Volume 18, Fall 2021

Volume 18

EDITORIALS 4 We Technically Started the COVID Vaccine Over 50 Years Ago: The Serendipitous Use of “Useless Research” 10 The Mature Minor Doctrine: When Can Teenagers Medically Consent? We Must Expand their Rights, But We Cannot Draw a Hard Line 14 A Desperate Need for Change: Public Health & Medical Measures in Vietnamʼs Van Mon Village

To Our Readers, Since our last issue, the world has lived through what will surely be one of the most momentous events of our lifetimes. Yet, as the COVID-19 pandemic continues to be felt around the world, we must recognize it not only for the public health crisis it poses, but as a testament to human resilience and our ability to withstand the adversities our society faces.

As COVID-19 puts public health systems around the world to the test, it has simultaneously opened up new opportunities in navigating and improving the many facets of modern public health work.

FEATURES 18 Exploring Maternal Health Challenges in Uganda: A Case Study of the Rural Rakai Village

To highlight the importance of exploration and discovery in these times of uncertainty, we proudly present the 18th volume of Epidemic Proportions, “Uncharted Territories”.

By tapping into the minds of the students of an institution helping to lead the efforts against our current challenges, this volume serves as a platform for research endeavors and unique perspectives that tackle underexplored issues in health: endeavors and perspectives that we hope will inspire students, academics, and researchers alike as we journey together through the pandemic and face the public health challenges of the future.

RESEARCH 24 Limited English Proficiency and Mental Health Outcomes Among Immigrants and Refugees in the United States: A Review of the Literature 36 Accessibility of Suicide Gatekeeper Training for the Student Population

Han Zhang Editor-in-Chief Class of 2023

With their different research and training backgrounds, this yearʼs writers hope to provide you with their unique ideas on rethinking some of the most challenging public health problems of the era. As you peruse the pages that follow, we encourage you to take the opportunity to reflect on your very own pandemic experience and share with others your newfound insights into global public health. Together, we can inspire people around us to imagine a healthier world as we begin moving into the post-pandemic era. As always, we hope you find as much enjoyment in reading this volume of Epidemic Proportions as we did in producing it.

Han Zhang & Jesse Huang Editors in Chief Jesse Huang Editor-in-Chief Class of 2022

We Technically Started the COVID Vaccine Over 50 Years Ago: The Serendipitous Use of “Useless Research” While the development of a safe and effective COVID-19 vaccine is a scientific triumph, the real work began long before the first human case of COVID-19. Ellie Rose Mattoon explains how research often deemed "useless" by cynics can suddenly become essential during a public health emergency. Unfortunately, society has yet to value serendipitous research as much as it should.

Ellie Rose Mattoon Molecular & Cellular Biology Class of 2024

I

n the winter of 2013, Dr. Rolf Hilgenfeld and Dr. Malik Peiris published an overview of the rise and fall of research into SARS, a coronavirus that caused a relatively minor outbreak in the early 2000s.¹ The paper begins with an optimistic summary of antiviral treatments that began development, but its summary falls into eulogy once the reader realizes few promising innovations made it to human testing. After SARS infections dropped to zero (among humans),² fears of a deadly foreign illness turned over to the next eye-catching headline of the season, and funding for SARS research tapered and closed. Hilgenfeld and Peiris make a remark towards the end of their paper which feels like it could have come from the mouth of a prophet: “We will be in the same ‘drug-lessʼ situation when the next zoonotic transmission of a coronavirus into the human population will occur.”

I first read this review on my parentsʼ kitchen table during a break from virtual classes. Five surgical face masks hung looped on the door handle, their light blue sprinkled with red lipstick speckles. News about ICU beds and variants of concern (VOCs) were now quotidian enough to serve as the background noise I loaded the dishwasher to. The scientistsʼ prescient warning still made my stomach drop; for a moment I believed I had found a pair of prophets. The paperʼs use of “we” makes this statement feel too informal for a scientific paper: it wasnʼt like two sharp-suited academics were standing like a preacher on a street corner, wailing that the end was near. However, the use of “when” instead of “if” connotes grim confidence. I wonder if these two men reacted to the COVID-19 pandemic with the smug satisfaction of a weatherman who got the forecast right or the disappointed acceptance of Cassandra, the Greek oracle who was cursed by Apollo to never be believed. The warnings did not stop with SARS. Researchers working with the genetically similar Middle East Respiratory Syndrome (MERS) also struggle to find funding for vaccine development.³ MERS emerged in 2012. It continues to infect humans and camels in mostly en-

demic regions around the Arabian Peninsula.

From 2012 to early 2020, the disease infected 2519 individuals and killed 866.⁴ Over that course of time, some potential funders watched the outbreak progress with folded hands,⁵ but this was not necessarily out of malice. As with any resource, there was limited research funding for vaccines, and private companies especially had to consider the economic returns of their investments. MERS had been listed as a priority pathogen by the World Health Organization,⁶ meaning that effective interventions for MERS were deemed vital to global health security. MERS also has a limited infection range in mostly low or middleincome countries. In other words, it holds little commercial appeal.

When COVID-19 emerged, the virus was found to genetically be 80% similar to SARS and 50% similar to MERS. For reference, humans share about 80% of their DNA with a cow.⁷ For two viruses, which can reproduce and evolve much more rapidly than a cow or a human, such similarity is providential. More-importantly, COVID-19 shares its spike protein with these related coronaviruses.

Viruses infect humans by infiltrating our cells, attacking our mainframes, and making virus factories out of our own machinery. Coronaviruses in particular break into human cells by forging a key that fits perfectly into a lock on the cell membrane. This forged key is called the spike protein, and it lurks on the surfaces of Coronaviruses like a disguise. The spike protein binds to a receptor known as Angiotensin-Converting Enzyme 2 (ACE2) to enter our cells, akin to a Trojan horse presenting itself to the city gates and demanding entry.

ACE2 simply follows orders by directing a visitor with the proper passcode inside, but a vaccine can train the immune system to detect the spike protein before it reaches ACE2. The Oxford, Pfizer, and Moderna vaccines all work to help the immune system recognize this nefarious protein before it can attack cells.

Luckily, the spike proteins of SARS, MERS, and COVID-19 are all relatively similar.⁸ In addition, 5

SARS spike proteins bind to the same ACE2 receptor that COVID-19 does. Thanks to the researchers who did not give up on researching SARS or MERS in the face of low interest, scientists did not have to start from scratch when developing COVID-19 vaccines. For example,

“THEY ARE STANDING ON

A VAST PYRAMID OF UNDER-APPRECIATED SCIENTISTS PUTTING THEIR TIME INTO WHAT AN UNINFORMED CYNIC WOULD CALL “USELESS RESEARCH.”

spike proteins tend to shapeshift, but researchers at Scripps were able to immobilize it with a patented “2P mutation” involving the addition of 2 amino acids.⁹ This was in 2017, two years before the first case of COVID-19 was detected. While it is understandable to question how the scientific community was able to create a safe and effective vaccine for a virus unknown to mankind eighteen months ago, it is important to understand that the real work began much earlier. Vaccine teams from AstraZeneca to Oxford are not standing on the

shoulders of giants; they are standing on a vast pyramid of under-appreciated scientists putting their time into what an uninformed cynic would call “useless research.”

The speed at which science developed a safe and effective COVID-19 vaccine is a triumph, but the response could have been even better.

According to Dr. Peter Hotez at the Baylor College of Medicine in a testimony to the Committee on Science, Space, and Technology, his team could have had a vaccine ready by early March of 2020, millions of deaths ago.¹⁰ His teamsʼ SARS vaccine had lain idle in a freezer for over four years;¹¹ few investors would agree to fund the clinical trials on humans for a vaccine that would be stockpiled rather than distributed. If the vaccine had been deemed safe and effective before the pandemic, it might have needed minimal modifications before it was ready for distribution. This claim is admittedly speculative, but Dr. Hotezʼs testimony makes it clear that we can do better than we are.

Investors did not stray away from Dr. Hotez out of sadism. As outlined above, in times of epidemic peace research funding is based on economic viability. However, the problems with such a model extend far beyond the current

COVID-19 pandemic. For example, retroviruses exploded in popularity after the AIDS epidemic, but what would this health crisis look like if we had understood them better before it was too late? While chronic disease medicine brings in significant revenue, less profitable antibiotic research would benefit lower-income nations and stop outbreaks of drug-resistant infection from turning into global phenomena. Even if improving existing vaccines is not glorious, how many sick days (and lives) could we save with a better flu vaccine?

In a 2015 article in the New England Journal of Medicine, Drs. Stanley Plotkin, Adel Mahmoud, and Jeremy Farrar made a similar observation.¹² These scientists agree that preliminary research into vaccines is strong, but there is a lack of market incentive to conduct the additional studies that would prepare a drug for human use. If the market cannot be bothered to invest in these vaccines, the three argue that an international vaccine development fund is the best option for prioritizing global health over immediate economic return. In 2017, the authors and other contributors formally launched the Coalition for Epidemic Preparedness Innovations (CEPI) to focus on overlooked priority pathogens that could prepare the global health community for the next pandemic.¹³ This included research funding for MERS vaccines. Before the pandemic in the year 2019, CEPI collected donations from the Bill and Melinda Gates Foundation, in addition to some countries in Europe and Asia (not the United States), which amounted to 211 million US dollars.¹⁴ For reference, the New England article states that it would cost at least 500 million US dollars to develop a single vaccine of minimal complexity. By February 2020, CEPI had raised much more thanks to a reactionary influx of donations from Australia, Belgium, Canada, and the UK.¹⁵ Unfortunately, it was too

Created with Biorender.com. late to prevent this pandemic.

Beyond research with a purely prophylactic purpose, it is also important to observe the serendipitous nature of scientific innovation.

Think about it like this: the scientific paper outlining the mRNA vaccine for COVID-19 had about 30 references. Assuming each of those papers referenced 30 articles, one could say that the vaccine drew off the work of 900 papers. The connections grow exponentially from there, extending far beyond the field of vaccinology or virology. After going down a rabbit hole of reference sheets, one can discover that 1970s studies on wheat germ proteins are separated from the mRNA COVID-19 vaccine article by five levels of citation. That perspective makes plenty of labs, even labs with no immediate medical application, seem like stepping

“WHAT KEEPS RESEARCHERS MOTIVATED IF KLEOS, Diagram explaining how SARS-CoV-2 enters a human cell.

Acknowledgements to Glaunsinger Lab: Jessica M Tucker, Britt A Glaunsinger et al.

(Content Experts). Created in Biorender.com.

6

OR HEROIC GLORY, IS NEVER GUARANTEED? INDEPENDENTLY GENERATED, GENUINE PASSION? COFFEE? A MIXTURE OF DISCIPLINE AND CONTENTMENT?”

7

stones to breakthroughs.

140523-mers-vaccine-camels-virus-flu-saudi-pandemic-science#close. Accessed March 1, 2021.

