pattern was found for MDE, OR = 1.98, 95% CI [1.11, 3.51]; and OR = 1.02, 95% CI [0.65, 1.62], respectively. Although refugees arrive in host countries with more pressing psychiatric needs, onset is comparable over time, suggesting that postmigration refugees and voluntary migrants may be best served by similar programs.
doi:10.1002/jts.21763
PMCID: PMC3619190  PMID: 23184423
3.  Colon Cancer Knowledge and Attitudes in an Immigrant Haitian Community 
Objective
To qualitatively evaluate the views of Haitian immigrants on cancer and the influence of cultural and socio-ecological factors on cancer screening behavior.
Methods
Six focus groups, consisting of 4–10 individuals each, were conducted among Haitian adults at average risk for colorectal cancer. The interviews were conducted in Haitian Creole and featured questions that addressed beliefs and attitudes about general health, access to health care, colon cancer, and screening practices.
Results
The focus groups provided insight into the health service utilization patterns in the Haitian community, as well as the factors driving them including language and the pattern of accessing healthcare only for emergencies.
Conclusions
Many misconceptions regarding cancer and its development were evident in the discussions. However participants were willing to follow the recommendations of a physician. This highlighted the importance in this community of disseminating information at every opportunity about preventative care, including colorectal cancer screening.
doi:10.1007/s10903-008-9126-6
PMCID: PMC3327052  PMID: 18322798
Colon cancer screening; Immigrant; Knowledge; Attitudes; Focus group
4.  Mexican Immigrant Male Knowledge and Support Toward Breast and Cervical Cancer Screening 
Background
We conducted a focus group study to assess the influence of partner communication on breast and cervical cancer screening and the perceived existing and potential support from male partners in participating in cancer screening. Secondarily, Mexican male and female views on health care and cancer were explored.
Methods
Seven focus groups (two female-only, three male-only, and two couples) were conducted in Spanish.
Results
Findings suggest that knowledge about cervical cancer was significantly less than knowledge about breast cancer among both men and women. Barriers to cancer screening included language barriers, lack of health insurance, and lack of awareness of the need for screening. Male partners expressed willingness to support their female partners in cancer screening activities.
Conclusion
Cervical cancer education is desperately needed, including education on the availability of free and low cost screening services. Education efforts should include the male community members, especially as the males perceive themselves as responsible for the financial burden of care.
doi:10.1007/s10903-008-9161-3
PMCID: PMC3326388  PMID: 18551367
Cervical cancer; Breast cancer; Screening; Mexican-American; Male involvement; Access to care
5.  Cancer Screening and Haitian Immigrants: The Primary Care Provider Factor 
Background
Haitian immigrants, among the fastest growing immigrant communities in the United States, have low cancer screening rates. Several patient barriers have been identified and associated with low screening rates but little is known on provider barriers for cancer screening. To address this gap, we assessed the cancer screening practices, attitudes, and beliefs of primary care providers serving the Haitian community.
Methods
We surveyed a random sample of physicians serving first generation Haitian immigrants in New York City, identified through their zip codes of practice. Participants completed a questionnaire to assess their beliefs, attitudes and practices surrounding cancer screening, and their perceptions of patient barriers to screening.
Results
50 of 87 physicians (58%) consented to participate in the study. Cancer site-specific and overall cancer screening scores were created for breast, cervical, and colorectal cancer screening. 75% of providers followed breast cancer screening guidelines, 16% for cervical cancer, and 30% for colorectal cancer. None of the providers in the sample were following guidelines for all three cancer sites. Additionally, 97% reported recommending digital rectal exam and PSA annually to patients 50 years or older with no family history, and 100% to patients over 50 years old with family history.
Conclusions
The reported practices of providers serving the Haitian immigrant community in New York City are not fully consistent with practice guidelines. Efforts should be made to reinforce screening guideline knowledge in physicians serving the Haitian immigrant community, to increase the utilization of systems that increase cancer screening, and to implement strategies to overcome patient barriers.
