Shaping Health Care Research Articles

The promise and limits of inclusive public policy: federal safety net clinics and immigrant access to health care in the U.S.

Abstract In the United States, exclusionary public policies generate inequalities within and across labor, financial, and legal status hierarchies, which together undermine immigrant well-being. But can inclusive public policies improve immigrant health? We examine whether and how an immigrant-inclusive federal program, Federally Qualified Health Centers (FQHCs), shaped health care access and use among farmworkers over nearly three decades, paying particular attention to disparities at the intersection of nativity and legal status. Linking historical administrative data on the location and funding of FQHCs with the National Agricultural Workers Survey from 1989–2017, we first document trends in farmworkers’ county-level proximity to FQHCs and identify a steady increase in FQHC access among undocumented farmworkers following the Affordable Care Act. Next, using time-series cross-sectional regressions with a battery of fixed effects, we find that living in a county where FQHCs are available and better resourced is associated with increased health care use among undocumented farmworkers, but not among U.S.-born or documented immigrant farmworkers. We also find that county-level access to FQHCs is associated with reduced reports of language barriers to care among both documented and undocumented foreign-born farmworkers. These findings suggest that FQHCs may improve access for immigrants who are typically excluded from U.S. health care institutions. Still, county-level FQHC infrastructure is not associated with cost-related barriers to care for any nativity or legal status groups. Taken together, our study highlights both the potential and constraints of inclusive public policies for promoting health equity in a welfare state context characterized by commodification and stratification.

Telehealth Uptake Among Hispanic People During COVID-19: Retrospective Observational Study.

The Hispanic community represents a sizeable community that experiences inequities in the US health care system. As the system has moved toward digital health platforms, evaluating the potential impact on Hispanic communities is critical. The study aimed to investigate demographic, socioeconomic, and behavioral factors contributing to low telehealth use in Hispanic communities. We used a retrospective observation study design to examine the study objectives. The COVID-19 Research Database Consortium provided the Analytics IQ PeopleCore consumer data and Office Alley claims data. The study period was from March 2020 to April 2021. Multiple logistic regression was used to determine the odds of using telehealth services. We examined 3,478,287 unique Hispanic patients, 16.6% (577,396) of whom used telehealth. Results suggested that patients aged between 18 and 44 years were more likely to use telehealth (odds ratio [OR] 1.07, 95% CI 1.05-1.1; P<.001) than patients aged older than 65 years. Across all age groups, patients with high incomes were at least 20% more likely to use telehealth than patients with lower incomes (P<.001); patients who had a primary care physician (P=.01), exhibited high medical usage (P<.001), or were interested in exercise (P=.03) were more likely to use telehealth; patients who had unhealthy behaviors such as smoking and alcohol consumption were less likely to use telehealth (P<.001). Male patients were less likely than female patients to use telehealth among patients aged 65 years and older (OR 0.94, 95% CI 0.93-0.95; P<.001), while male patients aged between 18 and 44 years were more likely to use telehealth (OR 1.05, 95% CI 1.03-1.07; P<.001). Among patients younger than 65 years, full-time employment was positively associated with telehealth use (P<.001). Patients aged between 18 and 44 years with high school or less education were 2% less likely to use telehealth (OR 0.98, 95% CI 0.97-0.99; P=.005). Results also revealed a positive association with using WebMD (WebMD LLC) among patients aged older than 44 years (P<.001), while there was a negative association with electronic prescriptions among those who were aged between 18 and 44 years (P=.009) and aged between 45 and 64 years (P=.004). This study demonstrates that telehealth use among Hispanic communities is dependent upon factors such as age, gender, education, socioeconomic status, current health care engagement, and health behaviors. To address these challenges, we advocate for interdisciplinary approaches that involve medical professionals, insurance providers, and community-based services actively engaging with Hispanic communities and promoting telehealth use. We propose the following recommendations: enhance access to health insurance, improve access to primary care providers, and allocate fiscal and educational resources to support telehealth use. As telehealth increasingly shapes health care delivery, it is vital for professionals to facilitate the use of all available avenues for accessing care.