Although it is natural human instinct to want your work to be instantly meaningful, many researchers (and funding sources) retire unaware of the future applications their findings hold. The role of a researcher thus holds an immense capacity for impact, even in the face of uncertain rewards. What keeps researchers motivated if kleos, or heroic glory, is never guaranteed? Independently generated, genuine passion? Coffee? A mixture of discipline and contentment? Importantly, how do we transfer this grit to investors who can be dissatisfied with taking long and winding roads to an answer?

6. EXPERT COMMITTEE ON BIOLOGICAL STANDARDIZATION Geneva, 19 to 23 October 2020.

Thereʼs a reason trauma hospital shows a la Greyʼs Anatomy get produced while a primary care clinic show might not get a pilot. Thereʼs a reason history textbooks list names of generals who finished wars but neglect to mention the diplomats who stopped a war before it started. Something feels more glorious about reacting to something, rather than acting to prevent it. Despite this instinct, we still want to feel prepared for what comes next. We demonize procrastination, but we only start appreciating a Girl Scout with a first aid kit when we need it. The process of refocusing research to be proactive, rather than reactive, fundamentally goes against human nature, yet logic shows us that itʼs worth it.

10. Beyond Coronaviruses: Understanding the Spread of Infectious Diseases and Mobilizing Innovative Solutions.

References

7. Humans share almost all of our DNA with cats, cattle and mice | The Independent | The Independent. https:// www.independent.co.uk/news/science/human-dnas h a re - c a t s - c a t t l e - m i c e - s a m e - g e n e t i c s - c o d e a8292111.html. Accessed March 1, 2021.

8. Zhu Z, Lian X, Su X, Wu W, Marraro GA, Zeng Y. From SARS and MERS to COVID-19: a brief summary and comparison of severe acute respiratory infections caused by three highly pathogenic human coronaviruses. Respir Res. 2020;21(1):224. doi:10.1186/ s12931-020-01479-w 9. They spent 12 years solving a scientific puzzle. It yielded the first COVID-19 vaccines. https://www.nationalgeographic.com/science/article/these-scientistsspent-twelve-years-solving-puzzle-yielded-coronavirus-vaccines. Accessed March 1, 2021.

11. Scientists were close to a coronavirus vaccine years ago. Then the money dried up. https://www.nbcnews .com/health/health-care/scientists-were-close-coronav i r u s - va c c i n e - ye a r s - a g o -t h e n - m o n e y - d r i e d n1150091. Accessed March 1, 2021.

12. Plotkin SA, Mahmoud AAF, Farrar J. Establishing a Global Vaccine-Development Fund. N Engl J Med. 2015;373(4):297-300. doi:10.1056/NEJMp1506820 13. CEPI | New Vaccines For A Safer World. https:// cepi.net/. Accessed March 1, 2021.

14. Annual Progress Report Covering the period from: 1 January to 31 December 2019. https://cepi.net/wp-content/uploads/2020/04/CEPI-Annual-Progress-Report-2019_website.pdf.

15. Inovio Pharmaceuticals (INO) Is Building a Coronavirus Vaccine Bloomberg. https://www .bloomberg.com/news/articles/2020-02-13/this-oslofacility-may-be-the-key-to-the-coronavirus-vaccine.

Accessed March 1, 2021.

1. Hilgenfeld R, Peiris M. From SARS to MERS: 10 years of research on highly pathogenic human coronaviruses.

Antiviral Res. 2013;100(1):286-295. doi:10.1016/j.antiviral.2013.08.015 2. Shi Z, Hu Z. A review of studies on animal reservoirs of the SARS coronavirus. Virus Res. 2008;133(1):74-87. doi:10.1016/j.virusres.2007.03.012 3. Cho H, Excler J-L, Kim JH, Yoon I-K. Development of Middle East Respiratory Syndrome Coronavirus vaccines - advances and challenges. Hum Vaccin Immunother.

2 0 1 8 ; 1 4 ( 2 ) : 3 0 4 - 3 1 3 . doi:10.1080/21645515.2017.1389362 4. WHO | Middle East respiratory syndrome coronavirus (MERS-CoV) – The Kingdom of Saudi Arabia. https:// www.who.int/csr/don/24-february-2020-mers-saudiarabia/en/. Accessed March 1, 2021.

5. Why a MERS Vaccine Wonʼt Be Easy | Innovators. https://www.nationalgeographic.com/science/article/

8

9

The Mature Minor Doctrine: When Can Teenagers Medically Consent? We Must Expand their Rights, But We Cannot Draw a Hard Line Eighteen is the age of majority, but there is legal precedent and scientific evidence to lower the minimum age at which teenagers can make their own healthcare decisions. Creating a new minimum age has itʼs own challenges, though—creating a hard cutoff may not be just to adolescents approaching the cutoff age. Instead, this article argues in favor of a slightly altered framework involving a new minimum age to make healthcare decisions.

Kathleen Li Public Health Studies Class of 2022

A

t what age can you make your own medical decisions? Last year, a 22 year old woman named Cassandra Callendar died after battling cancer.¹ She had first become nationally famous at seventeen in a Connecticut court case where she was forced to undergo chemotherapy against both her and her motherʼs wishes. The government has the legal authority to dictate the healthcare decisions of minors like Callendar in a way they could not for an adult--but some states have laws to give these rights to minors if they are sufficiently “mature.”² However, the Connecticut court ruled that Callendar was not.¹ Thus, Callendarʼs case raises the question: should more teenagers close to the age of majority be allowed to make their own healthcare decisions, not just ones the court deems mature?

And on the other hand, is there some benefit to our current system where we decide maturity on a case-to-case basis?

abortion. In his dissent on the 2005 Roper v Simmons case, Supreme Court Justice Scalia points out this supposed double standard. He questioned how we can judge minors incapable of adult reasoning when they commit crimes, yet allow them to make health care decisions for themselves.⁸ These sometimes contradictory laws have thus complicated the healthcare decision making process for minors making unorthodox healthcare choices or ones against their guardianʼs wishes. Each system seems to have different definitions for when a minor is mature enough to understand their decisions.

The American Psychological Association (APA) wrote the amicus briefs that Justice Scalia accused of being contradictory and produced a response about their apparent “flip-flop.” In regards to Roper v Simmons, the APA argues that adolescent crimes may be committed out of

“SHOULD MORE TEENAGERS CLOSE TO THE AGE OF MAJORITY BE ALLOWED TO MAKE THEIR OWN HEALTHCARE DECISIONS, NOT JUST ONES THE COURT DEEMS MATURE?”

Callendarʼs case stands in stark contrast to other applications of the mature minor doctrine, and the existence of this doctrine is at ideological odds with federal law. Historically, this doctrine has been applied to teenagers fifteen years old or older, but some states now apply it to minors they deem able to give informed consent or otherwise sufficiently “mature.”²,³ Furthermore, the existence of the mature minor doctrine is furthermore complicated

by Supreme Court cases like Roper v Simmons that have ruled that the death penalty or lifetime imprisonment without parole for minors is unconstitutional because adolescents are less mentally developed than adults.⁴-⁷ In these cases, minors were judged to be less mature than adults and therefore not deserving of the same punishment. This stands in contrast to cases like Hodgson vs Minnesota, where adolescents are considered to be sufficiently developed to make these decisions in the case of

passion or emotion. Since frontal lobe development is thought to curb impulses and adolescents have less frontal lobe development than adults, the APA argues that adolescents simply cannot be held responsible for their actions to the same degree as an adult.⁹, ¹⁰ They cite evidence of increased risk taking, sensation seeking, susceptibility to peer pressure, and MRI scans of the underdeveloped frontal lobe. Contrastingly, in the case of Hodgson v.

Minnesota, the APA argues that abortions, and presumably other health decisions, are not usually committed in the heat of the moment.

When removed from this heightened emotional context, the adolescent brain is developed enough to properly consider healthcare decisions.¹⁰ Adolescents are thought to be cognitively but not emotionally mature. Thus, given enough time, an environment with low emotional arousal, and the opportunity to talk with an adult expert, adolescents can make mature 11

decisions.

Research supports the APA claim that a situation with lessened emotional arousal and no peer influence can be helpful when adolescents need to make a mature decision. These situations activate “cold cognition,” which may be achieved with proper counseling and communication of the adolescentʼs medical situation.¹¹-¹³ This occurs in contrast to the “hot cognition,” activated during emotional situations or circumstances where peers are present.

During times of “hot cognition,” adolescents display the same impulsiveness and lack of consideration for consequences that opponents of the mature minor doctrine fear. A complicating factor regarding this theory is that adolescents in “cold” situations may become impulsive again when peers are reintroduced or the situation becomes emotional.

Nevertheless, the application of this hot and cold cognition theory may allow minors the right to make their own medical decisions in sufficiently calm situations.

Indeed, recognition of these differing types of cognition has led some researchers to recommend multiple legal age boundaries––one for decisions made in “cold” situations and one for “hot” ones. In an article published in an APA journal, researchers recommend the ages of 16 and 18, respectively.¹⁴ Their study found that cognitive capacity, the ability to reason logically, plateaued around age 16 even as psychosocial maturity continued to increase.

Since psychosocial maturity includes an individualʼs ability to regulate their emotions, full psychosocial maturity would not be necessary in “cold” situations. Only the age at which cognitive capacity matters––age 16––would matter.

By this proposed law amendment, the 17 year old Callendar would have been able to decline chemotherapy like she wanted, if she demonstrated she would make this decision in a “cold” context. This system of two legal ages would be excellent at expanding decisionmaking capacity to groups we know to have adult levels of cognitive capacity. However, the 12

issue of the Callendar case is not only that she likely had the capacity but was overruled. Another discomforting aspect is that Callendar was close to majority, the age at which she would be able to make her own choices. If we were to make 16 the new age one can make healthcare decisions without keeping some flexibility in this framework, 15 year olds may similarly be disempowered. It should be noted that while Callendar did continue with chemotherapy even after she became an adult, her family argues that her choice at 17 should have also been respected.¹ And although the research used to argue for the legal age for independent medical decision making to be moved to 16 may demonstrate a cognitive capacity gap between 14-15 and 16-17 year olds, there is variation within age groups. Some adolescents under 16 may have adult-levels of cognitive capacity. They should also be allowed to make their own healthcare decisions. As such, the Callendar case can both support the lowering of legal age to medically consent, but also cautions the existence of an inflexible age boundary.

“THESE PROTECTIONS

SHOULD BE APPLIED ON A CASE-BY-CASE BASIS FOR TEENAGERS WITH CLOSE TO ADULT LEVELS OF COGNITIVE CAPACITY” Establishing this legal minimum age may also threaten the health of minors in states with mature minor doctrines who allow adolescents under 16 to make healthcare decisions. This doctrine is not only applied to cases where teenagers can refuse lifesaving treatment, though those cases may headline the news. It and adjacent laws allow minors to seek out immunizations, abortions, and drug treatment without parental consent.²,¹⁵ Adolescents can thus better protect their health by seeeking out these services, even when their parents are opposed or when they do not want their parents to know. In this way, making 16 the mini-

mum age to medically consent could be harmful when younger adolescents may need them.

