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1.  Water consumption beliefs and practices in a rural Latino community: Implications for fluoridation 
Adequate fluoride exposure is especially important for those experiencing disproportionately high prevalence of dental caries, such as rural Latino farmworkers and their children. Water is an important source of fluoride. This qualitative study examined water consumption beliefs and practices among Latino parents of young children in a rural community.
Focus groups and open-ended in-depth interviews explored parents’ beliefs about tapwater, beverage preferences and knowledge of fluoride. A questionnaire documented socio-demographic characteristics and water consumption practices. Qualitative analysis revealed how water-related beliefs, social and cultural context, and local environment shaped participants' water consumption.
The vast majority of participants (N=46) avoided drinking unfiltered tap water based on perceptions that it had poor taste, smell and color, bolstered by a historically justified and collectively transmitted belief that the public water supply is unsafe. Water quality reports are not accessible to many community residents, all of whom use commercially bottled or filtered water for domestic consumption. Most participants had little knowledge of fluoride beyond a general sense it was beneficial. While most participants expressed willingness to drink fluoridated water, many emphatically stated that they would do so only if it tasted, looked, and smelled better and was demonstrated to be safe.
Perceptions about water quality and safety have important implications for adequate fluoride exposure. For vulnerable populations, technical reports of water safety have not only to be believed and trusted but matched or superceded by experience before meaningful change will occur in people’s water consumption habits.
PMCID: PMC3536824  PMID: 20735717
Hispanic Americans; rural population; dental caries; water; culture
2.  Perceived Susceptibility to Illness and Perceived Benefits of Preventive Care: An Exploration of Behavioral Theory Constructs in a Transcultural Context 
This article describes how the social context of transculturation (cultural change processes) and transmigration (migration in which relationships are sustained across national boundaries) can directly influence use of mammography screening. The authors conducted semistructured interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behavior (Behavioral Constructs and Culture in Cancer Screening study). Iterative analyses identified themes of the transcultural domain: colonialism, immigration, discrimination, and therapeutic engagement. In this domain, the authors examine two key behavioral theory constructs, perceptions of susceptibility to illness and perceptions of benefits of preventive medical care. The findings raise concerns about interventions to promote mammography screening primarily based on provision of scientific information. The authors conclude that social context affects behavior directly rather than exclusively through beliefs as behavioral theory implies and that understanding contextual influences, such as transculturation, points to different forms of intervention.
PMCID: PMC2941192  PMID: 19805792
mammography screening; perceived benefits; perceived susceptibility; transculturation; health disparities
3.  Social and Cultural Meanings of Self-Efficacy 
This article describes the influences of social context on women’s health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars’ and practitioners’ understandings of health behavior and intervention development.
PMCID: PMC2921833  PMID: 19805794
self-efficacy; social capital; social context; mammography screening
4.  Medical students’ conceptualizations of quality of life associated with children who have Inflammatory Bowel Disease 
To investigate second year medical students’ understanding of quality of life associated with childhood inflammatory bowel disease (IBD).
Cross-sectional study in a major teaching institution in San Francisco. A questionnaire was administered following an hour long gastroenterology lecture which featured two young patients with pediatric-onset IBD who addressed everyday life with the disease. Analyses of numerate responses to the questionnaire were paired with a content and thematic analysis of audiotape recordings of the patients’ commentaries.
Medical student responses to the patient interviews were very positive. Medical students gained a new awareness of the psychosocial complexities associated with living with a pediatric chronic illness and a new way of thinking about the meaning of “healthy.” Despite listening to two healthy young patients, however, the medical students still conceptualized pediatric IBD in mostly, although not exclusively, negative terms.
Medical students’ perceptions of pediatric IBD improved as a result of listening to the patient interviews. While this teaching modality effectively introduced students to a complex condition, it did not overcome their unfavorable impression of IBD’s impact on children’s lives. The symptoms associated with IBD have stigma attached to them, and these stereotypes influence how medical students perceive those living with this chronic illness. More research and training in this area is necessary.
PMCID: PMC3788836  PMID: 23752075
Chronic illness; pediatric IBD; quality of life; patient narratives; medical education
Journal of psychoactive drugs  2007;39(2):115-129.