The Value of International Exchange Programs for Physician Assistants: Surveying a US-Netherlands Advanced Practice Provider Exchange Program.

International exchange programs between physician assistants (PAs) and other advanced practice providers (APPs) from different countries can facilitate opportunities for global health training and experiences. This article examines a survey of 5 PAs, 4 nurse practitioners, and 1 certified nursing specialist working in the United States (US) about their experience collaborating in an international exchange program with APPs in the Netherlands. Ten APPs in the United States anonymously answered an 8-item survey on their experience in an international exchange program with APPs in the Netherlands with a 100% response rate. The survey contained questions regarding the impact of the program on cultural competence, professional development, and perception of health care systems. All respondents agree or strongly agree that the program contributed to APP growth in cultural competence and professional development. Eighty percent of respondents found APP practices in the United States compared with the Netherlands to be somewhat or extremely similar, with differences noted in training and education, patterns of utilization, and roles in procedures. Free responses indicate APPs are used similarly in the Netherlands and the United States, while APP training models and health care infrastructure in the 2 countries have notable differences. Survey results examined in this article underscore how an international exchange program can not only enrich individual professional paths but also positively contribute to the broader global health care landscape. The lessons learned, shared experiences, and insights gained have the potential to shape health care practices on an international scale, fostering a collaborative and interconnected future for health care providers worldwide.

Bringing Value to Health Care

Health care in the US remains challenged by affordability, availabili­ty, and wasteful spending. To address these challenges, the various constituents in health care payment and delivery all seek to reduce total cost of care while maintaining or improving the relevant clinical outcome expected (value-based care). It is generally acknowledged that health care is not one system but is, in fact, fragmented in control and delivery between local and national commercial payers, government payers, employers, private and public providers, and drug and device manufacturers, all of whom are overseen by state and federal reg­ulations. To help guide further discussion on current and evolving value-based care strategies, this paper provides insights and perspective from each constit­uent involved in shaping health care payment and delivery throughout the US.

Creating a Vibrant Organization Using the Dynamic Leadership Model and a Teaming Approach.

The pandemic exposed existing weaknesses in the health care system, and innovative leaders stepped up to address the compounding effects the novel anomaly created. Postpandemic disruption persists, and the behaviors and actions of these positive deviants demonstrate that new ways of leadership are available to those who are willing to embrace the dynamic leadership model and teaming methodology to shape health care delivery of the future. As we look to new ways of being and leading, we begin from a changed world-one that has been reset and cannot go back. Dynamic leaders are called upon to create cultures that reflect the needs of the future workplace and workforce. They pave new pathways and new ways of thinking, reimagine new realities, and create abundance. Their consistent practice of 5 essential behaviors-self-awareness, deep listening, curiosity, empathy, and decisiveness-strengthen their leadership and ability to meet the demands of health care today.

INFLAMMATORY BOWEL DISEASE IN YOUTH UNDER 20 FROM 1990-2019: A GLOBAL PERSPECTIVE ON REGIONAL AND NATIONAL VARIATIONS FROM THE GBD 2019 ANALYSIS