Setting the minimum age for medical consent to 16 still should be implemented, despite these possible flaws. Research has shown that these mid-adolescent minors are capable of logical decision making, and therefore they should be given the rights to decide on their own treatments. Furthermore,the mature minor doctrine has only been adopted by a select few states. If the age for medical consent was established in more or all states, this would be greatly beneficial for minors who want to and are capable of making their own healthcare choices. This especially adds another layer of protection to more stigmatized issues like abortions, where politically charged courts may exploit a subjective definition of “maturity” to deny minors care.² However, we still must include some flexibility in this law for cases where younger people need to make their own healthcare decisions. If abortions or drug treatment were also affected by this law, some adolescents under 16 may not seek out the treatment they need. These cases may require special exceptions to be built into the law.

And for cases where individuals under the legal age may have the cognitive capacity to medically consent, we already have a similar system that should be applied alongside this new minimum age. One cannot deny that the mature minor doctrine often seems unevenly or confusingly applied, like in Cassandra Callendarʼs case, but a combination of this new law with the doctrine would be better at addressing situations like hers.

A new legal age for “cold” situations like medical consent will protect the decision making rights for minors under 18. But for younger adolescents, we need to build in further protections. Besides building in exceptions for certain treatments or medical procedures, these protections should be applied on a caseby-case basis for teenagers with close to adult levels of cognitive capacity. This was the ethos of the mature minor doctrine––and now, in this new framework, still is.

References 1. Eaton-Robb P. Cassandra Callender, forced to undergo chemo, dies at 22. ABC News. https://abcnews.go .com/Health/wireStory/cassandra-callender-forced-undergo-chemo-dies-22-70682187. Published May 14, 2020. Accessed March 6, 2021.

2. Coleman DL, Rosoff PM. The legal authority of mature minors to consent to general medical treatment. Pediatrics.

2013;131(4):786-793. doi:10.1542/ peds.2012-2470 3. Holder AR. Legal Issues in Pediatrics and Adolescent Medicine. 2nd ed. New Haven, CT: Yale University Press; 1985 4. Roper v. Simmons, 541 US 551 (2005) 5. Graham v. Florida, 560 US (2010).

6. Miller v. Alabama, 567 US (2012).

7. Levesque R.J.R. (2018) Mature Minor Doctrine. In: Levesque R.J.R. (eds) Encyclopedia of Adolescence.

Springer, Cham 8. Roper v. Simmons, 541 US 551 (2005) (Scalia, J., dissenting).

9. Brief for the American Psychological Association, and the Missouri Psychological Association as Amici Curiae Supporting Respondent, Roper v. Simmons, 541 US 551 (2005) 10. Steinberg L, Cauffman E, Woolard J, Graham S, Banich M. Are adolescents less mature than adults?: minors' access to abortion, the juvenile death penalty, and the alleged APA "flip-flop".

Am Psychol.

2009;64(7):583-594. doi:10.1037/a0014763 11. Silber TJ. Adolescent brain development and the mature minor doctrine. Adolesc Med State Art Rev. 2011;22(2):207-viii.

12. Grootens-Wiegers P, Hein IM, van den Broek JM, de Vries MC. Medical decision-making in children and adolescents: developmental and neuroscientific aspects.

BMC Pediatr. 2017;17(1):120. Published 2017 May 8. doi:10.1186/s12887-017-0869-x 13. Steinberg L. Does recent research on adolescent brain development inform the mature minor doctrine?. J Med Philos. 2013;38(3):256-267. doi:10.1093/jmp/ jht017 14. Icenogle G, Steinberg L, Duell N, et al. Adolescentsʼ cognitive capacity reaches adult levels prior to their psychosocial maturity: Evidence for a “maturity gap” in a multinational, cross-sectional sample. Law and Human Behavior. 2019;43(1):69-85. doi:10.1037/lhb0000315 15. Sigman GS, O'Connor C. Exploration for physicians of the mature minor doctrine. The Journal of Pediatrics.

1991;119(4):520-525.doi:10.1016/ s0022-3476(05)82398-4

13

A Desperate Need for Change: Public Health & Medical Measures in Vietnamʼs Van Mon Village A brief look into Vietnam's leprosy crisis, why it's being exacerbated, and the role public health should play in alleviating these medical disparities.

Volunteering in Vietnam he summer before my freshman year at Hopkins, I saw firsthand the importance of overcoming socio-cultural divides to provide comprehensive medical care in Vietnam. As the daughter of two immigrants from this medically disadvantaged country, I wanted to explore a healthcare system different from my own.

T

Spurred by this curiosity, I volunteered to care for individuals affected by leprosy (or Hansenʼs Disease) in Van Mon, a small village in the remote countryside of Northern Vietnam. My time working in this 400-resident community designated specifically for leprosy patients further highlighted the barriers that prevent patients from seeking immediate medical care.

Because there are few resources in place for those suffering from this treatable condition, individuals affected by leprosy are separated into colonies far away from the general population.

With little to no early detection or education programs in place, many in this hospice had not sought treatment before their symptoms

“MR. VU, ONE OF THE

ELDERLY PATIENTS WHOSE FAMILY HAD ABANDONED HIM, FEARED THE DISCRIMINATION HE WOULD FACE OUTSIDE THE WALLS OF THE COMPOUND AND THE BURDEN HE WOULD PLACE UPON SOCIETY.”

Kristine Nguyen Molecular & Cellular Biology and Public Health Studies Class of 2022

became irreversible. Further, the stigmatization against this community meant that they remained ostracized and physically isolated from society. Outcasts because of their appearance, patients are forgotten by their family and the outside world, and left completely dependent on their government caretakers. With a meager monthly stipend of $9 USD per resi-

dent,¹ necessary resources are scarce, and it is clear that leprosy and poverty are inextricably linked. These communities suffer from poor sanitation, inadequate food and housing, and overall faulty healthcare.

Beyond this, the physical barriers that limit patients intensify the sense of marginalization, translating into emotional and social disconnects. Mr. Vu, one of the elderly patients whose family had abandoned him, feared the discrimination he would face outside the walls of the compound and the burden he would place upon society. By helping him perform daily tasks such as getting dressed and consuming meals, I hoped to at least alleviate the physical aspects of his hesitancy to reintegrate into the community.

Although patients accepted their situations and strove to maintain a better outlook, I was bothered by the fact that they hadnʼt been helped earlier, before their condition became irreversible. I became curious about who was making the decisions related to public health and if there were any policies or medical procedures in place to target and prevent this ailment.

The Issue at Hand Leprosy, a chronic infectious disease affecting the skin and the nerves, is mostly unheard of in developed countries.² Incidence occurs at all ages and can result in permanent deficits, although early treatment can prevent disability.

On average, there are 150 to 250 annual cases of Hansenʼs Disease in the United States (as opposed to over 1,000 cases in Vietnam).³ The issue of this devastating illness has been recently revived due to unrecognized cases among immigrants, increased global travel to endemic countries, and the rising number of social and health workers joining international leprosy relief projects. In 1991, the World Health Organization (WHO) set a goal to achieve the global elimination of leprosy as a public health problem by the year 2000,⁴ which was later extended to 2005. Still, this goal is far from being achieved.⁵ 15

Necessary Changes The struggle to eliminate such a complex and destructive infectious disease does not end with the cure, as deep-seated medical and social problems remain. In order to improve conditions, a variety of community-based approaches can be taken.

From the start, increased awareness and active detection of latent or hidden cases in remote regions can prevent permanent nerve damage or disability. This would require trained grassroots health workers and highly dedicated volunteers. Leprosy control operations and elimination monitoring inspection systems with trained staff, in addition to improved information and communication systems could promote awareness and self-reporting of new cases. Further, improvements in living conditions will also be necessary to produce a reduction in the risk factors of poverty. With proper sanitation measures, we can avoid facilitating bacterial growth that propagates and worsens Hansenʼs Disease.

“ENACTING THESE COM-

MUNITY-CENTERED INITIATIVES COULD PROVIDE LASTING CHANGE AND TRUE HEALING.” The majority of the patients in Van Mon were simply not treated in a timely manner, leading to perpetual disability. Thus, the creation of set standards for leprosy indicators should be implemented, such that early case detection is possible and management of disabilities can occur before irreversible effects take place.

Further, having increased access to multidrug therapy (MDT),⁷ as well as improved administration of this drug, can decrease disease incidence.

Finally, the refutation of myths and stigma is essential to foster social rehabilitation and the integration of cured patients back into society.

This process can be streamlined by long-term

social programs such as low-cost shelters providing material support and emotional security, as well as expanded job opportunities to secure independence and food sufficiency/clean drinking water.

Many antileprosy operations currently in place have been able to raise awareness and understanding of this issue; however, much work toward the full elimination of leprosy remains.

This public health problem encompasses both medical and social components, as its victims are plagued with persistent physical disabilities and deformities which result in poverty and discrimination. Through my volunteering, I gained an awareness of the gaps in resources and their implications in other cultural regions.

The preventable progression of disease associated with an absence of care demonstrates a loss of hope, but I envision redemption. Enacting these community-centered initiatives could provide lasting change and true healing. I am determined to pursue further information pertaining to these underlying issues, and look forward to the day when disparities in healthcare across countries can be alleviated.

References 1. The Straits Times | Van Mon Leprosy Village in Vietnam. January 25, 2019. https://www.straitstimes.com/ multimedia/photos/in-pictures-van-mon-leprosy-hospice-in-vietnam 2. Abdurrahman M, Keystone JS. Leprosy, Recognizing Hansen's disease today—the bell tolls quietly. Parkhurst Exchange 2006;14:88–92.

3. CDC: https://www.cdc.gov/leprosy/transmission/index .html 4. World Health Assembly. Elimination of leprosy: resolution of the 44th World Health Assembly. Geneva, 6–16 May 1991 (Resolution No WHA 44.9).

5. Lockwood DNJ, Suneetha S. Leprosy: too complex a disease for a simple elimination paradigm. Bull World Health Organ 2005;83:230–5.

6. Nguyen, N., Tat Nguyen, T., Hong Phan, H., & Tam Tran, T. (2008). Leprosy: ongoing medical and social struggle in Vietnam. Journal of cutaneous medicine and surgery, 12(4), 147–154. https://doi.org/ 10.2310/7750.2008.07058 7. WHO Multidrug Therapy (MDT). (2016, September 15). https://www.who.int/lep/mdt/en/

Living quarters and retention pond for residents of Van Mon village.

Image courtesy of Macksey, 2014⁸ 16

8. Macksey, E. (n.d.). Ho Chi Minh Photographer: Van Mon: A Forgotten Existence. http://www.ehrinmacksey .com/Stories/Van_Mon.html

17

Exploring Maternal Health Challenges in Uganda: A Case Study of the Rural Rakai Village.