GHB (gamma hydroxybutyrate) is a significant new drug of abuse added to the United States Controlled Substance Act in 2000. The majority of the published literature on GHB consists of clinical case reports, mainly from emergency departments, and a collection of laboratory-based studies, focused mainly on anesthesia. While comments about the various experiences and behaviors of human users are often included in such studies or reports, these aspects of GHB are only just beginning to be systematically investigated or detailed. Reported here are data from a qualitative study using focus group methods on the consumption habits, experiences, and beliefs of GHB users. A total of 51 people, 30 men and 21 women, mean age of 31.1±7.6 years (range 18 – 52 years), who report having used GHB for an average of 4.3±2.5 years (range 1–11 years), were interviewed in 10 separate groups held in 2004. This paper discusses broadly the general experience of the GHB ‘high,’ major perceived benefits including sexual responses to the drug, perceived risks and dangers of ingestion, co-ingestion, and various contexts of use. The paper concludes with a discussion of the implications drawn from this information for clinicians treating patients who use GHB.
PMCID: PMC2257870  PMID: 17703706
6.  Falling through the cracks: gaps in depression treatment among older Mexican-origin and white men 
1) To compare depression frequency and self-reported depression treatment in Mexican-origin and white men; 2) to examine ethnic differences in self-reported prior depression diagnosis and treatment; 3) to determine whether Mexican-origin men (both English and Spanish language preferring) are less likely than white men to report receiving depression treatment after controlling for potential confounders.
This is a cross-sectional, observational study of Mexican-origin and white men (60-years and over) presenting for primary care visits at six outpatient clinics in California’s Central Valley. Clinical depression was assessed with the SCID module for past-year major depression and questions for chronic depression. Past-year, self-reported prior depression diagnosis and treatment (i.e. medication, psychotherapy, mental health referral) were assessed through a structured questionnaire.
The frequency of past year clinical depression was similar for both ethnic groups yet Mexican-origin men were significantly less likely than whites to report receiving a prior diagnosis of depression or prior depression treatment. Compared with whites, the odds of untreated depression in Mexican-origin men was 4.35 (95% CI 1.35–14.08) for those interviewed in English and 10.40 (95% CI 2.11–51.25) for those interviewed in Spanish. For both ethnic groups, the majority (i.e. approximately two-thirds) of men receiving depression treatment also met criteria for past year clinical depression.
Mexican-origin older men in primary care suffer from significant gaps in depression care (i.e. diagnosis and treatment) compared with whites. Delivering effective depression treatment (i.e. so that depression remits) remains elusive for both ethnic groups.
PMCID: PMC3560929  PMID: 22383214
depression; access and quality of care; elderly; men; minorities; primary care
7.  Caregiver Acceptability and Preferences for Preventive Dental Treatments for Young African American Children 
Our prior research focused on parental treatment acceptability (TA) and preferences (TP) for preventive dental treatments for young Hispanic children. We adapted the interview for administration to parents of young African American children.
In a sample of African American parents, determine parental TA and TP for 5 dental treatments to prevent early childhood caries.
Interviewed 48 parents/caregivers of African American children attending Head Start, assessing TA and TP for 3 treatments for children: toothbrushing with fluoride toothpaste (TB), fluoride varnish (FV), and xylitol in food (XF); and 2 treatments for mothers: xylitol gum (XG) and chlorhexidine (CHX) rinse. The interview included verbal information, illustrated treatment cards, photos/video clips, and samples. Parents provided TA of each treatment (1–5 scale), TP between each of 10 pairs of the 5 treatments, and open-ended reasons for their preferences. TP were summed (0–4) to create overall preference.
All treatments were acceptable (means 4.4–4.9). TB was more acceptable than FV and XF (p<0.05). Summed TP revealed a strong preference for TB (mean 3.1) above other treatments (all p<0.01). Primary reasons for preferring TB were: promotes healthy habits; child-focused; and effectiveness.
All treatments were acceptable, however, parents/guardians strongly preferred TB. Parents’ emphasis on healthy habits and child-focused treatment supports efforts for oral health education programs in early childhood settings. Some parents expressed concerns about FV, XF, and CHX. Results may be useful in planning prevention programs for young children in African American communities.