Abstract BACKGROUND Inflammatory Bowel Disease (IBD) ranks as the 9th primary cause of mortality and the 10th main source of disability worldwide among individuals aged under 20. Grasping the worldwide implications for this age bracket is pivotal for shaping health care approaches and optimizing patient care. METHOD Leveraging the Global Burden of Disease instrument, we discerned the incidence, prevalence, mortality, and Disability Adjusted Life Years (DALYs) of IBD by age, gender, and year across 204 nations and territories spanning 1990-2019. The DisMod-MR 2.1 tool shed light on non-fatal health metrics like incidence and prevalence, whereas the Cause of Death Ensemble Model (CODEm) framework illuminated fatal health outcomes. RESULTS From 1990 to 2019, the overall prevalence of IBD escalated from 74,975 (95%UI: 60,678-92,219) to 88,828 (72,606-108,301), marking an Annual Percentage Change (APC) of 18% (16-22). Incidence exhibited an APC surge of 23% (20-26). Conversely, deaths and DALYs plummeted by 56% and 53% respectively during the same period. Delving into global regions, Sub-Saharan Africa noted a 6% death upswing, trailed by the African Union at 65% and Low SDI nations at 1%. Southeast Asia, East Asia, and Oceania recorded the steepest APC in age-standardized incidence rates at 67%, followed by High-SDI regions at 35%, OECD nations at 31%, and affluent countries at 30%. The 15-19 age bracket registered the most pronounced incidence rise by 24%. Males witnessed a steeper APC in incidence (24% vs. females at 21%) and prevalence (21% vs. females at 16%) from 1990-2019. CONCLUSION In 2019, IBD was responsible for 1.61% of all mortality linked to digestive diseases and contributed to 1.50% of the total digestive disease-induced disabilities. For pediatric clinicians, these findings underline the necessity for early intervention, tailored care strategies, and rigorous research into pediatric IBD. From a policy-making perspective, there is an urgent demand for resource allocation, enhanced public health campaigns, and international collaboration to mitigate the growing threat of IBD among the youth. Source: Global Burden of Disease 2019, IHME

An Egalitarian Perspective on Information Sharing: The Example of Health Care Priorities

In health care, the provision of pertinent information to patients is not just a moral imperative but also a legal obligation, often articulated through the lens of obtaining informed consent. Codes of medical ethics and many national laws mandate the disclosure of basic information about diagnosis, prognosis, and treatment alternatives. However, within publicly funded health care systems, other kinds of information might also be important to patients, such as insights into the health care priorities that underlie treatment offers made. While conventional perspectives do not take this as an obligatory part of the information to be shared with patients, perhaps through viewing it as clinically “non-actionable,” we advocate for a paradigm shift. Our proposition diverges from the traditional emphasis on actionability. We contend that honoring patients as equal moral agents necessitates, among other principles, a commitment to honesty. Withholding specific categories of information pertinent to patients’ comprehension of their situation is inherently incompatible with this principle. In this article, we advocate for a recalibration of the burden of proof. Rather than requiring special justifications for adding to the standard set of information items, we suggest that physicians should be able to justify excluding relevant facts about the patient’s situation and the underlying considerations shaping health care professionals’ choices. This perspective prioritizes transparency and empowers patients with a comprehensive understanding, aligning with the ethos of respect for the patient as person.

Evaluation of gender-affirming care experiences of transgender and gender diverse patients within a LGBTQ+ community pharmacy

BackgroundTransgender and gender diverse (TGD) populations require personalized care. Lived experiences and needs TGD populations express, compounded by limited care access, negatively shape health care involvement. Manifestations from these barriers may present as health care avoidance, identity concealment, or preventive care hinderance. Community pharmacies remain engagement points for TGD patients, but gender diverse services remain limited. What remains unknown is how TGD pharmacy perceptions and behaviors are influenced with gender-affirming care (GAC) accessibility. ObjectivesThe primary objective is to assess how TGD patient perceptions and behaviors toward community pharmacy experiences are affected through a lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+) community-based health system. MethodsA cross-sectional, multisite, reflective survey was conducted at 4 LGBTQ+ community pharmacies in central and southwest Ohio. Nine 5-point Likert-item questions and one ordinal question were used to analyze perception and behavior. Participants responded for LGBTQ+ and external pharmacy experiences respectively. Data were analyzed through descriptive methods, paired Student’s t test, and Fisher’s exact test or c2 test where appropriate. ResultsIn total, 267 surveys were completed with 96 TGD submissions qualifying for analysis. Perceptions toward pharmacy experience saw statistically significant differences among all evaluations of perception. Behavioral assessment demonstrated statistically significant improvements in pharmacy outreach except for seeking medications from outside sources. Respondents indicated more involvement with the LGBTQ+ pharmacies versus external pharmacies in discussing medications (96.9% vs. 60.4%), care plans (64.6% vs. 41.6%), disclosure of pronouns or gender (97.9% vs. 43.8%), and feeling needs were understood (96.8% vs. 51%). ConclusionInclusive community pharmacies may positively affect pharmacy perceptions and behaviors of TGD patients. These findings call attention to barriers in the provision of care for TGD patients while highlighting the change community pharmacies can have when providing these services. Community pharmacies should be encouraged to incorporate inclusive environments to improve TGD patient care involvement and access.