Uganda is an Eastern African country with high maternal mortality and complications rates.

In January 2020, a group of Johns Hopkins and Makerere University undergraduates joined forces in a unique mentorship program to study various public health topics in a rural Ugandan village. Suzan and Mackenzie studied maternal health, and their qualitative findings in the field reflected the numbers.

Mackenzie Simon-Collins Public Health Studies Class of 2023 Suzan Nakalawa Makerere University Class of 2020

U

ganda, a low-income developing nation in Eastern Africa, faces one of the highest maternal mortality rates in the world.

For every 100,000 live births in 2016, 336 mothers lost their lives due to a multitude of public health factors.¹ The rates of medical complications experienced after birth are even higher. Among the major causes of poor maternal health care in Uganda are access to reproductive and maternal services, poor nutrition practices, lack of access to HIV and AIDs services, and poor water, sanitation and hygiene practices (WASH).

In January 2020, a group of Johns Hopkins Public Health Studies majors embarked on a journey to Uganda to study different health-related topics. Small groups pairing up Johns Hopkins and Makerere University students were formed and each group selected a focus topic. Suzan and I studied maternal health in Uganda through a series of lectures, site visits, and interviews with community members. We hope our qualitative maternal health findings can demonstrate the importance of public health innovation and policy in developing nations like Uganda.

“WE IMMEDIATELY

NOTICED THAT THERE WAS NOT ENOUGH SPACE TO ACCOMMODATE ALL OF THE PATIENTS IN TERMS OF BOTH QUALITY AND LENGTH OF CARE COMPARED TO MEDICAL RECOMMENDATIONS.” length of care compared to medical recommendations. In light of these tight space conditions, mothers and their families tend to stay for extremely short durations of time. Although mothers who give birth via cesarean section are advised to stay in the hospital for 3-4 days following surgery by most experts––or at the very least 24 hours––the head nurse told us that many women leave after only a few hours.² The lack of education about post-surgical proper hygiene has caused some of these c-

Ten days of the trip to Uganda were spent in the rural area of Rakai, Uganda. Like in most countries, rural areas tend to experience more serious medical and public health challenges compared to urban areas, making Rakai an interesting place to study. The goal of this portion of this trip was to both observe and assimilate into the culture of Rakai, which included living with homestay families, who were just as excited to learn about our culture too. While in Rakai, we had the opportunity to tour Kalisizo Hospital, listen to expert lectures about public health programs, and interview our homestay mothers to hear about their personal experiences in maternal health care.

Tour of Kalisizo Hospital The overall conditions of the Kalisizo Hospital maternity ward were not favorable. Entering the main room, we immediately noticed that there was not enough space to accommodate all of the patients in terms of both quality and

The crowded maternity ward at Kalisizo hospital.

19

section mothers to return to the hospital with severe infections in the surgical wound area.

Infection rates in these wounds are increased by obesity, which creates folds in the skin that bacteria can thrive in. Moreover, the maternity ward is so overwhelmed with patients that some sit on the floor or wait outside before they can receive their own bed. Although the hospital is doing the best it can with the funding that they are provided, the maternity ward nevertheless lacks proper patient isolation. If any patient or their family member is experiencing symptoms of a dangerous illness, it is likely to spread within the ward.

Besides the cramped space and absence of patient isolation, the maternity ward lacks the supplies (medications, gauze, cotton wool, gloves, etc.) necessary to allow for every woman to have a safe birth. To combat this issue, mothers can privately buy “mommy kits” with these supplies and bring them to the ward for their delivery. However, not every woman is capable of purchasing these kits. The mothers

who are unable to bring their own “mommy kits” will not receive the same level of sanitary care as other patients, leading to increased risk of infection. If the patient presents with any bleeding or complications, there may not be an adequate amount of supplies for her if she does not bring her own kit. Moreover, the maternity ward lacks medical instruments like stethoscopes; instead, simplified tools (such as agricultural cones) and gloved hands take their place.

The Kalisizo Hospital as a whole faces an alarming number of sanitation issues. For example, medical tools are sanitized in buckets of bleach for twenty minutes and do not go through the rigorous inspection process performed in more economically developed countries such as the United States. Healthcare providers do not always wear gloves and hands are seldom washed in the ward. Additionally, there is a poorly covered pit outside of the ward where placentas are thrown to decay just a few feet from the street, posing even more of a problem to general public health in the area.

We also witnessed issues in the maternal health of underage girls. Most of the women in the maternity ward were between fifteen and eighteen years old. Most of these pregnant girls either drop out or are expelled from school. Some girls lack basic necessities like food and thus engage in sexual acts or early marriages. The antenatal, delivery, and postnatal times require certain necessities and most of these young girls lack the means to attain these. We observed some of them reusing dirty children's clothes, and most of them lacked general infant requirements like diapers, baby sheets and blankets.

The few medical tools available in Kalisizo hospital are sanitized in bleach buckets.

20

In Uganda, many adolescent girls fall victim to early pregnancies, leading to greater maternal and newborn complications. Due to poverty and other socioeconomic factors, these girls drop out of schools and engage in early sex with fellow peers or with older men, who may or may not provide support to mother and child, leading to increased teen pregnancies. In comparison with other sub-Saharan countries,

“DUE TO POVERTY AND OTHER SOCIOECONOMIC

FACTORS, THESE GIRLS DROP OUT OF SCHOOLS AND ENGAGE IN EARLY SEX WITH FELLOW PEERS OR WITH OLDER MEN, WHO MAY OR MAY NOT PROVIDE SUPPORT TO MOTHER AND CHILD, LEADING TO INCREASED TEEN PREGNANCIES.” Uganda has elevated rates of early pregnancies and births. In 2015, 1 in 3 young women (20-24) were recorded to have already given birth.³ During one site visit, we learned about a Rakailocated program combatting the unique issues facing young women. Besides teen pregnancy, young Ugandan women often struggle with abuse, poor/no education, or lack of familial support. Among its different projects and health camps, the Rakai Health Sciences Program has an initiative called the DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) project. Under this project young girls (underage pregnant girls inclusive) are taught tailoring, hair dressing, and arts and crafts skills in order to empower them with the skill set necessary to generate their own income. After acquiring these skills, these young girls then choose whether they will go back to school or start up their own small businesses.

While in this program, young women who are pregnant or have small children are fully supported to pursue their dreams.

Personal Experiences from Two Rakai Mothers To continue our exploration of maternal health in Uganda, we interviewed two of our host mothers about pregnancy, childbirth, gynecological care, and birth control. Prossy and Jane are two women living near Rakai, Uganda.

Prossy has four children and Jane has three children. They had normal deliveries with no complications. However, they cited blood loss as a common complication experienced by Ugandan mothers. Both mothers attended a primary checkup at four months pregnant.

They had four additional prenatal visits. While these women attended all five checkups, a re-

cent UNICEF study found that 90% of Ugandan mothers attend the first checkup but only 57% of these women attend the remaining four.⁴ At the first checkup, antimalarials were prescribed. At all five checkups an HIV test was performed on the mother and the father (if the father was present). Since the mothers had normal deliveries, only hot tea was provided as medication. Due to space constraints, Prossy left the hospital five hours after giving birth and Jane left after twenty-four hours. When asked about the quality of maternal care in Uganda, both cited lack of resources and medical supplies as a major area of concern.

We then asked Prossy and Jane about gynecological care and birth control in Uganda. While the mothers had similar birthing experiences, their experiences with gynecological care and birth control differ. Prossy has only been to the gynecologist for UTI and STI complications.

Jane did not mention visits to the gynecologist.

There was no mention of annual gynecological wellness exams, which are a health standard

This NICU incubator is often used to accommodate four premature infants at once.

21

abroad. Prossy proudly said she uses birth control for family planning. Jane said she did not use any family planning and does not know anyone who does.

Concluding Thoughts Suzan and Iʼs observations in Rakai, Uganda reflected a rural experience in the Ugandan maternal health care system. Although our experiences do not reflect all of Uganda, it does reflect a common occurrence for many Ugandan women living outside of major cities.⁵ Many Ugandan health care problems result from lack of resources; for example, mothers are responsible for their own “mommy kits” during birth, which contain life-saving equipment like cotton pads for bleeding. Similarly, rural hospitals struggle with sanitation and adequate medical instruments from lack of funding. Maternal childhood mortality can be prevented through promoting reproductive, maternal and neonatal health, nutrition, HIV and AIDS, and Water, Sanitation and Hygiene (WASH) among the community and especially for pregnant women.

Thankfully, there are programs funded by the Bill & Melinda Gates Foundation, several countries, and multiple universities, including Johns Hopkins. These research programs are solving major issues in Ugandaʼs health sector, ranging from tropical diseases and HIV/AIDS to water systems and garbage collection.⁶ Similarly, Ugandan programs like DREAMS are empowering young women with skills and education to overcome socioeconomic challenges in rural communities. Suzan and I have great hope that mother and child mortality and complication rates will decrease from the great humanitarian efforts of all these programs.

c ove r y/ # : ~ : t ex t = Re c ove r i n g % 2 0 i n % 2 0 h o s p i t a l ,painkillers%20to%20reduce%20any%20discomfort> [Accessed 8 March 2021].

3. UNICEF. 2021. Maternal and Newborn Health Disparities Uganda. [online] Available at: <https://www.google .com/url?q=https://data.unicef.org/wp-content/uploads/ c o u n t r y_ p r o f i l e s / U g a n d a / c o u n t r y % 2 5 2 0 p r o file_UGA.pdf&sa=D&source=editors&ust=1615240876358000&usg=AOvVaw0ttsaKrAfsjZQweAVvAABv> [Accessed 8 March 2021].

4. Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review. BMJ Open.

2019;9(10):e031890. Published 2019 Oct 7. doi:10.1136/ bmjopen-2019-031890 5. Munabi-Babigumira S, Glenton C, Willcox M, Nabudere H (2019) Ugandan health workersʼ and mothersʼ views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study.

PLoS ONE 14(3): e0213511. https://doi.org/10.1371/journal.pone.0213511 6. Sensalire S, Isabirye P, Karamagi E, Byabagambi J, Rahimzai M, Calnan J. Saving Mothers, Giving Life Approach for Strengthening Health Systems to Reduce Maternal and Newborn Deaths in 7 Scale-up Districts in Northern Uganda. Glob Health Sci Pract. 2019;7(Suppl 1):S168-S187. Published 2019 Mar 13. doi:10.9745/ GHSP-D-18-00263

References 1. Uganda Bureau of Statistics (UBOS) and ICF, 2018.

Uganda Demographic and Health Survey 2016. [online] Dhsprogram.com. Available at: <https://dhsprogram .com/pubs/pdf/FR333/FR333.pdf> [Accessed 8 March 2021].

2. United Kingdom National Health Service, 2019. Caesarean section - Recovery. [online] nhs.uk. Available at: <https://www.nhs.uk/conditions/caesarean-section/re-

22

23

Limited English Proficiency and Mental Health Outcomes Among Immigrants and Refugees in the United States: A Review of the Literature An addition to the growing literature on mental health disparities, this review seeks to characterize the body of research on the link between English language proficiency and mental health.

