According to UCLAresearchers, a survey of a U.S.-based Latino immigrant population shows thatmore than half have been exposed to political violence, including torture, intheir homeland. However, very few patients inform their primary-care physicianabout their experiences. The combination of exposure to violence andnon-disclosure to the doctors affects the patients' overall health, diagnosisand treatment.
The study, reported in the Aug. 6 issue of the Journal of theAmerican Medical Association, looked at whether exposure to different types ofpolitical violence and ability to discuss these issues with a doctor was a keypredictor of a patient's current mental health status and health-relatedquality of life. The results indicate primary-care clinicians should ask theirimmigrant and refugee patients about past exposure to war and politicalviolence.
According to Dr. David Eisenman, clinical instructor of medicinespecializing in health services research at UCLA Medical Center, a researcherat RAND and the study's lead author, "Torture, forced disappearances of familymembers and witnessing massacres are just some of the traumas that still affectour patients."
The Latino population is the fastest-growing minority group in theUnited States, comprising 12.5 percent of the population. More than 4.2 millionLatino people live in Los Angeles County alone, representing 44.6 percent ofits population.
"This population is very significant," Eisenman said. "Manydoctors treat patients who are Latino immigrants. This problem is right underour noses."
Previousstudies focused on asylum seekers, refugees living in refugee camps indeveloping countries or people in specialty clinic settings, and looked mainlyat post-traumatic stress disorder and depression. These studies have limitedrelevance to U.S.-based populations of immigrants and refugees and toprimary-care clinicians practicing in the United States.
This current study used a trauma survey and mental health andhealth-related quality of life surveys to look at the primary care of theLatino immigrant population in a major American city, Los Angeles.
Adult patients from three community-based, primary-care clinics inLos Angeles were randomly chosen to participate in the study. All three sitesare free-standing community clinics offering medical, pediatric andobstetric-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. Noneof the sites had special programs targeted to particular populations such asnew immigrants, refugees or migrant workers.
Of the 638 patients who participated in the trauma survey, 54percent had been exposed to political violence. Participants were consideredexposed to political violence if they had ever directly experienced one act ofpolitical violence at any time in their life while living in their nativecountry.
To improve comparability and quantificationof the effects of specific events and to avoid the difficulties presented bythe possibly varying meanings of "political violence" among cultures, anevent-specific checklist, or trauma survey, was developed, as opposed toletting the patients self-define political violence.
Political violence was broken down as follows: 8 percent reportedtorture, 15 percent witnessed violence against their family, 27 percentreported forced disappearance of family members, 26 percent witnessed massviolence and 32 percent reported their lives having been endangered by attackswith bombs or heavy weapons. Five percent reported witnessing torture or anexecution and 3 percent reported being raped.
The results show patients exposed to political violence were twoto five times more likely than those not exposed to have symptoms consistentwith a diagnosis of post-traumatic stress disorder, depression,panic disorder and any mental health disorder. In addition, the impairment ofhealth-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 scoresis comparable to, or greater than, differences seen when comparing groups withchronic diseases such as mild asthma to groups without such diseases.
Although more than half of the study participants had some form ofexposure to political violence, only 3 percent of the participants had reportedtheir 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 arepsychological or chronic pain problems, so that these patients can receiveproper 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 withUCLA's Division of General Internal Medicine and Health Services Research, andGelberg is associated with UCLA's Department of Family Medicine. The study wasfunded by a grant from the Health Resources and Services Administration, andthe Mary andIrving Lazar Program in Health Services Research.