PMCID: PMC3786744  PMID: 22506551
oral health; acceptability of healthcare; pediatric dentistry; preventive dental treatments; African American
8.  Urban Mexican-American mothers’ beliefs about caries etiology in children 
Caries is a severe condition which disproportionately affects Latino children in the U.S. This study sought contextual understanding of urban, low-income Mexican-American mothers’ beliefs, perceptions, knowledge and behavior surrounding causes of caries.
In urban San José, CA, a qualitative study was conducted with a convenience sample of Mexican-American mothers of young children about their beliefs and knowledge about the causes of caries. Audio-taped in-depth interviews with open-ended questions, primarily in Spanish, were translated to English and then transcribed verbatim. Texts were independently read and thematically analyzed by two researchers.
Even while expressing uncertainty, all 48 mothers mentioned specific causes of caries, most frequently citing candy or juice consumption (85%), poor oral hygiene (65%) and use of the bottle (52%). Mothers rarely recognized cariogenic foods beyond candy, did not know or perform recommended oral hygiene routines, and demonstrated confusion and uncertainty about exactly how baby bottles are detrimental to teeth. Nearly half of these mothers also mentioned secondary cavity causes, such as genetics, lack of calcium, not going to the dentist, or lack of fluoride. Mothers did not mention the role of bacteria. While mothers recognize that oral hygiene can counteract the detrimental effects of candy consumption, they did not recognize its beneficial effects in other contexts. Nor did they know about other preventive activities.
Mothers recognized the three major important factors causing caries: sugar consumption, poor oral hygiene, and bottle use. However, their knowledge is limited in depth and specificity which restricts development of caries prevention behaviors. More comprehensive education is needed, including on caries prevention (oral hygiene) behaviors, which could lead to an increased sense of self-efficacy with respect to their children’s oral health.
PMCID: PMC3600053  PMID: 20156233
Caries; Caries etiology; Mothers’ beliefs and knowledge; Mexican-American children; Qualitative research
9.  Curing and Caring: The Work of Primary Care Physicians With Dementia Patients 
Qualitative health research  2011;21(11):1469-1483.
The symbolic framework guiding primary care physicians’ (PCPs) practice is crucial in shaping the quality of care for those with degenerative dementia. Examining the relationship between the cure and care models in primary care offers a unique opportunity for exploring change toward a more holistic approach to health care. The aims of this study were to (a) explore how PCPs approach the care of patients with Alzheimer’s disease (AD), and (b) describe how this care unfolds from the physicians’ perspectives. This was a cross-sectional study of 40 PCPs who completed semistructured interviews as part of a dementia caregiving study. Findings show that PCPs recognize the limits of the cure paradigm and articulate a caring, more holistic model that addresses the psychosocial needs of dementia patients. However, caring is difficult to uphold because of time constraints, emotional burden, and jurisdictional issues. Thus, the care model remains secondary and temporary.
PMCID: PMC3581606  PMID: 21685311
Alzheimer’s disease; emotions / emotion work; empathy; health care; primary; health care professionals; holistic care; interviews; semistructured; medicine; practice guidelines; psychosocial issues; qualitative analysis
10.  Theorizing Social Context: Rethinking Behavioral Theory 
Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the “Behavioral Constructs and Culture in Cancer Screening” study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socio-culturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like that in the United States.
PMCID: PMC3548316  PMID: 19805791
Social context; culture; health behavior theory; social science theory
11.  Maternal Beliefs and Motivations for First Dental Visit by Low-Income Mexican-American Children in California 
Pediatric dentistry  2011;33(5):392-398.
To examine Mexican-American immigrant caregivers’ beliefs and motivations surrounding the first dental visit for their young children (median age 5 years).
Qualitative interviews with a convenience sample of 48 low-income, Mexican-American mothers about their young children’s oral health. Transcripts were independently read, coded and thematically analyzed.
Half (51%) of first dental visits were for parent-initiated reasons: for pain or visible dental problems, parent’s proactive desire to get a checkup, or to avoid future dental problems. The other half was initiated by external prompts, especially pediatrician recommendation and school requirement. Once a child went to the dentist for his/her first visit, 94% continued with regular checkups. The mean age for a first dental visit was 3 years. Three parents reported cases in which dentists discouraged visits for symptomatic children before 3 years of age.