doi:10.1007/s10903-007-9076-4
PMCID: PMC3315358  PMID: 17647104
Haitian immigrants; Physicians practices; Cancer screening
6.  Cancer Screening Practices among Physicians Serving Chinese Immigrants 
Chinese immigrants in the United States are broadly affected by cancer health disparities. We examined the cancer screening attitudes and practices of physicians serving Chinese immigrants in the New York City (NYC) area by mailing a cancer screening survey, based on current guidelines, to a random sample of physicians serving this population. Fifty three physicians (44%) completed the survey. Seventy-two percent reported following the guidelines for breast cancer, 35% for cervical cancer screening, and 45% for all colorectal cancer screening tests. Sixty-eight percent of physicians were satisfied with their current rates of cancer screening with their Chinese immigrant patient population. Physicians serving the Chinese community in NYC follow cancer screening guidelines inadequately. Cancer screening rates in this population could likely be increased by interventions that target physicians and improve awareness of guidelines and recommended best practices.
doi:10.1353/hpu.0.0117
PMCID: PMC3314376  PMID: 19202247
Chinese; immigrants; cancer screening; physician practices; primary care
7.  Targeting Social and Economic Correlates of Cancer Treatment Appointment Keeping among Immigrant Chinese Patients 
Chinese immigrants have high rates of a variety of cancers and face numerous social and economic barriers to cancer treatment appointment keeping. This study is a nested cohort of 82 Chinese patients participating in the Immigrant Cancer Portal Project. Twenty-two percent reported having missed appointments for oncology follow-up, radiation therapy, and/or chemotherapy. Patients most commonly reported needing assistance with financial support to enable appointment keeping. Efforts to further address social and economic correlates in cancer care should be developed for this population.
doi:10.1007/s11524-010-9512-y
PMCID: PMC3042088  PMID: 21246300
8.  A Randomized Controlled Trial of a Multilevel Intervention to Increase Colorectal Cancer Screening among Latino Immigrants in a Primary Care Facility 
BACKGROUND
Latino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low.
OBJECTIVE
To assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants.
DESIGN
A randomized controlled trial, with randomization at the physician level.
PARTICIPANTS
Pairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group.
INTERVENTION
CRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician.
MEASUREMENTS
Completed CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening.
RESULTS
The overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007).
CONCLUSIONS
The intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions.
doi:10.1007/s11606-010-1266-4
PMCID: PMC2869418  PMID: 20213208
colorectal cancer; immigrant health; primary care; prevention; intervention
9.  Cancer Portal Project: A Multidisciplinary Approach to Cancer Care Among Hispanic Patients 
Journal of Oncology Practice  2011;7(1):31-38.
Most patients in this study reported that financial, social, and logistical support would help them attend their appointments for cancer care and treatment. Further multidisciplinary interventions should be evaluated to address social and economic determinants in cancer care for this population.
Purpose:
This study investigates the impact of a multilingual, multidisciplinary team targeting social and economic determinants of cancer treatment adherence among at-risk Hispanic immigrants.
Methods:
Patients were recruited at 10 hospital-based cancer clinics in New York City between December 2008 and November 2009. This is a nested cohort study of Hispanic patients and their sociodemographic characteristics, areas of needed assistance, and reported impact of meeting service needs on keeping appointments. At the core of the intervention is the trained, bilingual Portal Access Facilitator, who assesses needs and synchronizes an individualized set of transdisciplinary services for each patient.
Results:
A total of 328 Hispanic patients participated in the study. Of these, 89% preferred to speak Spanish in the health care setting, and 17% had no health insurance. The most common cancer diagnosis among participants was breast cancer (35%) followed by GI (17%) and gynecologic (16%) cancers. Patients most commonly requested financial support (59%), food support (37%), transportation assistance (21%), social work services (14%), psychosocial support (6%), help with health insurance issues (5%), and legal services (5%). In a follow-up assessment of high-need patients in urgent need of financial support, 86% reported that portal services helped them attend cancer care and treatment appointments, and 72% reported that portal services decreased worry about their care.
Conclusion:
Most patients reported that financial, social, and logistical support would help them attend their appointments for cancer care and treatment. Further multidisciplinary interventions should be implemented and evaluated to address social and economic determinants in cancer care for this population.