Charlie Nguyen Public Health Studies Class of 2021

F

oreign-born individuals comprise 13.7% of the U.S. population, a percentage which has grown within the last ten years.¹ With the foreign-born population expected to grow to 78 million by 2065,² greater attention to immigrants and refugee mental health is warranted.

Notably, immigrants and refugees face unique experiences, stressors, and needs that increase their risk for poor mental health outcomes.³ One dimension of the immigrant and refugee experience that may influence mental health outcomes is English language proficiency, with prior studies demonstrating its relationship with self-reported health.⁴,⁵ Some explanations for this relationship include difficulties in accessing quality health care, low treatment adherence, and low utilization of preventive care due to language barriers.⁶,⁷ An important framework for understanding the potential relationship between English proficiency and mental health outcomes, however, is that of acculturative stress. Berry (2006) defines acculturative stress as “a response by people to life events that are rooted in intercultural contact [acculturation].”⁸ In his acculturative stress model, the experience of acculturation at the group level is appraised at the individual level before long-term adaptation is achieved. Depending on contextual and individual factors prior to and during acculturation, stressors arising from these intercultural conflicts may be overwhelming and lead to immediate mental effects such as depression and anxiety. Indeed, empirical research has demonstrated that acculturative stress does have implications for mental health among immigrants.⁹ From this lens, the discrepancy between an immigrant or refugeeʼs native language and the language of the host country is an acculturation experience; the experience of stress during acculturation is moderated by the individualʼs proficiency in the host country language.

Using the acculturative stress model as a framework, one might hypothesize that lower levels of English proficiency are associated with immediate mental health outcomes

among U.S. immigrants and refugees. With 46.4% of the U.S. foreign-born population speaking English less than very well,¹⁰ insight on the relationship between LEP and mental health outcomes may help to inform health eq-

“DEPENDING ON

CONTEXTUAL AND INDIVIDUAL FACTORS PRIOR TO AND DURING ACCULTURATION, STRESSORS ARISING FROM THESE INTERCULTURAL CONFLICTS MAY BE OVERWHELMING AND LEAD TO IMMEDIATE MENTAL EFFECTS SUCH AS DEPRESSION AND ANXIETY.” uity policies through language access. Though there is already evidence to show that language assistance increases mental health service utilization for LEP individuals,¹¹ insight on the direct link between LEP and mental health outcomes could provide additional rationale for implementing language assistance.

To my knowledge, no studies summarize the current state of the literature on LEP and mental health among U.S. immigrants and refugees. To address this gap, this review aims to characterize the current state of the literature investigating the association between English proficiency and U.S. immigrant and refugee mental health outcomes.

Methods Search Methods and Study Selection PubMed and PsycInfo served as the databases for this literature review. The search strategy included the use of controlled vocabulary and keywords for three concepts: (1) English language proficiency, (2) mental health, and (3) immigrants and refugees individuals. Search 25

queries were tailored to each database, and filters restricted results to English articles published between January 2010 and November 2020.

Identified records were imported to Zotero, and duplicates were removed. Titles and abstracts were screened for potential eligibility, after which full-text versions of remaining articles were further assessed to determine final inclusion.

Eligibility Criteria English language peer-reviewed academic journal publications from January 2010 to November 2020 were included in this review.

Book chapters, conferences, theses, and case reports were excluded. Included articles must have examined the association between English language proficiency and mental health outcomes among immigrants and/or refugees of any age living in the U.S. Those focusing on bilingualism without addressing English proficiency were excluded. In this review, participants who had migrated to the U.S. from another country (or from a U.S. territory due to the potential exposure to acculturative stress upon migration) were considered immigrants.

Refugees included those forced to migrate to the U.S. due to the threat of persecution or conflict. In studies where immigrants and/or refugees were not the only participants, analyses must have stratified by nativity, in order to draw conclusions about mental health specifically in immigrants and/or refugees.

Data Items and Analysis Data extracted from publications included author, year, study design, sample size, sample population, English language proficiency measure, mental health outcome, mental health instrument, relevant findings, and reported limitations. For studies performing secondary data analyses rather than collecting their own data, the data source was also recorded. Risk of bias assessment was based on selected items from the Appraisal tool for Cross-Sectional Studies (AXIS tool).¹²

26

Results Study Selection The search strategy yielded 250 publications from PubMed and 80 studies through PsycInfo, resulting in 290 publications after removing duplicates. After title and abstract screening, 248 publications were removed, yielding 42 for full-text review. Six publications were excluded for including non-foreign-born individuals without stratifying analyses by nativity, and 1 was excluded for not focusing on the U.S. Twelve were excluded due to irrelevance to the research question, yielding a total of 23 final articles included in this review.¹³-³⁵ Characteristics of Included Articles Extracted data are summarized in this section.

Study Design and Sample All studies were cross-sectional, with eight performing secondary data analyses of nationally representative surveys.¹⁴,¹⁷,²⁰,²³–²⁶,²⁸ Among secondary analyses, the most common data source was the National Latino and Asian American Study (NLAAS), utilized by five studies.¹⁴,²⁰,²³,²⁴,²⁶ Other sources included the California Health Interview Survey (CHIS; n = 1), the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B; n = 1) survey, and the New Immigrant Survey (NIS; n = 1). While the ECLSB survey and the NIS are longitudinal sources, studies using them did not exploit their sourcesʼ temporal features (e.g., using only data from one wave).²⁵,²⁸ Immigrant and refugee sample sizes for relevant analyses ranged from 34 to 3,264, though one study did not indicate how many observations formed the basis of the analysis relevant to the current review.²³ Two studies utilized a sample including U.S. immigrants and refugees regardless of country of origin.²⁸,³⁵ Three studies used a sample of Latino and Asian immigrants.¹⁷,²⁰,²³ Thirteen studies used an Asian sample, with three focusing on Asians broadly and the others on specific subgroups,¹⁴,²⁴,²⁶ including immigrants and refugees from Burma,²⁹ China,¹⁹,³⁴ Korea,¹⁵,¹⁸,²¹,²²,²⁷ Vietnam,¹³ and Western Asia.¹⁶

Three studies used a sample of immigrants from the Americas, including one on Latina mothers generally,³¹ one on Brazilian immigrants,³⁰ and one on Puerto Rican migrants after Hurricane Maria.³³ Two studies focused on African immigrants, including one on Somali immigrants and one on Sub-Saharan African immigrants.³²,²⁵ Special populations studied included women (n = 3; 2 focused on mothers), refugees (n = 2), the Asian Americans labor force (n = 1), and LGBTQ asylum seekers (n = 1). Eleven studies focused on specific U.S. regions.¹³,¹⁵,¹⁷–¹⁹,²¹,²²,²⁷,²⁹,³⁰,³² Mental Health Outcomes Studied Sixteen studies examined the relationship between English proficiency and mood disorders,¹⁵,¹⁶,¹⁸,¹⁹,²¹–²⁵,²⁷–³¹,³⁴ with some explicitly examining depressive symptoms.¹⁴,¹⁵,¹⁶,¹⁸,¹⁹,²¹– , , – , ²³ ²⁵ ²⁷ ³¹ ³⁴ Five studies included anxiety disorders as an outcome¹⁸,²³,²⁴,²⁹,³³; two categorized post-traumatic stress disorder (PTSD) as an anxiety disorder,²³,²⁴ while two examined PTSD separately.²⁹,³³ Five studies examined psychological and general distress.¹³,¹⁷,²⁶,³³,³⁵ General mental health was examined by three studies.¹⁴,²⁰,³² Three studies examined substance use disorders, though one limited analysis to alcohol use disorder only.²⁹ Other unique outcomes are natural disaster-related distress,³³ somatic distress,¹³ and performance distress.¹³ Only one study made a distinction between lifetime and recent mental health outcomes.²³ Measures of English Language Proficiency All studies except one relied on self-reported English language proficiency. In 12 studies, this was measured using a single survey question.

In eight studies,¹⁵,¹⁹–²¹,²⁵,²⁹,³¹,³³ questions addressed multiple domains (e.g., speaking, reading, writing). Two studiesʼ²⁹,³¹ self-report

and colleagues' study was the only study to assess self-reported English proficiency using a binary response question rather than a Likert scale question.²⁶ In the only included study to assess English proficiency through a standardized examination, Murphy and colleagues utilized the Basic English Skills Test Plus (BEST Plus),³² an exam developed by the Center for Applied Linguistics to assess proficiency for English language education.³⁸ Mental Health Instruments Of the 14 studies to focus on depression as an outcome, six¹⁵,²¹,²⁷,²⁸,³⁰ utilized the Center for Epidemiologic Studies Depression Scale (CESD)³⁹ or a modified version. Notably, Bernstein and colleagues employed the CES-D-K,¹⁵ tailored to Korean culture.⁴⁰ Three studies¹⁶,¹⁹,²² measured depression using the Geriatric Depression Scale (GDS) or its short form.²⁹ Other depression instruments included the Patient Health Questionnaire depression module (PHQ-9),⁴² the Chinese American Depression Scale (CADS-9),⁴³ the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH–CIDI),⁴⁴ the Hopkins Symptom Checklist (HSCL),⁴⁵ the General Well-Being Schedule (GWBS),⁴⁶ and questions based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Instruments used by studies examining anxiety include Generalized Anxiety Disorder scale (GAD-7),⁴⁷ WMH–CIDI, HSCL, and GWBS. PTSD, specifically, was measured with the PTSD Checklist for DSM-5 (PCL-5)⁴⁸ and the Refugee Health Screener-15 (RHS-15).⁴⁹ Psychological distress was measured using both the 6-item and 10item Kessler Screening Scales for Psychological Distress (K6 and K10),⁵⁰ a 21-item version of the HSCL, and RHS-15. Carl and colleaguesʼ

“ALL BUT FOUR STUDIES FOUND A STATISTICALLY

SIGNIFICANT RELATIONSHIP BETWEEN ENGLISH PROFICIENCY AND MENTAL HEALTH OUTCOMES.” measures were based on the Asian American Multidimensional Acculturation Scale,³⁶ and one studyʼs²¹ measure was based on the Interagency Language Roundtable scale.³⁷ Singh

study³³ measured hurricane-related distress using the Post-Hurricane Distress Scale (PHDS).⁵¹ Substance use disorders were measured using WMH–CIDI and the Alcohol Use 27

Disorders Identification Test (AUDIT).⁵² In studies performing a secondary analysis of NLAAS data, general mental health was measured through a Likert scale survey question. Murphy and colleagues'³² instrument was based on the Short-Form Health Survey (SF-12).⁵³ Quality of Studies No study satisfied all AXIS checklist criteria.