These low-income, urban Mexican-American parents are taking their children to their first dental visit around 3 years of age, much later than the recommended 1 year for this at-risk population. Physicians are well-situated to play an important role in prompting first dental visits.
PMCID: PMC3536823  PMID: 22104706
Oral Health; Child; Preschool; Parent; Healthcare Disparities; Mexican Americans
12.  Rural Latino farmworker fathers' understanding of children's oral hygiene practices 
Pediatric dentistry  2010;32(5):400-406.
To examine rural Latino fathers' understanding of their children's oral hygiene practices.
A convenience sample (n=20) of fathers from a small agricultural city in California was recruited in their homes. Individual qualitative interviews in Spanish were conducted. Interviews were audio-taped, translated and transcribed. Codes were developed and the text analyzed for recurrent themes.
Fathers came from Mexico (n=15) and El Salvador (n=5). Fathers had very little understanding of the etiology and clinical signs of dental caries. Overall, 18 of 19 fathers reported that their wife was primarily responsible for taking care of the children's hygiene. Fathers agreed that children's teeth should be cared for from a young age, considered to be after 2 years. The fathers described very minimal hygiene assistance given to children by either parent, and often considered a verbal reminder to be sufficient assistance. Fathers generally thought a child did not need supervision after about age 4 (range 1 to 11 years).
While rural Latino fathers might not actively participate in their children's oral hygiene, they do place value on it. Men are supportive of dental treatments, albeit later than recommended. Educational messages aimed at these families will disseminate to the fathers, indirectly.
PMCID: PMC3526820  PMID: 21070706
Latinos; children; fathers; oral health; knowledge
13.  Mexican-American mothers’ initiation and understanding of home oral hygiene for young children 
Pediatric dentistry  2009;31(5):395-404.
To investigate caregiver beliefs and behaviors as key issues in the initiation of home oral hygiene routines. Oral hygiene helps reduce the prevalence of early childhood caries, which is disproportionately high among Mexican-American children.
Interviews were conducted with a convenience sample of 48 Mexican-American mothers of young children in a low income, urban neighborhood. Interviews were digitally recorded, translated, transcribed, coded and analyzed using standard qualitative procedures.
The average age of tooth brushing initiation was 1.8±0.8 years; only a small proportion of parents (13%) initiated oral hygiene in accord with American Dental Association (ADA) recommendations. Mothers initiated 2 forms of oral hygiene: infant oral hygiene and regular tooth brushing. For the 48% of children who participated in infant oral hygiene, mothers were prompted by pediatrician and social service (WIC) professionals. For regular tooth brushing initiation, a set of maternal beliefs exist about when this oral hygiene practice becomes necessary for children. Beliefs are mainly based on a child’s dental maturity, interest, capacity and age/size.
Most (87%) of the urban Mexican-American mothers in the study do not initiate oral hygiene practices in compliance with ADA recommendations. These findings have implications for educational messages.
PMCID: PMC3523181  PMID: 19947134
infant oral health; early childhood caries; tooth brushing; oral habits; Mexican-American children
Community dental health  2009;26(4):216-221.
Mexican-origin children have higher rates of decay and lower dental utilization rates than children from all other racial/ethnic groups. Different cultural groups’ interpretations of dental symptoms illuminate their different decision-making process about seeking care. Through ethnography in a small rural U.S. city, we examined low-income Mexican immigrant caregivers’ interpretations of their children’s dental symptoms and evaluations of the need for treatment.
Basic Research Design
We conducted 49 in-depth interviews with 26 Mexican immigrant caregivers about their perceptions of their children’s dental symptoms, and observations of five such caregivers’ help-seeking episodes and 30 other caregivers’ presentation of their children’s symptoms at dental clinics. All interviews and fieldnotes were analyzed qualitatively through a series of readings and codings.
A conceptual model of caregivers’ decision-making processes was developed. Most caregivers deduced the health of teeth from visible appearance, and thus children’s complaints of pain alone were often ineffective in triggering a dental visit. Caregivers often delayed treatment because they viewed their children’s oral disease as mere “stains” requiring cleaning rather than as bacterial infections requiring restorative treatment. Parents appeared to confuse carious “stains” with fluorosis stains common in rural Mexico.