doi:10.1200/JOP.2010.000036
PMCID: PMC3014508  PMID: 21532808
10.  Access to Multilingual Medication Instructions at New York City Pharmacies 
An essential component of quality care for limited English proficient (LEP) patients is language access. Linguistically accessible medication instructions are particularly important, given the serious consequences of error and patient responsibility for managing often complex medication regimens on their own. Approximately 21 million people in the U.S. were LEP at the time of the 2000 census, representing a 50% increase since 1990. Little information is available on their access to comprehensible medication instructions. In an effort to address this knowledge gap, we conducted a telephone survey of 200 randomly selected NYC pharmacies. The primary focus of the survey was translation need, capacity, and practice. The majority of pharmacists reported that they had LEP patients daily (88.0%) and had the capacity to translate prescription labels (79.5%). Among pharmacies serving LEP patients on a daily basis, just 38.6% translated labels daily; 22.7% never translated. In multivariate analysis, pharmacy type (OR=4.08, 95%CI=1.55–10.74, independent versus chain pharmacies) and proportion of Spanish-speaking LEP persons in the pharmacy’s census tract (OR=1.09, 95%CI=1.05–1.13 for each 1% increase in Spanish LEP population) were associated with increased label translation. Although 88.5% of the pharmacies had bilingual staff, less than half were pharmacists or pharmacy interns and thus qualified to provide medication counseling. More than 80% of the pharmacies surveyed lacked systematic methods for identifying linguistic needs and for informing patients of translation capabilities. Consistent with efforts to improve language access in other health care settings, the critical gap in language appropriate pharmacy services must be addressed to meet the needs of the nation’s large and ever-growing immigrant communities. Pharmacists may require supplemental training on the need and resources for meeting the verbal and written language requirements of their LEP patients. Dispensing software with accurate translation capability and telephonic interpretation services should be utilized in pharmacies serving LEP patients. Pharmacists should post signs and make other efforts to inform patients about the language resources available to them.
doi:10.1007/s11524-007-9221-3
PMCID: PMC2232041  PMID: 17926130
LEP patients; Medical instructions; Pharmacists; Label translation;  Immigrants; Language access
11.  Paan and Gutka Use in the United States: A Pilot Study in Bangladeshi and Indian-Gujarati Immigrants in New York City 
Smokeless tobacco and areca nut are popular with South Asians and South Asian immigrants, most commonly used as paan and gutka. Their regular use leads to oral cancer. The South Asian community in the U.S. is rapidly growing, where paan and gutka are readily available. The study was the first exploration of the migration of the paan and gutka habits, and their use in the U.S.
A 108-item questionnaire on paan and gutka usage and beliefs was administered to 138 first-generation Bangladeshi and Indian-Gujarati immigrant adults at community sites in the New York metropolitan area. Forty-five percent Indian-Gujaratis reported ever-regular paan use; of which 5% are current users. Thirty-one percent reported ever-regular gutka use; of which 77% are current users. Thirty-five percent Bangladeshis reported ever-regular paan use; of which 70% arc current users. Nine percent reported ever-regular gutka use; of which 67% are current users. Bangladeshis are more likely to identify paan as causing oral cancer. Indian-Gujaratis are more likely to identify gutka as causing oral cancer.
Between the two communities, there were significant differences in paan and gutfca usage, migration effects, and oral career risk perception. There is a need for comprehensive migration studies on the determinants of usage, and for community-specific interventions for these carcinogenic products.
doi:10.300/J500v04n01_07
PMCID: PMC1867456  PMID: 17492057
Immigrants; smokeless tobacco; South Asians; oral cancer; paan; gutka
12.  An Academic Dental Center Grapples with Oral Cancer Disparities: Current Collaboration and Future Opportunities 
Journal of dental education  2004;68(5):531-541.
This article reviews the epidemiology of oral cancer in the United States, explores the complex reasons for its disproportionate burden in minority groups, and describes the efforts of New York University’s College of Dentistry to address these oral cancer disparities. These efforts include the development of state and regional consortia and networks, public education and community screening efforts, undergraduate dental curriculum development, professional education, intensive research efforts, and significant dental-medical collaborations. Future directions include the need to develop and assess oral cancer education/awareness programs, specifically customized to the various dental-medical professionals/trainees and to populations at risk. Improving the quality of life of patients during and following treatment for oral cancer is another important area that has great opportunity for dental-medical collaboration.
PMCID: PMC1409711  PMID: 15186070
oral cancer; minorities; early detection; prevention; dental-medical
13.  The Impact of Medical Interpretation Method on Time and Errors 
Journal of General Internal Medicine  2007;22(Suppl 2):319-323.
Background
Twenty-two million Americans have limited English proficiency. Interpreting for limited English proficient patients is intended to enhance communication and delivery of quality medical care.
Objective
Little is known about the impact of various interpreting methods on interpreting speed and errors. This investigation addresses this important gap.