Human Factors Engineering for the Pediatric Hospitalist.

As pediatrics hospitalists, we care for a diverse population of hospitalized children with increasing acuity and complexity in large, multidisciplinary medical teams. In this Method/ology paper, we summarize how human factors engineering (HFE) can provide a framework and tools to help us understand and improve our complex care processes and resulting outcomes. First, we define and discuss the 3 domains of HFE (ie, physical, cognitive, and organizational) and offer examples of HFE's application to pediatric hospital medicine. Next, we highlight an HFE-based framework, the Systems Engineering for Patient Safety model, which conceptualizes how our work system shapes health care processes and outcomes. We provide tools for leveraging this model to better understand the context in which our work is done, which, consequently, informs how we design our systems and processes to improve the quality and safety of care. Finally, we outline the basics of human-centered design and highlight a case study of a project completed in a pediatric hospital setting focused on making rounds more family-centered. In addition, we provide resources for those interested in learning more about HFE.

Factors influencing access to water, sanitation, and hygiene among crisis-affected populations

Abstract Background The Central African Republic is suffering a long and complex humanitarian crisis. Population access to water, sanitation, and hygiene (WASH) services remain a challenge in the context of protracted conflicts. However, research on access to WASH in this population is limited. The purpose of the study was to investigate factors associated with access to WASH among crisis-affected populations in the Central African Republic. Methods This study analyzed 11,723 crisis-affected households from the 2020 Central African Republic Multi-Cluster Needs Assessment survey data. This survey was conducted between June to August 2020 by the Racial and Ethnic Approaches to Community Health (REACH) Initiative and geographically covered all sub-prefectures of the country.Sampling weighted multivariable binary logistic regression analysis was performed. Results Internally displaced persons (IDPs) were more likely to affect their access to WASH than their host families.Movement restricted due to COVID-19, household members with difficulties in self-care (e.g., washing, dressing), education level, and monthly household income were significantly associated with access to WASH. Discussion This study suggests that certain factors place the crisis-affected populations in the Central Africa Republic a thigh risk for access to WASH, especially among IDPs. The findings in this study can inform public health professionals to develop support and education programs and shape health care policies. In addition, the results highlight the importance of access to safely managed WASH services during infectious disease outbreaks, including the current COVID-19 pandemic Key messages • The findings in this study can inform public health professionals to develop support and education programs and shape health care policies. • The results highlight the importance of access to safely managed WASH services during infectious disease outbreaks, including the current COVID-19 pandemic.

Religious Beliefs Shaping Health Care and Transforming Health Concepts: The Case of Shanghai.

This study examines the connection between health and religious beliefs in modern Chinese society and builds a model reimagining the conception of health. The study draws on interviews with 108 patients (52 were women and 56 were men) at Huashan Hospital (Shanghai City, China). The survey ran between May 10 and May 14, 2021. More than 50% of female and male respondents reported having religious beliefs. Most acknowledged the crucial role of faith and religious beliefs in overcoming treatment challenges and alleviating patient suffering. The role of faith and religious beliefs in physical/mental treatment and health maintenance received the highest average percent positive score among female respondents. According to the multipleregression results of demographic parameters (age, ethnicity, gender, education, and urban or rural residence), only gender had a statistically significant effect on the impact of religious beliefs on health care attitudes. The proposed model builds on the Confucian concept of Ren (humanity), which refers to a harmonious relationship between people within a family or society bound by specific rules. The results of this study can help expand awareness about religion and its role in healthcare as a means to support patients' spiritual and physical health.