The most commonly violated criterion was measuring both the risk factor and outcome correctly using instruments, typically due to the lack of a validated instrument to measure English proficiency. None of the studies demonstrated issues with using appropriate study design, defining the target population,

when analyses are stratified by ethnicity. Hong and colleagues find that poor or fair English proficiency was associated with any mood disorder among Asian Americans in their analysis of NLAAS data.²⁴ Leong and colleagues confirm this in their analysis of the same data source but find no such relationship among Latinos.²³ Other studies found that LEP was associated with depressive symptoms among Brazilian, Chinese, Kurdish, Korean, Puerto Rican, and Sub-Saharan African immigrants, even when controlling for variables including sociodemographic factors, psychosocial factors, clinical characteristics, and experiences of discrimination.¹⁵,¹⁶,¹⁸,¹⁹,²¹,²²,²⁵,²⁷,²⁹,³⁰,³³ It should be noted however, that three studies investigating de-

“THE INCLUDED STUDIES PROVIDE STRONG BUT NOT UNANIMOUS SUPPORT THAT ENGLISH PROFICIENCY IS PROTECTIVE AGAINST MOOD DISORDERS”

describing the statistical significance method, describing the basic data, response rate, and funding conflicts. Additionally, all studies reported limitations, with 17 reporting cross-sectional analysis as a limitation (though analyses in all studies were cross-sectional).¹⁴-¹⁶,¹⁸²⁴,²⁶,²⁷,²⁹,³¹,³²,³⁴,³⁵ Only seven studies mentioned self-reported English proficiency measures as a limitation,¹⁴,¹⁵,²⁰,²⁹,³¹,³³,³⁴ despite nearly all using such measures.

Limited English Proficiency and Immigrant/ Refugee Mental Health All but four studies found a statistically significant relationship between English proficiency and mental health outcomes. Of these, only one study found that high English proficiency was associated with adverse mental health outcomes,²⁹ specifically anxiety and PTSD among refugees from Burma. While other studies generally showed a negative correlation between high English proficiency and adverse mental health outcomes, the strengths and nature of associations varied by outcome.

The included studies provide strong but not unanimous support that English proficiency is protective against mood disorders, especially 28

pressive symptoms did not find that English proficiency was statistically significant.²⁸,³¹,³⁴ Chen and colleagues suggest that such a relationship is mediated by interpersonal support and social status.³⁴ Analyses of English proficiencyʼs relationship with anxiety disorders yielded mixed findings.

In addition to Kimʼs finding described above,²⁹ studies by Carl and colleagues³³ and Leong and colleagues²³ did not present evidence of a meaningful association among Asian, Latino, and Puerto Rican immigrants. That being said, two studies contradict this,¹⁸,²⁴ finding English proficiency to be protective against anxiety disorders among Korean and other Asian immigrants.

Brown and colleagues found English proficiency to be negatively associated with general mental distress,¹³ even when controlling for age of arrival to the U.S. Fox and colleagues similarly accounted for social integration-related variables and further control for minority stress factors³⁵; they also arrive at the same conclusion. Regarding psychological distress, two studies find significant negative relationships with English proficiency among Asian,

Latino, and Puerto Rican immigrants.²⁹,³³ Singh and colleagues, however, demonstrate the importance of measuring ethnicity more granularly, demonstrating that having a language barrier was only associated with psychological distress in Vietnamese immigrants, but not Chinese and Filipino immigrants.²⁶ English proficiency was found to be negatively associated with general mental health, but Murphy and colleagues found this relationship to be insignificant once other factors were controlled for.³² None of the included studies found a significant relationship between English proficiency and substance use disorder.

Discussion This review sought to summarize the characteristics and findings of the literature between 2010 and 2020 on the relationship between English proficiency and mental health outcomes among U.S. immigrants and refugees.

While most studies provided evidence that LEP is associated with poorer mental health outcomes, this varied by specific outcome and population. Further, the findings show a need to study additional immigrant and refugee communities and refine methods for measuring both English language proficiency and mental health outcomes.

The strong evidence that general mental health, psychological distress, and depression are related to LEP builds upon the literature highlighting acculturation as a factor for immigrant and refugee mental health issues.⁵⁴ The findings in the current review seem to be consistent with Berry's acculturative stress model,⁸ conceptualizing acculturation as a driver of stress and depression. Synthesizing this reviewʼs finding with the model presents implications for policy; providing greater access to interpretation and translation services for immigrants and refugees may ultimately reduce acculturative stress-related outcomes.

This may address an alternative mechanism for the relationship between LEP and poor mental health: reduced quality of mental health care resulting from inadequate language accommodations.⁷

Mixed findings on English proficiency and anxiety disorders may be explained by a number of reasons. First, cross-cultural differences in the conceptualization of mental health disorders may have resulted in measurement error. Studies of ethnopsychology, for example, have illuminated factors that may cause differences in reporting anxiety symptoms that are not captured in instruments such as the GAD-7.⁵⁵ Fu-

“CROSS-CULTURAL

DIFFERENCES IN THE CONCEPTUALIZATION OF MENTAL HEALTH DISORDERS MAY HAVE RESULTED IN MEASUREMENT ERROR” ture studies may consider placing greater emphasis on using scales developed and validated specifically for marginalized populations, such as CADS-9,⁴³ which were only used by few of the included studies in this review.

Second, it may be that unmeasured immigrant and refugee mental health factors such as discrimination and traumatic events confound the relationship between language proficiency and outcomes such as anxiety, PTSD, and substance use disorders. An important consideration is the difference in discrimination and traumatic event experiences between immigrants and refugees,⁵⁶ which may be explored by disaggregating migrant subtype in future research. In addition to disaggregating by subtype, allowing for more granularity in race and ethnicity categories for analysis may provide further insight on the seemingly disparate findings between sub-ethnicities in this review.

A key finding of this review was the lack of standardized English proficiency measures (that do not rely on self-report) among included studies. This is consistent with the finding that 67% of American Journal of Public Health studies of acculturation rely on self-reported proficiency measures, vulnerable to social desirability bias and poor reliability.⁵⁷ More studies using objective measures of English 29

proficiency such as BEST Plus, as done by Murphy and colleagues,³² are warranted.

Although this review contributes to the immigrant and refugee health literature by characterizing recent studies focusing on English proficiency as a factor for mental health outcomes, there are some important limitations to consider. First, the search strategy did not account for all possible health outcomes experienced by immigrants and refugees. Due to varying conceptualizations of mental health globally, English proficiency may contribute to culturally specific conditions not captured by the search terms. Second, this review was completed by a single author; future studies should consider incorporating multiple authors in the screening and quality appraisal processes to enhance the accuracy of conclusions about the literature. Third, data were qualitatively synthesized. Other researchers may consider using meta-analyses to quantify the association between English proficiency and mental health outcomes as described by the recent literature. Despite the risk of bias created by these limitations, this review nevertheless offers insight on current trends in the study of English proficiency as an immigrant and refugee mental health factor.

LEP has been shown to be associated with poor mental health outcomes among immigrants and refugees, a growing population in the U.S. Further study is warranted to better understand the nature of this relationship among immigrant and refugee groups not adressed by the literature. Although refinements to instruments to measure English proficiency and mental health outcomes among immigrants and refugees are greatly needed, the existing literature offers a strong case for policies that enhance language access on an institutional level.

References 1. U.S. Census Bureau. Selected social characteristics in the United States, 2019 American Community Survey 1year estimates. Published 2019. https://data.census.gov /cedsci/table?q=DP02&tid=ACSDP1Y2019.DP02&hidePreview=false 2. Budiman A. Key findings about U.S. immigrants. Pew Research Center; 2020. Accessed December 11, 2020. https://www.pewresearch.org/fact-tank/2020/08/20/ key-findings-about-u-s-immigrants/ 3. Pumariega AJ, Rothe E, Pumariega JB. Mental health of immigrants and refugees. Community Ment Health J. 2005;41(5):581-597. doi:10.1007/s10597-005-6363-1 4. Kirmayer LJ, Narasiah L, Munoz M, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ Can Med Assoc J J Assoc Medicale Can. 2011;183(12):E959-967. doi:10.1503/cmaj.090292 5. Lommel LL, Chen J-L. The relationship between selfrated health and acculturation in Hispanic and Asian adult immigrants: a systematic review. J Immigr Minor Health.

2016;18(2):468-478. doi:10.1007/ s10903-015-0208-y 6. Applebaum B, Robbins S. Language access and health equity: changes under the Affordable Care Act. J Health Care Poor Underserved. 2016;27(2):416-426. doi:10.1353/hpu.2016.0064 7. Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-299. doi:10.1177/1077558705275416 8. Berry JW. Stress perspectives on acculturation. In: Sam DL, Berry JW, eds. The Cambridge Handbook of Acculturation Psychology. Cambridge University Press; 2006:43-57. doi:10.1017/CBO9780511489891.007 9. Sirin SR, Sin E, Clingain C, Rogers-Sirin L. Acculturative stress and mental health: implications for immigrant-origin youth.

Pediatr Clin North Am. 2019;66(3):641-653. doi:10.1016/j.pcl.2019.02.010 10. U.S. Census Bureau. Selected characteristics of the foreign-born population by period of entry into the United States, 2019 American Community Survey 1-year estimates. Published 2019. https://data.census.gov/ cedsci/table?q=immigrant&tid=ACSST1Y2019.S0502&hidePreview=false 11. McClellan SR, Wu FM, Snowden LR. The impact of

30

threshold language assistance programming on the accessibility of mental health services for persons with limited English proficiency in the Medi-Cal setting. Med Care.

2012;50(6):554-558. doi:10.1097/MLR.0b013e3182463432 12. Downes MJ, Brennan ML, Williams HC, Dean RS. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open.

2016;6(12):e011458. doi:10.1136/ bmjopen-2016-011458 13. Brown C, Schale CL, Nilsson JE. Vietnamese immigrant and refugee womenʼs mental health: An examination of age of arrival, length of stay, income, and English language proficiency. J Multicult Couns Dev. 2010;38(2):66-76. doi:10.1002/ j.2161-1912.2010.tb00115.x 14. de Castro AB, Rue T, Takeuchi DT. Associations of employment frustration with self-rated physical and mental health among Asian American immigrants in the U.S. labor force.

Public Health Nurs.

2010;27(6):492-503. doi:10.1111/ j.1525-1446.2010.00891.x 15. Bernstein KS, Park S-Y, Shin J, Cho S, Park Y. Acculturation, discrimination and depressive symptoms among Korean immigrants in New York City. Community Ment Health J. 2011;47(1):24-34. doi:10.1007/ s10597-009-9261-0 16. Cummings S, Sull L, Davis C, Worley N. Correlates of depression among older Kurdish refugees. Soc Work.