Design
Four scripted clinical encounters were used to enable the comparison of equivalent clinical content. These scripts were run across four interpreting methods, including remote simultaneous, remote consecutive, proximate consecutive, and proximate ad hoc interpreting. The first 3 methods utilized professional, trained interpreters, whereas the ad hoc method utilized untrained staff.
Measurements
Audiotaped transcripts of the encounters were coded, using a prespecified algorithm to determine medical error and linguistic error, by coders blinded to the interpreting method. Encounters were also timed.
Results
Remote simultaneous medical interpreting (RSMI) encounters averaged 12.72 vs 18.24 minutes for the next fastest mode (proximate ad hoc) (p = 0.002). There were 12 times more medical errors of moderate or greater clinical significance among utterances in non-RSMI encounters compared to RSMI encounters (p = 0.0002).
Conclusions
Whereas limited by the small number of interpreters involved, our study found that RSMI resulted in fewer medical errors and was faster than non-RSMI methods of interpreting.
doi:10.1007/s11606-007-0361-7
PMCID: PMC2078536  PMID: 17957418
interpreting; medical errors; access to care; language; immigrant health
14.  Patient Satisfaction with Different Interpreting Methods: A Randomized Controlled Trial 
Journal of General Internal Medicine  2007;22(Suppl 2):312-318.
Background
Growth of the foreign-born population in the U.S. has led to increasing numbers of limited-English-proficient (LEP) patients. Innovative medical interpreting strategies, including remote simultaneous medical interpreting (RSMI), have arisen to address the language barrier. This study evaluates the impact of interpreting method on patient satisfaction.
Methods
1,276 English-, Spanish-, Mandarin-, and Cantonese-speaking patients attending the primary care clinic and emergency department of a large New York City municipal hospital were screened for enrollment in a randomized controlled trial. Language-discordant patients were randomized to RSMI or usual and customary (U&C) interpreting. Patients with language-concordant providers received usual care. Demographic and patient satisfaction questionnaires were administered to all participants.
Results
541 patients were language-concordant with their providers and not randomized; 371 were randomized to RSMI, 167 of whom were exposed to RSMI; and 364 were randomized to U&C, 198 of whom were exposed to U&C. Patients randomized to RSMI were more likely than those with U&C to think doctors treated them with respect (RSMI 71%, U&C 64%, p < 0.05), but they did not differ in other measures of physician communication/care. In a linear regression analysis, exposure to RSMI was significantly associated with an increase in overall satisfaction with physician communication/care (β 0.10, 95% CI 0.02–0.18, scale 0–1.0). Patients randomized to RSMI were more likely to think the interpreting method protected their privacy (RSMI 51%, U&C 38%, p < 0.05). Patients randomized to either arm of interpretation reported less comprehension and satisfaction than patients in language-concordant encounters.
Conclusions
While not a substitute for language-concordant providers, RSMI can improve patient satisfaction and privacy among LEP patients. Implementing RSMI should be considered an important component of a multipronged approach to addressing language barriers in health care.
doi:10.1007/s11606-007-0360-8
PMCID: PMC2078551  PMID: 17957417
immigrant health; satisfaction; language
15.  Letter to the Editor Regarding Aranguri et al 
doi:10.1111/j.1525-1497.2006.00625.x
PMCID: PMC1924798  PMID: 16995889
16.  The Impact of Medical Interpretation Method on Time and Errors 
Journal of General Internal Medicine  2007;22(Suppl 2):319-323.
Background
Twenty-two million Americans have limited English proficiency. Interpreting for limited English proficient patients is intended to enhance communication and delivery of quality medical care.
Objective
Little is known about the impact of various interpreting methods on interpreting speed and errors. This investigation addresses this important gap.
Design
Four scripted clinical encounters were used to enable the comparison of equivalent clinical content. These scripts were run across four interpreting methods, including remote simultaneous, remote consecutive, proximate consecutive, and proximate ad hoc interpreting. The first 3 methods utilized professional, trained interpreters, whereas the ad hoc method utilized untrained staff.
Measurements
Audiotaped transcripts of the encounters were coded, using a prespecified algorithm to determine medical error and linguistic error, by coders blinded to the interpreting method. Encounters were also timed.
Results
Remote simultaneous medical interpreting (RSMI) encounters averaged 12.72 vs 18.24 minutes for the next fastest mode (proximate ad hoc) (p = 0.002). There were 12 times more medical errors of moderate or greater clinical significance among utterances in non-RSMI encounters compared to RSMI encounters (p = 0.0002).
