The study, reported in the Aug. 6 issue of the Journal of the American Medical Association, looked at whether exposure to different types of political violence and ability to discuss these issues with a doctor was a key predictor of a patient's current mental health status and health-related quality of life. The results indicate primary-care clinicians should ask their immigrant and refugee patients about past exposure to war and political violence.
According to Dr. David Eisenman, clinical instructor of medicine specializing in health services research at UCLA Medical Center, a researcher at RAND and the study's lead author, "Torture, forced disappearances of family members and witnessing massacres are just some of the traumas that still affect our patients."
The Latino population is the fastest-growing minority group in the United States, comprising 12.5 percent of the population. More than 4.2 million Latino people live in Los Angeles County alone, representing 44.6 percent of its population.
"This population is very significant," Eisenman said. "Many doctors treat patients who are Latino immigrants. This problem is right under our noses."
Previous studies focused on asylum seekers, refugees living in refugee camps in developing countries or people in specialty clinic settings, and looked mainly at post-traumatic stress disorder and depression. These studies have limited relevance to U.S.-based populations of immigrants and refugees and to primary-care clinicians practicing in the United States.
This current study used a trauma survey and mental health and health-related quality of life surveys to look at the primary care of the Latino immigrant population in a major American city, Los Angeles.
Adult patients from three community-based, primary-care clinics in Los Angeles were randomly chosen to participate in the study. All three sites are free-standing community clinics offering medical, pediatric and obstetric-gynecologic services to a mainly uninsured Latino population. Together, the three sites serve approximately 24,000 adult patients per year. Latino patients in the study came mostly from Central America and Mexico. None of the sites had special programs targeted to particular populations such as new immigrants, refugees or migrant workers.
Of the 638 patients who participated in the trauma survey, 54 percent had been exposed to political violence. Participants were considered exposed to political violence if they had ever directly experienced one act of political violence at any time in their life while living in their native country.
To improve comparability and quantification of the effects of specific events and to avoid the difficulties presented by the possibly varying meanings of "political violence" among cultures, an event-specific checklist, or trauma survey, was developed, as opposed to letting the patients self-define political violence.
Political violence was broken down as follows: 8 percent reported torture, 15 percent witnessed violence against their family, 27 percent reported forced disappearance of family members, 26 percent witnessed mass violence and 32 percent reported their lives having been endangered by attacks with bombs or heavy weapons. Five percent reported witnessing torture or an execution and 3 percent reported being raped.
The results show patients exposed to political violence were two to five times more likely than those not exposed to have symptoms consistent with a diagnosis of post-traumatic stress disorder, depression, panic disorder and any mental health disorder. In addition, the impairment of health-related quality of life was more severe than researchers anticipated. Patients reporting exposure to political violence had greater chronic pain, impaired physical functioning and diminished health-related quality of life. The magnitude of the effect seen in the health-related quality of life scores is comparable to, or greater than, differences seen when comparing groups with chronic diseases such as mild asthma to groups without such diseases.
Although more than half of the study participants had some form of exposure to political violence, only 3 percent of the participants had reported their experiences to a physician after immigration to the United States.
Stating the significance of the study for primary-care physicians, Eisenman said, "Doctors should ask patients who are immigrants about war, torture and political violence experiences, especially if there are psychological or chronic pain problems, so that these patients can receive proper diagnosis, treatment and referrals."
The study was co-authored by UCLA researchers Lillian Gelberg, Honghu Liu and Martin F. Shapiro. Eisenman, Liu and Shapiro are affiliated with UCLA's Division of General Internal Medicine and Health Services Research, and Gelberg is associated with UCLA's Department of Family Medicine. The study was funded by a grant from the Health Resources and Services Administration, and the Mary and Irving Lazar Program in Health Services Research.