2011;56(2):159-168. doi:10.1093/sw/56.2.159 17. Kim G, Loi CXA, Chiriboga DA, Jang Y, Parmelee P, Allen RS. Limited English proficiency as a barrier to mental health service use: A study of Latino and Asian immigrants with psychiatric disorders. J Psychiatr Res. 2011;45(1):104-110. doi:10.1016/j.jpsychires.2010.04.031 18. Lee KH, Yoon DP. Factors influencing the general well-being of low-income Korean immigrant elders. Soc Work. 2011;56(3):269-279. doi:10.1093/sw/56.3.269 19. Kang S-Y, Boyas J, Salehin M. Correlates of depression among Chinese immigrant elders in Arizona: The role of acculturative stress and social support. J Hum Behav Soc Environ.

2012;22(3):334-350. doi:10.1080/10911359.2012.655609 20. Schachter A, Kimbro RT, Gorman BK. Language proficiency and health status: Are bilingual immigrants

healthier? J Health Soc Behav. 2012;53(1):124-145. doi:10.1177/0022146511420570 21. Choi SE, Reed PL. Contributors to depressive symptoms among Korean immigrants with type 2 diabetes.

Nurs Res. 2013;62(2):115-121. doi:10.1097/ NNR.0b013e31827aec29 22. Kang S-Y, Basham R, Kim YJ. Contributing factors of depressive symptoms among elderly Korean immigrants in Texas. J Gerontol Soc Work. 2013;56(1):67-82. doi:10.1080/01634372.2012.734369 23. Leong F, Park YS, Kalibatseva Z. Disentangling immigrant status in mental health: psychological protective and risk factors among Latino and Asian American immigrants. Am J Orthopsychiatry. 2013;83(2-3):361-371. doi:10.1111/ajop.12020 24. Hong S, Walton E, Tamaki E, Sabin JA. Lifetime prevalence of mental disorders among Asian Americans: nativity, gender, and sociodemographic correlates.

Asian Am J Psychol. 2014;5(4):353-363. doi:10.1037/ a0035680 25. Orjiako O-EY, So D. The role of acculturative stress factors on mental health and help-seeking behavior of sub-Saharan African immigrants. Int J Cult Ment Health.

2 0 1 4 ; 7 ( 3 ) : 3 1 5 - 3 2 5 . doi:10.1080/17542863.2013.797004 26. Singh S, McBride K, Kak V. Role of social support in examining acculturative stress and psychological distress among Asian American immigrants and three subgroups: Results from NLAAS. J Immigr Minor Health.

2015;17(6):1597-1606. doi:10.1007/s10903-015-0213-1 27. Jang Y, Yoon H, Park NS, Chiriboga DA. Health vulnerability of immigrants with limited english proficiency: a study of older Korean Americans. J Am Geriatr Soc. 2016;64(7):1498-1502. doi:10.1111/jgs.14199 28. Martinson ML, Tienda M. Birthing, nativity, and maternal depression: Australia and the United States. Int Migr Rev. 2016;50(3):793-824. doi:10.1111/imre.12173 29. Kim I. Behavioral health symptoms among refugees from Burma: examination of sociodemographic and migration-related factors. Asian Am J Psychol.

2018;9(3):179-189. doi:10.1037/aap0000103 30. Lazar-Neto F, Louzada ACS, de Moura RF, Calixto FM, Castro MC. Depression and its correlates among Brazilian immigrants in Massachusetts, USA. J Immigr Minor Health.

2018;20(4):832-840. doi:10.1007/ s10903-017-0632-2

31

31. Kiang L, Broome M, Chan M, Stein GL, Gonzalez LM, Supple AJ. Foreigner objectification, English proficiency, and adjustment among youth and mothers from Latinx American backgrounds. Cultur Divers Ethnic Minor Psychol. 2019;25(4):461-471. doi:10.1037/cdp0000216 32. Murphy JE, Smock L, Hunter-Adams J, et al. Relationships between English language proficiency, health literacy, and health outcomes in Somali refugees. J Immigr Minor Health. 2019;21(3):451-460. doi:10.1007/ s10903-018-0765-y 33. Carl Y, Frias RL, Kurtevski S, et al. The correlation of English language proficiency and indices of stress and anxiety in migrants from Puerto Rico after Hurricane Maria: a preliminary study. Disaster Med Public Health Prep. 2020;14(1):23-27. doi:10.1017/dmp.2019.22 34. Chen SH, Zhang E, Liu CH, Wang LK. Depressive symptoms in Chinese immigrant mothers: relations with perceptions of social status and interpersonal support.

Cultur Divers Ethnic Minor Psychol. Published online April 30, 2020. doi:10.1037/cdp0000343 35. Fox SD, Griffin RH, Pachankis JE. Minority stress, social integration, and the mental health needs of LGBTQ asylum seekers in North America. Soc Sci Med 1982.

2020;246:112727. doi:10.1016/j.socscimed.2019.112727 36. Gim Chung RH, Kim BSK, Abreu JM. Asian American Multidimensional Acculturation Scale: development, factor analysis, reliability, and validity. Cultur Divers Ethnic Minor Psychol. 2004;10(1):66-80. doi:10.1037/10999809.10.1.66 37. Clark JL, Clifford RT. The FSI/ILR/ACTFL proficiency scales and testing techniques: development, current status, and needed research. Stud Second Lang Acquis.

1988;10(2):129-147.

38. Center for Applied Linguistics. BEST Plus technical report: development of a computer assisted assessment of oral proficiency for adult English language learners.

Center for Applied Linguistics; 2015. https://www.cal.org/aea/pdfs/Original-BP-Technical-Report.pdf

32

41. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17(1):37-49. doi:10.1016/0022-3956(82)90033-4 42. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/ j.1525-1497.2001.016009606.x 43. Wong R, Wu R, Guo C, Lam JK, Snowden LR. Culturally sensitive depression assessment for Chinese American immigrants: development of a comprehensive measure and a screening scale using an item response approach. Asian Am J Psychol. 2012;3(4):230-253. doi:10.1037/a0025628 44. Kessler RC, Ustün TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res. 2004;13(2):93-121. doi:10.1002/mpr.168 45. Winokur A, Winokur DF, Rickels K, Cox DS. Symptoms of emotional distress in a family planning service: stability over a four-week period. Br J Psychiatry J Ment Sci. 1984;144:395-399. doi:10.1192/bjp.144.4.395 46. Depuy HJ. The General Well-being Schedule. In: McDowell I, Newell C, eds. Measuring Health: A Guide to Rating Scales and Questionnaire. 2nd ed. Oxford University Press.; 1977:206-213.

47. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092 48. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059

39. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas.

1977;1(3):385-401. doi:10.1177/014662167700100306

49. Hollifield M, Verbillis-Kolp S, Farmer B, et al. The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees. Gen Hosp Psychiatry.

2013;35(2):202-209. doi:10.1016/j.genhosppsych.2012.12.002

40. Cho MJ, Kim KH. Use of the Center for Epidemiologic Studies Depression (CES-D) Scale in Korea: J Nerv Ment D i s . 1 9 9 8 ; 1 8 6 ( 5 ) : 3 0 4 - 3 1 0 . doi:10.1097/00005053-199805000-00007

50. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32(6):959-976. doi:10.1017/

s0033291702006074 51. Carl Y, Ortiz ER, Cintrón M, et al. Post-Hurricane Distress Scale (PHDS): A novel tool for first responders and disaster researchers. Disaster Med Public Health Prep.

2019;13(1):82-89. doi:10.1017/dmp.2019.12 52. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful Alcohol Consumption--II. Addict Abingdon Engl.

1993;88(6):791-804. doi:10.1111/ j.1360-0443.1993.tb02093.x 53. Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Med Care.

1 9 9 6 ; 3 4 ( 3 ) : 2 2 0 - 2 3 3 . doi:10.1097/00005650-199603000-00003 54.

Balidemaj A, Small M. The effects of ethnic identity and acculturation in mental health of immigrants: A literature review.

Int J Soc Psychiatry.

2 0 1 9 ; 6 5 ( 7 - 8 ) : 6 4 3 - 6 5 5 . doi:10.1177/0020764019867994 55. Hofmann SG, Hinton DE. Cross-cultural aspects of anxiety disorders. Curr Psychiatry Rep. 2014;16(6):450. doi:10.1007/s11920-014-0450-3 56. Beiser M, Hou F. Mental health effects of premigration trauma and postmigration discrimination on refugee youth in Canada.

J Nerv Ment Dis. 2016;204(6):464-470. doi:10.1097/ NMD.0000000000000516 57. Ayers JW. Measuring English proficiency and language preference: are self-reports valid? Am J Public Health.

2010;100(8):1364-1366. doi:10.2105/ AJPH.2010.194167

33

Accessibility of Suicide Gatekeeper Training for the Student Population This article focuses on the analysis of suicide prevention efforts and the implementation of a student-led suicide prevention intervention at The Johns Hopkins University. We find that suicide prevention gatekeeper trainings have historically not been accessible to undergraduate students unless they were student leaders or athletes. We recommend general suicide prevention gatekeeper training sessions to be held for the undergraduate student population to further its accessibility.

Carol Lu Cognitive Science Class of 2022

S

uicide is a global epidemic. Among adults, it is the tenth leading cause of death in the United States, and the second leading cause of death among young people 10-34 years of age.¹ Suicide deaths are at its highest absolute numbers among individuals between 15-29 years of age.² Despite being a leading cause of death worldwide, with 48,344 deaths attributable to suicide in 2018, it has remained a low public health priority.³ While suicide itself is not a mental illness, one of the principal causes of suicide is mental illness. College students in particular face a unique set of circumstances when dealing with suicide and mental illnesses. Many of these young adults are living away from home for the first time, and are burdened by new experiences in addition to academic and societal expectations. As a result, 12-50% of students meet the criteria for mental disorders, and 6% of undergraduate students and 4% of graduate students reported having seriously considered suicide.⁴,⁵ Among college students, approximately 1,100 individuals die by suicide every year.⁶ However, suicides are preventable. With proper training, individuals at risk can be identified and guided to the help they need.⁶,⁷ One such method to identify and support students at risk is gatekeeper training, a model that teaches individuals the warning signs of suicide and how to effectively respond to them.⁸ One such training is the Question, Persuade, Refer (QPR) gatekeeper suicide prevention training, which has three core goals: increasing intention to question the individual at-risk of suicide, persuading them to accept and seek help, and referring them to the appropriate resources.⁸ QPR is a nationally-registered, evidence-based practice and tool for suicide prevention listed in the Best Practices Registry for Suicide Prevention.⁸ Prior research has indicated that this training can increase oneʼs ability to identify individuals in distress and help them intervene and provide referrals.⁶,⁸ Additionally, individuals become more knowledgeable about suicide.⁶,⁸ As a result, they are more willing to intervene in situations with individuals perceived to be suicidal.⁶ Gatekeeper train-

ing has been successfully implemented in the university setting, with all three core goals effectively demonstrated.⁶ This study seeks to review the work the Johns Hopkins University has done in mental health and wellness, particularly on the topic of suicide prevention, by critically analyzing past and present prevention efforts and initiatives.