Conclusions
Whereas limited by the small number of interpreters involved, our study found that RSMI resulted in fewer medical errors and was faster than non-RSMI methods of interpreting.
doi:10.1007/s11606-007-0361-7
PMCID: PMC2078536  PMID: 17957418
interpreting; medical errors; access to care; language; immigrant health
17.  Patient Satisfaction with Different Interpreting Methods: A Randomized Controlled Trial 
Journal of General Internal Medicine  2007;22(Suppl 2):312-318.
Background
Growth of the foreign-born population in the U.S. has led to increasing numbers of limited-English-proficient (LEP) patients. Innovative medical interpreting strategies, including remote simultaneous medical interpreting (RSMI), have arisen to address the language barrier. This study evaluates the impact of interpreting method on patient satisfaction.
Methods
1,276 English-, Spanish-, Mandarin-, and Cantonese-speaking patients attending the primary care clinic and emergency department of a large New York City municipal hospital were screened for enrollment in a randomized controlled trial. Language-discordant patients were randomized to RSMI or usual and customary (U&C) interpreting. Patients with language-concordant providers received usual care. Demographic and patient satisfaction questionnaires were administered to all participants.
Results
541 patients were language-concordant with their providers and not randomized; 371 were randomized to RSMI, 167 of whom were exposed to RSMI; and 364 were randomized to U&C, 198 of whom were exposed to U&C. Patients randomized to RSMI were more likely than those with U&C to think doctors treated them with respect (RSMI 71%, U&C 64%, p < 0.05), but they did not differ in other measures of physician communication/care. In a linear regression analysis, exposure to RSMI was significantly associated with an increase in overall satisfaction with physician communication/care (β 0.10, 95% CI 0.02–0.18, scale 0–1.0). Patients randomized to RSMI were more likely to think the interpreting method protected their privacy (RSMI 51%, U&C 38%, p < 0.05). Patients randomized to either arm of interpretation reported less comprehension and satisfaction than patients in language-concordant encounters.
Conclusions
While not a substitute for language-concordant providers, RSMI can improve patient satisfaction and privacy among LEP patients. Implementing RSMI should be considered an important component of a multipronged approach to addressing language barriers in health care.
doi:10.1007/s11606-007-0360-8
PMCID: PMC2078551  PMID: 17957417
immigrant health; satisfaction; language
18.  Can a Web-Based Curriculum Improve Students' Knowledge of, and Attitudes About, the Interpreted Medical Interview? 
Objectives
To develop and evaluate a web-based curriculum to introduce first year medical students to the knowledge and attitudes necessary for working with limited English proficient (LEP) patients through interpreters.
Method
Six hundred and forty first year medical students over 4 consecutive years took this curriculum as part of their Patient Physician and Society course. They viewed 6 patient-physician-interpreter video vignettes, gave open text analyses of each vignette, and compared their responses to those generated by experts, thereby receiving immediate formative feedback. They listened to video commentaries by a cultural expert, lawyer, and ethicist about working with LEP patients, completed pre- and postmodule questionnaires, which tested relevant knowledge and attitudes, and were provided a summative assessment at the end of the module. Students completed an optional survey assessing the educational value of, and providing open text commentary about, the module.
Results
Seventy-one percent (n=456) of first year students who completed the module consented to have their data included in this evaluation. Mean knowledge (19 items) scores improved (46% pre- to 62% postmodule, P<.001), reflecting improvements in knowledge about best interpreter practices and immigration demographics and legal issues. Mean scores on 4 of 5 attitude items improved, reflecting attitudes more consistent with culturally sensitive care of LEP patients. Mean satisfaction with the educational value of the module for 155 students who completed the postmodule survey was 2.9 on a scale of 1 to 4.
Conclusion
Our web-curriculum resulted in short-term improvement in the knowledge and attitudes necessary to interact with LEP patients and interpreters. The interactive format allowed students to receive immediate formative feedback and be cognizant of the challenges and effective strategies in language discordant medical encounters. This is important because studies suggest that the use of these skills in patient encounters leads to greater patient and provider satisfaction and improved health outcomes.
doi:10.1111/j.1525-1497.2005.0193.x
PMCID: PMC1490228  PMID: 16191140
medical education; curriculum; computer-assisted instruction; cross cultural communication; interpreted medical interview; physician-patient relation

Results 1-20 (20)