Even when Mexican immigrant caregivers recognize a dental problem, they often misinterpret it as a “stain.” Caregivers’ interpretations of decay were shaped by their lack of experience with children’s decay in rural Mexico. Oral health education programs should help rural immigrant caregivers distinguish between “stains” and “cavities,” and understand the heightened oral hygiene requirements of the cariogenic diet in industrialized countries.
PMCID: PMC3523183  PMID: 20088219
Latino/Hispanic children; Immigrants; Early Childhood Caries; Parental health beliefs and behaviors; Dental help-seeking; Ethnography; Rural; Low income; Oral Health Education
15.  Rural Latino Immigrant Caregivers’ Conceptions of Their Children’s Oral Disease 
To examine Latino immigrant caregivers’ explanatory models of the causes of early childhood caries (ECC).
In a rural area, we conducted 71 open-ended qualitative interviews with 26 Mexican immigrant and 12 Salvadoran immigrant caregivers of children under six about the causes of ECC. Two researchers independently read each interview and classified each interviewee’s response.
Caregivers mentioned three biomedical causes of oral disease (sweets, poor oral hygiene, and bottle-feeding) and two lay or popular causes (lack of milk consumption and “bad” genes). Although caregivers were aware that the consumption of sweet foods causes decay, they expressed particular confusion about how bottle-feeding causes decay. Nineteen caregivers attributed decay specifically to bottle-feeding, yet 14 believed the cause of decay was the bottle’s nipple. Seven Mexican immigrant caregivers attributed their children’s decay specifically to a lack of calcium, and six immigrant caregivers to “bad teeth genes.”
Conceptions of oral disease derived from caregivers’ own dental experiences, their conceptions of the body, and interactions with dental professionals. The fact that biomedical explanations dominate the list of causes of caries for both groups indicates that caregivers’ explanatory models of oral disease are powerfully shaped by interactions with health professionals. Immigrant caregivers’ mistaking of the baby bottle’s nipple as the source of decay indicates the need for more effective oral health promotion. Yet Mexican immigrants’ conceptions of a lack of calcium as a major factor in their children’s decay may illustrate a strong cultural link between teeth and milk.
PMCID: PMC3523184  PMID: 18248338
Latino/Hispanic children; Rural immigrants; Early Childhood Caries; Parental beliefs and behaviors; Ethnography; Low income; Oral Health Education
16.  Stigmatized Biologies: Examining the Cumulative Effects of Oral Health Disparities for Mexican American Farmworker Children 
Medical anthropology quarterly  2010;24(2):199-219.
Severe early childhood caries (ECC) can leave lasting effects on children’s physical development, including malformed oral arches and crooked permanent dentition. This article examines the way that ECC sets up Mexican American farm worker children in the United States for lasting dental problems and social stigma as young adults. We examine the role of dietary and environmental factors in contributing to what we call “stigmatized biologies,” and that of market-based dental public health insurance systems in cementing their enduring effects. We adapt Margaret Lock’s term, local biology, to illustrate the way that biology differs not only because of culture, diet, and environment but also because of disparities in insurance coverage. By showing the long-term effects of ECC and disparate dental treatment on farmworker adults, we show how the interaction of immigrant caregiving practices and underinsurance can have lasting social effects. An examination of the long-term effects of farm worker children’s ECC illustrates the ways that market-based health care systems can create embodied differences that in turn reproduce a system of social inequality.
PMCID: PMC3523191  PMID: 20550093
oral health disparities; Latino health paradox; Medicaid; local biologies; immigrant health
17.  Older People and Social Connectedness: How Place and Activities Keep People Engaged 
Journal of Aging Research  2012;2012:139523.
To understand how older adults perceive and navigate their neighborhoods, we examined the implications of activity in their neighborhoods for their health. We interviewed 38 adults (ages 62–85) who lived in San Francisco or Oakland, California. Seven key themes emerged: (1) people express a wide range of expectations for neighborliness, from “we do not bother each other” to “we have keys to each other's houses”, (2) social distance between “other” people impede a sense of connection, (3) ethnic differences in living arrangements affect activities and activity locations, (4) people try to stay busy, (5) people able to leave their homes do many activities outside their immediate residential neighborhoods, (6) access to a car is a necessity for most, and (7) it is unusual to plan for the future when mobility might become limited. Multiple locations influence older adults' health, including residential neighborhoods. Older adults value mobility, active lives, and social connections.