By implementing a student-led suicide preven-

“HOWEVER, SUICIDES

ARE PREVENTABLE…ONE SUCH METHOD TO IDENTIFY AND SUPPORT STUDENTS AT RISK IS GATEKEEPER TRAINING” tion project and surveying the outcomes of a QPR suicide gatekeeper training session aimed at undergraduate students, this study seeks to provide evidence for a growing interest in mental health and wellness from students in the university setting.

Methods The Johns Hopkins University is an institution committed to student health and well-being, including mental health. In March 2016, the university recognized the need for more mental wellness strategies for its students and thus founded the Task Force on Student Mental Health and Well-being.⁹ They were tasked with reviewing current mental health resources and making recommendations on how the university may better support its studentsʼ mental health.⁹ Twenty-eight individuals from across the university, including faculty, staff, and students, were selected for the task force.⁹ In February 2018, the report detailing the findings of the task force, including input from over 2,300 students, was published.⁹ The recommendations made by the task force are as follows: “Recommendation 1: The university should promote a climate of awareness and support for student mental health, wellness, and stress 35

reduction. Recommendation 2: The university should take necessary steps to improve student care at JHU mental health service providers and provide greater access to mental health services. Recommendation 3: The university should offer, and in some cases require, training on mental health awareness and resources for faculty, staff, and students.”⁹ Proposed Initiative – Suicide Prevention Week 2020 While the JHU Counseling Center began implementing these recommendations in 2016, there remains a notable gap in Recommendation 3 — accessibility to suicide prevention training. QPR suicide gatekeeper training is the most commonly used suicide prevention model used across counseling centers in the United States at 30.2%.⁹ It is also the primary model utilized by the JHU Counseling Center.⁸ While QPR training is available for all university departments, offices, and student organizations at the university by request, analysis of past trainings held between 2018 and 2020 shows that only 17 trainings have ever been conducted at Johns Hopkins. (Susan Han, Ph.D., e-mail communication, July 9, 2020) In total, only 403 Hopkins affiliates had ever been trained at the time of analysis (Susan Han, Ph.D., e-mail communication, July 9, 2020). Of these 403 individuals, 289 were undergraduate students (71.71%), and the rest consisted of staff and faculty, including but not limited to, security officers and academic staff and faculty. With 5,292 enrolled undergraduate stu-

dents,¹⁰ this training reached a shockingly low proportion of the overall undergraduate student population at 5.46%. Of the 17 training sessions hosted by Hopkins, only 5% of these trainings were given to the general undergraduate student population. Records show that QPR training is most commonly offered to student leaders (59%) and student athletes (36%).

As a result of this disparity, this initiative focused on increasing the accessibility of QPR suicide gatekeeper training for the general student population. As September is National Suicide Prevention Month, JHU held its first-ever suicide prevention week in September 2020, with a week of suicide prevention events, including trivia, bingo, and yoga in addition to a pilot QPR gatekeeper training session.

QPR Suicide Gatekeeper Training QPR training is a 1.5 hour long training that teaches attendees how to recognize the warning signs of suicide, offer hope, get help, and save a life.⁸ To assess knowledge and comfort about suicide and receive feedback regarding the training session, all participants are invited to complete a pre- and post-training survey. In both surveys, five questions are scored using a 5-point Hedonic-index (1 - poor, 2 - below average, 3 - average, 4 - above average, 5 - outstanding):

B

Figure 1. Histories of QPR Training from 2018-2020 for JHU Populations.

(A) Training for all JHU affiliates (n = 403).

(B) Training for the JHU Undergraduate population (n = 289).

Adapted from Susan Han, Ph.D., via e-mail communication, July 9, 2020 Q2. How to ask someone about suicide.

Q3. How to persuade someone to get help.

Q4. Information about campus resources for help with suicide.

Q5. What is your comfort level in asking someone if they are contemplating suicide?”¹¹ Results Due to the COVID-19 pandemic, all events were hosted virtually. A total of 132 students participated in JHUʼs 2020 Suicide Prevention Week. Support was provided by JHU offices, student organizations, and academic departments.

QPR Suicide Gatekeeper Training Twenty-four students registered and participated in the pilot QPR suicide gatekeeper train ing session held on day 2 of the suicide prevention week. Each participant completed a pre- and post-training survey to help us assess the effectiveness of the QPR program. n=24 participants completed the pre-survey, and n=10 participants completed the post-survey.

Across every category, survey results indicate a positive difference in the level of comfort students have before and after a suicide gatekeeper training session.

“How would you rate your knowledge of suicide in the following areas?

Q1. Warning signs of suicide.

Table 1. Most Commonly Used Suicide Prevention Models.

Taken and adapted from the Johns Hopkins University Task Force on Student Mental Health and Well-Being.

36

A

Figure 2. Comparison of participantsʼ responses to the QPR pre- and post- surveys.

37

Discussion The level of participation from students for the JHUʼs first-ever Suicide Prevention Week provides support for growing student interest in mental health and well-being on campus. In addition to participation of over 100 students over the weekʼs events, students expressed interest in future opportunities for training and outreach. The QPR survey results indicate a positive difference in the level of comfort students have before and after a suicide gatekeeper training session, providing further evidence for its effectiveness.

QPR Suicide Gatekeeper Training Although both pre- and post- surveys were sent to all registered participants for the QPR training session held, not all participants responded. Out of n=24 participants, only 10 (41.67%) completed the post-survey. Therefore, results should be approached with reservations. More training data needs to be collected to corroborate the results.

COVID-19 Pandemic While this initiative was initially planned as a face-to-face experience, due to the COVID-19 pandemic that led to a university-wide shutdown, only a virtual experience was feasible.

This was applied to all events held, including the QPR training, which is traditionally conducted in-person. As a result, student participation was limited. With students in varied time zones and living situations, participation was limited to those in convenient time zones and had stable WiFi connections, since sessions could only be held at the convenience of counseling center staff, all of which are in the Eastern Time Zone (ET). Despite these limitations, this pilot session provides evidence that a virtual training session is comparable in effectiveness to the in-person training. Data from

both the in-person sessions and the online sessions demonstrate a positive change as a result of attending the training. We recommend that the counseling center continue to host additional QPR training sessions, both virtually during the current COVID-19 pandemic and in-person once on-campus activities resume.

“EVEN WHILE VIRTUAL

AND IN THE MIDST OF A WORLDWIDE PANDEMIC, WE CAN ALL DO OUR PART IN PROMOTING STUDENT MENTAL WELLNESS” Conclusion This is the first Suicide Prevention Week the JHU Counseling Center has hosted, as well as its first general QPR suicide gatekeeper training session. It was well-attended with over 100 student participants in total, with results indicating a positive change in studentsʼ comfort level when addressing suicide with their peers.

With these results, the JHU Counseling Center is encouraged to host more general training sessions for Hopkins affiliates, particularly undergraduate students, in the near future. The JHU Counseling Center has already begun training many in-house therapists to become QPR training certified, which is a step in the right direction. Even while virtual and in the midst of a worldwide pandemic, we can all do our part in promoting student mental wellness both on and off campus.

Acknowledgements Thank you to Dr. Susanna Ferradas, Keri Frisch, Dr. Durriya Meer, Dr. Susan Han, Karen Taylor, Dr. Matthew Torres, Dr. Jian-Ming Hou, Nila Berger, William Nation, Nyasha Chikowore, and the Counseling Center Advisory Board for all their support in this endeavor. The following organizations provided support for this project: JHU Student Wellness, First-generation and limited income (FLI) Network, Preventative Education and Empowerment for Peers (PEEPs), Student Leadership and Involvement, Student Life, A Place to Talk (APTT), Religious and Spiritual Life, Athletic Training, Study Consulting, the Intercultural Greek Council, Kranti, Matriculate, South Asian Students at Hopkins (SASH), Omega Psi (Cognitive Science honor society), department of Materials Science, and the freshmen and junior student class councils.

References 1. Preventing Suicide Fact Sheet. Center for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/suicide-factsheet.pdf. 2018. Accessed August 10, 2020.

2. Bachmann S. “Epidemiology of Suicide and the Psychiatric Perspective.” International Journal of Environmental Research and Public Health. 2018;15(7), 1425. doi: 10.3390/ijerph15071425.

3. Suicide and Self-Harm Injury. Center for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/ suicide.htm. 2020. Accessed August 10, 2020.

students: Shifting the paradigm.” Professional Psychology:Research and Practice. 2009; 40(3), 213-222. doi: 10.1037/a0014465.

6. Aldrich, R. S., Wilde, J., & Miller, E. “The effectiveness of QPR suicide prevention training.” Health Education Journal.

2018; 77(8), 964-977. doi: 10.1177/0017896918786009.

7.Suicide Rising Across the US: Vital Signs Fact Sheet.

Center for Disease Control and Prevention. https:// www.cdc.gov/vitalsigns/pdf/vs-0618-suicide-H.pdf.

2018. Accessed August 10, 2020.

8. What is QPR? QPR Institute. https://qprinstitute.com/ about-qpr. Publication date unavailable. Accessed January 8, 2021.

9. Task Force on Student Mental Health and Well-being.

Johns Hopkins University. https://provost.jhu.edu/wpcontent/uploads/sites/4/2018/02/Task-Force-on-Student-Mental-Health-and-Well-being-Final-Report.pdf.

2018. Accessed June 3, 2020.

10. Get the Facts. Johns Hopkins University. https://apply.jhu.edu/discover-jhu/get-the-facts/. 2018. Accessed October 26, 2020.

11. QPR Gatekeeper Pre-Post Survey. QPR Institute. https://qprinstitute.com/uploads/instructor/Gatekeeperpre-post-survey.pdf. Publication date unavailable. Accessed October 26, 2020.

4. Hunt, J., & Eisenberg, D. (2010) “Mental Health Problems and Help-Seeking Behavior Among College Students.” Journal of Adolescent Health. 2010; 46(1), 3–10. doi:10.1016/j.jadohealth.2009.08.008.

5. Drum, D. J., Brownson, C., Denmark, A. B., & Smith, S. E. “New data on the nature of suicidal crises in college

Table 2. Mean scores of participantsʼ responses to the QPR pre- and post- surveys.

38

39

EDITORS-IN-CHIEF Han Zhang Class of 2023 Jesse Huang Class of 2022

EDITORIALS Kriti Bomb – Editor Class of 2022 Kristine Nyugen Class of 2022

Lydia Lee – Editor Class of 2021 Soonmyung Hwang Class of 2021

Anna Fiedor Class of 2021

Roshini Narayanan Class of 2022

Kathleen Li Class of 2022

Hannah Bruckheim Class of 2022

Ellie Rose Mattoon Class of 2024

FEATURES Joseph Kang – Editor Class of 2023 Courtney Harrington Class of 2021

Loaah Eltemsah Class of 2023 Ahimsa Aradhya Class of 2022

LAYOUT Devan Patel – Editor Class of 2023

Alyssa Lee Class of 2023

Trisha Parayil Class of 2021

Ian Chiu Class of 2023

Ying Zhang Class of 2022

Christiana Liu Class of 2023 40

RESEARCH

Volume 18