Anh N. Tran

Identifying clinical competencies that support rehabilitation and empowerment in individuals with severe mental illness

Individuals with severe mental illness often do not receive appropriate treatment or rehabilitation. One approach to improving their care begins by identifying competencies that clinicians should possess. This project developed a set of core clinical competencies that pertain to community-based care and support the goals of empowerment and rehabilitation. Development of the competency set began with review of existing literature and competency statements, and focus groups and interviews with clients, family members, clinicians, managers, experts, and advocates. Representatives from each of these groups participated in a national panel and used a structured process to identify 37 final competencies. Panel members agreed that these competencies are very important in determining outcomes and often are not present in current clinicians. This project demonstrates that it is possible to develop a core competency set that can be strongly supported by diverse groups of stakeholders. These competencies may be useful in clinician training, recruitment, and credentialing efforts.

Understanding African American Men's Perceptions of Racism, Male Gender Socialization, and Social Capital Through Photovoice

In this study we used a participatory qualitative research approach—photovoice—to collect information about African American mens perceptions of the factors that influenced their own health and the health of their communities. Photovoice was conducted as part of the “Men as Navigators (MAN) for Health” project, an evaluation of a male lay health advisor (LHA) intervention in central North Carolina. Twelve African American men living in both urban and rural communities took photographs and discussed the photos in six photo discussion sessions. Analysis involved identifying recurring themes from the photos and transcriptions of photo discussions. The results suggest that race and racism, male gender socialization, and social networks and social capital all have important influences on African American mens health. The implications for further research and public health practice are discussed.

A Structural Approach to Examining Prostate Cancer Risk for Rural Southern African American Men

Physical, cultural, and social factors influence health risk and behavior, but few have explored how the environmental context affects African American mens prostate cancer screening and treatment. This paper describes a structural analysis of data from eight focus groups of rural, southern African American men (n=66). A structural approach highlights the interrelationships between individuals, the health service system, and community factors that directly and indirectly affect screening and treatment for prostate cancer. The availability of accurate and timely health information and health services, social norms regarding health and professional help-seeking, and the sociopolitical context shaped mens screening and treatment behaviors. These proximal and distal health factors affected mens prostate cancer knowledge, perceived risk, willingness to seek care and trust in the health service system. The findings suggest that prostate cancer screening and treatment occurs in a larger structural context that has important implications for help-seeking and health promotion.

Results From a Pilot Promotora Program to Reduce Depression and Stress Among Immigrant Latinas

The stressful experiences that Latino immigrants face throughout the migration process to the United States put them at increased risk for poor mental health. Latinas are at heightened risk due to stigma, limited access to mental health resources, domestic violence, and gender role expectations. In addition, for those who live in new immigrant settlement areas, such as the Southeast, these disparities are magnified by even fewer culturally appropriate services and limited social support. This study evaluates the impact of ALMA (Amigas Latinas Motivando el Alma/Latina Friends Motivating the Soul), a pilot promotora intervention offered in three North Carolina counties to improve mental health among Latinas by offering coping skills training. The intervention trained community-based promotoras to conduct outreach to Latina women in their social network (compañeras). Using a pre–post test design, we assessed the mental health outcomes of compañeras. Compañeras improved on the following outcomes: depressive symptoms, attitudes of depression treatment, perceived and acculturative stress, perceived social support, and positive coping responses. Our findings suggest that promotora interventions, such as ALMA, that focus on building self-care strategies can be valuable to reducing preclinical symptoms and addressing health care disparities that are exacerbated by unavailable or underused mental health services.

Teaching Population Health: A Competency Map Approach to Education

A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals’ training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community’s health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke’s efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings.

Evaluation of Amigas Latinas Motivando el Alma (ALMA): a pilot promotora intervention focused on stress and coping among immigrant Latinas.

Recent immigrant Latinas are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. This study evaluated Amigas Latinas Motivando el Alma, a promotora intervention to reduce stress and promote health and coping among recent immigrant Latinas. Using a pre- and post-test design, we evaluated mental health outcomes, specifically, in promotoras. Promotoras’ knowledge levels related to role of promotora and stress management increased, depressive symptoms and stress levels decreased, and coping responses and perceived social support increased as well. Results suggest that promotora programs may be an effective way to improve mental health in recent immigrant Latinas.

The Primary Care Leadership Track at the Duke University School of Medicine: creating change agents to improve population health.

PROBLEM Physicians need training in community engagement, leadership, and population health to prepare them to work with partners within the community and to adapt medical care to address population health needs. APPROACH With an overall goal of training primary care practitioners to be change agents for improving population health, the Duke University School of Medicine launched the Primary Care Leadership Track (PCLT) in 2011. The four-year PCLT curriculum requires students to contribute to existing community health initiatives, perform community-engaged research, and participate in leadership training. The clinical curriculum incorporates a longitudinal approach to allow students to follow patient outcomes. In addition, students regularly interact with faculty to explore population health issues, review patient cases, and adjust individual learning opportunities as needed. OUTCOMES The first cohort of PCLT students will graduate in 2015. Prospective comparisons with traditional track students are planned on performance on standardized tests and career choices. NEXT STEPS The authors created the PCLT as a laboratory in which students can engage with the community and explore solutions to address the health of the public and the future delivery of health care. To meet the goal of training change agents, PCLT leaders need to expand opportunities for students to learn from providers and organizations that are successfully bridging the gap between medical care and public health.

A Community-Engaged Research Approach to Improve Mental Health Among Latina Immigrants: ALMA Photovoice

Recent Latina immigrants are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. Existing social and health care policies often do not adequately address the mental health concerns of new Latino populations. Amigas Latinas Motivando el Alma, a community-partnered research project, seeks to improve immigrant Latinas’ mental health outcomes. Using Photovoice methodology, promotoras (lay health advisors) reflected on community factors affecting mental health through photography and guided discussion. Discussions were audio-recorded, transcribed, and coded using content analysis to identify salient themes. Promotoras reviewed codes to develop themes that they presented in community forums to reach local policy makers and to increase community awareness. These forums included an exhibit of the promotoras’ photographs and discussion of action steps to address community concerns. Themes included transitioning to life in the United States, parenting, education, and combating racism. Nearly 150 stakeholders attended the community forums and proposed responses to promotoras’ photographic themes. Our findings suggest that Photovoice provides an opportunity for Latinas and the larger community to identify issues that they find most important and to explore avenues for action and change by creating sustainable partnerships between the community and forum attendees.

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

Objective Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners’ and teachers’ perceptions about appropriate behavioral health curricular components for internal medicine residents. Method Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents’ successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups. Results Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents’ skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient’s perspective, managing time in encounters, improving patients’ understanding, and patient counseling. Conclusions Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care’s role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

The ABCs of Empowered Communication: A Community-Based Intervention for Patients

Community education about how patients can best communicate with their physicians has been successful in various communities, particularly when working with an ethnically diverse patient population. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.