PMCID: PMC3261464  PMID: 22272374
NAPA bulletin  2010;34(1):68-83.
This article presents evidence of a “Latino oral health paradox,” in which Mexican immigrant parents in California’s Central Valley report having had better oral health status as children in Mexico than their U.S.-born children. Yet little research has explored the specific environmental, social, and cultural factors that mediate the much-discussed “Latino health paradox,” in which foreign-born Latinos paradoxically enjoy better health status than their children, U.S.-born Latinos, and whites. Through ethnography, we explore the dietary and environmental factors that ameliorated immigrant parents’ oral health status in rural Mexico, while ill-preparing them for the more cariogenic diets and environments their children face in the U.S. We argue that studies on the “Latino health paradox” neglect a binational analysis, ignoring the different health status of Latino populations in their sending countries. We use the issue of immigrant children’s high incidence of oral disease to initiate a fuller dialogue between U.S.-based studies of the “health paradox” and non-U.S. based studies of the “epidemiological transition.” We show that both models rely upon a static opposition between “traditional” and “modern” health practices, and argue that a binational analysis of the processes that affect immigrant children’s health can help redress the shortcomings of epidemiological generalizations.
PMCID: PMC2995897  PMID: 21132097
19.  When help becomes a hindrance: Mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer’s disease 
To describe structural barriers to mental health specialists and consequences of these barriers to care for patients with dementia and neuropsychological symptoms and their primary care physicians (PCPs).
Cross-sectional qualitative interview study of PCPs.
Physicians’ offices, primarily managed care.
40 PCPs in Northern California.
Open-ended interviews lasted 30–60 minutes. The interview guide covered clinician background, practice setting, clinical care of a particular patient, and general approach to managing patients with Alzheimer’s disease or related dementias. Interviews were transcribed and themes reflecting referrals identified.
93% of the PCPs described problematic access to and communication with mental health specialists (in particular psychiatrists and neuropsychologists) as impediments to effective care for dementia patients. Thematic analysis identified structural barriers to mental health referrals ranging from problems with managed care and reimbursement policies to lack of trained providers and poor geographic distribution of specialists. Structural barriers compromised care for patients with dementia because the barriers limited PCP treatment options, and resources, impacted office staff and time with other patients, impeded and delayed care, and fostered poor communication and lack of coordinated care. Negative consequences for PCPs included increased frustration, conflict, and burnout.
PCPs viewed problems created by onerous referral systems, such as mental health carve-outs, as particularly burdensome for elderly patients with co-morbid dementia and neuropsychiatric problems. These problems were cited by PCPs across different types of practice settings. PCPs managed treatment of neurobehavioral symptoms as best they could despite lack of specialist support.
PMCID: PMC2955197  PMID: 20593538
Alzheimer’s disease; dementia; managed care; referrals; barriers to care; qualitative; neuropsychiatric symptoms
20.  Clinician Approaches and Strategies for Engaging Older Men in Depression Care 
The aim of this study is to explore primary care physicians’ (PCPs) and depression care managers’ (DCMs) approaches to diagnosing and treating depression in older men. The authors focus on older men because studies have shown that they are under-treated compared with women and younger groups. The authors contribute to previous research by identifying facilitators of care for older men from the perspective of clinicians.
Participants in this study were part of the Improving Mood-Promoting access to Collaborative Treatment (IMPACT) trial, an effectiveness study of collaborative care for late-life depression in 18 diverse primary care practices. Nine PCPs and 11 DCMs were interviewed to collect information on specific roles in caring for depressed patients and their experiences in working with depressed older men. All interviews were tape-recorded, transcribed verbatim and analyzed thematically in several steps using standard qualitative data analysis techniques.
The authors identified three general approaches to building trust and talking about the depression: 1) an indirect approach (“call it something else”), 2) a gradual approach (“building up to depression”), and 3) a direct approach (“shock and awe”). The authors also found specific strategies that PCPs and DCMs used to manage depression among elderly male patients, such as increased monitoring of mood, treating somatic symptoms first, medicalizing depression, and enlisting the cooperation of family. In our interviews, enlisting family involvement was the most prominent strategy used by clinicians.
