Research That Matters (January 17 - 20, 2008)

Purpose: This action research project used mixed methods to strengthen primary care residents' assessment of potential trauma exposure in Afghani women who presented to an urban primary care clinic with medically unexplained symptoms. Methods: The researchers developed three open-ended, semi-structured interview guides, based on a review of the scholarly literature on trauma, somatization, migration and women from Central Asia. Using the guide for each type of respondent, interviews were conducted with 1. thirteen clinic patients; 2. five Muslim community leaders; and 3. twelve primary care residents. Pre- and post-test surveys were administered to fifty-five primary care residents, addressing their knowledge about trauma, somatization and immigration. Results: Findings from interviews with clinic patients revealed that some women experienced considerable pre- and post-migration trauma exposure. Other major themes included social isolation, lack of English, illiteracy, and post 9/11 bias. Religion emerged as a major support, but many respondents prayed at home rather than at a mosque. Interviews with community leaders revealed consistent themes: 1. post 9/11 anti-Muslim bias; 2. women were seen as valued major family caregivers, yet potentially at risk for further social isolation due to religious traditions in which women pray at home rather than at the mosque; 3. strong expectations that even ill mothers must still fulfill all care-giving tasks. Interviews with primary care residents revealed the following themes: 1. patient adherence, 2. how “difficult” patients can help physicians improve diagnosis, 3. challenges of cross-cultural and cross-linguistic medical interviews; and 4. residents' own migration experiences. Using these findings, the researchers presented three training sessions for primary care residents on the underlying psychosocial aspects of medically unexplained symptoms, including a trauma screening instrument, the PC-PTSD. Over thirty residents attended all three training sessions. Upon completion of the training, the PC-PTSD was piloted in the clinic. Piloting of the PC-PTSD revealed that many clinic patients screenedpositive for trauma exposure. Analysis of resident pre- and post-test surveys indicated that residents without trauma training did not ask about trauma in medical interviews, potentially diminishing their capacity to detect trauma's medical aftereffects. Several residents reported that some patients spontaneously report trauma exposure, even when physicians have not received training in assessing trauma. In addition, patients who disclose trauma are often difficult to diagnose. Implications for Practice: Urgent needs exist for trauma assessment and trauma-focused interventions in primary care settings, as well as development of connections with Muslim and Afghani community service agencies. Social work services in medical outpatient settings can address these needs through additional training in cross-cultural and cross-linguistic practice, along with in-hospital interpreters and ongoing outreach to the Muslim community. Literacy and English as a second language programs, offered by community agencies, can help alleviate social isolation.