A variety of approaches and strategies are used by clinicians for diagnosing and treating depressed older men. Clinicians change strategies as a response to a patient's compliance with treatment and the decision about which strategy to pursue is usually made on an “on-the-go” basis throughout the course of clinician-patient interaction. Based on clinicians’ experience, depression management requires concerted efforts and persistence, and the family seems to play an important role in how older men receive the diagnosis of depression and adhere to clinicians’ prescribed treatment. However, more research is needed to discover the best way of engaging and working with family members to facilitate effective depression care for older adults.
PMCID: PMC2981127  PMID: 20220598
Clinicians’ approaches; depression; older men; facilitators of care; qualitative methods
21.  Beyond Familism: Ethics of Care of Latina Caregivers of Elderly Parents With Dementia 
Health care for women international  2009;30(12):1055-1072.
Caregiving for elderly relatives with dementia is described as a stressful and challenging obligation which disproportionately befalls women in families. Studies of Latina caregivers tend to focus on how the cultural value of familism shapes caregiving expectations and experiences. However, these studies tend not to distinguish between familism as ideology and familism as practice to evaluate how caregiving may or may not conform to prescribed cultural scripts, nor to examine the ethics of care utilized by family caregivers. Through a case study of a second-generation daughter, we explore the nuances of an ethics of care that constitute her caregiving experiences and the tensions generated by efforts to respect divergent cultural mandates.
PMCID: PMC2955855  PMID: 19894151
22.  “Stains” on their self-discipline: Public health, hygiene, and the disciplining of undocumented immigrant parents in the nation's internal borderlands 
American ethnologist  2009;36(4):784-798.
Histories of the role of public health in nation building have revealed the centrality of hygiene to eugenic mechanisms of racial exclusion in the turn-of-the-20th-century United States, yet little scholarship has examined its role in the present day. Through ethnography in a Mexican migrant farmworking community in California's Central Valley, we explore the role of oral-hygiene campaigns in racializing Mexican immigrant parents and shaping the substance of their citizenship. Public health officials perceive migrant farmworkers' children's oral disease as a “stain of backwardness,” amplifying Mexican immigrants' status as “aliens.” We suggest, however, that the recent concern with Mexican immigrant children's oral health blends classic eugenic concerns in public health with neoliberal concerns regarding different immigrant groups' capacity for self-governance.
PMCID: PMC2787473  PMID: 20161433
governmentality; citizenship; public health; eugenics; Mexican immigrants; hygiene; United States
23.  Re-examining the relationships among dementia, stigma, and aging in immigrant Chinese and Vietnamese family caregivers 
Prior literature emphasizes that Asian Americans with dementia may be particularly vulnerable to the stigma of chronic mental illness. However, there is a dearth of empirical research to support this claim. This study examines the relationship of stigma and dementia in 32 qualitative interviews with Chinese and Vietnamese family caregivers. Stigma was a common theme in the interviews (91%). Further analysis of stigma revealed two sources: chronic mental illness stigma and stigma reflecting negative stereotypes of aging or the aged. Chinese and Vietnamese cultural views of normal aging are not a unitary category but accommodate different trajectories of aging, some more and some less desired. When applied to persons with dementia, a “normalized” but negative trajectory of aging carried with it significant stigma that was distinct from but in addition to the stigma of chronic and severe mental illness. Older Chinese and Vietnamese with dementia are thus at risk of experiencing multiple stigmas that include but go beyond the stigma associated with chronic and severe mental illness.
PMCID: PMC2958058  PMID: 18665444
24.  Behavioral Theory in a Diverse Society: Like a Compass on Mars 
The behavioral theory constructs most often used to study mammography utilization—perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms—have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. An intensive inductive investigation then targeted Latina and Filipina women to elucidate connections between social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother–daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and previews the detailed results presented in the other articles in this issue.
PMCID: PMC2921832  PMID: 19805789
behavioral theory; culture; social context; mixed methods; mammography
25.  Intention, Subjective Norms, and Cancer Screening in the Context of Relational Culture 
Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.
PMCID: PMC2921835  PMID: 19805793
relational culture; mammography; intention; subjective norms; social context

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