Health Care Professionals' Decision Making Related to Mobility and Safety for People in the Hospital: A Scoping Review.

Mobility dysfunction can have an impact on safety, and this fact is particularly relevant to hospital settings. There are no clear standards for how health care professionals should approach the aim to encourage mobility without compromising safety. The objective of this scoping review was to identify factors that shape health care professionals' decision making for people in hospitals, in situations in which mobility and safety are taken into consideration. For this scoping review, 4 databases (Medline, CINAHL, PubMed, and Scopus) were searched. Terms previously agreed upon were used to identify peer-reviewed articles related to decision making by health care professionals in hospital settings (acute and rehabilitation), in which safety and mobility were factors for consideration. An initial screening of titles and abstracts was conducted by a single reviewer. Two reviewers independently screened the full texts of the remaining articles. The key findings of the articles were synthesized to determine common themes. After 10,717 articles were screened, 28 met the inclusion criteria. Ten themes influencing decision making were identified: Clinical factors assessed; health care professional experience; limited use of standardized tests; impact of institutional governance; risk/benefit trade-off; capacity for decision making; role of the multidisciplinary team; families and others; communication; and fear of negative outcomes. A wide range of factors influence health care professionals' decision making. The decisions can be complex, and individual priorities may vary in the balancing of safety with promotion of independence. Health care professionals rely on experience, clinical judgment, and shared decision making. This review brings attention to many factors that contribute to decision making when mobility and safety are the factors. Health care professionals should include patients' values and monitor the impact of their personal preferences on this process.

"Intersections of Social Systems, Race, and Health in America: A Historical Perspective": A Novel Elective for Medical Students to Increase Antiracism Advocacy.

There are growing calls for medical education to effectively teach about and explicitly name racism as a driver of inequities in social determinants of health and inspire student action to address health inequities. Using a novel application of the generative co-design approach, in 2020 Perelman School of Medicine students and faculty implemented a student-led, interdisciplinary elective course for preclerkship medical students. The co-design process allowed for an iterative and conversation-based experience emphasizing how social systems and racist policies shape health care access and outcomes. Active student participation was integral to developing discussion questions to elicit how students' positions in power structures can uphold inequities. Community members and nonprofit leaders taught about the current realities of discrimination and how students could best advocate for patients in the future. Enrolled students (n = 17) and a control group of nonenrolled classmates (n = 37) completed the Anti-Racism Behavioral Inventory (ARBI) pre- and post-course to compare changes in antiracist behaviors. Course participants demonstrated a significant increase in ARBI scores (mean = 4.29 (7.30); t(16) = 2.42; P = .01), while students from the control group did not (mean = 1.43 (6.98); t(36) = 1.25; P = .11). The "individual advocacy" subdomain of the ARBI largely drove the change in ARBI scores, suggestive of increased antiracism behavior in the enrolled cohort. Students provided feedback offering praise for course elements and suggestions for improvement. Early findings suggest that this course, created with a co-design approach, generated new experiences for medical students, increased their understanding of systemic racism, and increased individual antiracist advocacy. Future work, with larger class sizes and longitudinal measurement of behavior change, should further investigate the transformative effects of applying co-design strategies to medical education courses about race and health.

Rethinking structural competency: Continuing education in mental health and practices of territorialisation in Brazil

ABSTRACT Brazilian mental health focuses on the social determination model within mental health policies and interventions to address mental and social suffering as resulting from social exclusion and structural violence. Structural concerns focused on class stratification and socioeconomic inequalities overweight cultural ones in Brazilian mental health. In this article we examine, first the role of culture and interculturality in mental health practices and mental health guidelines for health professionals continuing training in Brazil. Second, we explore interviews with health professionals around Continuing Education in Health provided by mental health collaborative care initiatives within primary health care as illustration of a local practice of structural competency in mental health. Finally, we examine the central role played by the practices of territorialisation in shaping health care training and care interventions. The focus on the territory can promote critical apprehensions of the intercultural and structural factors that shape health practices, enrich health professional education oriented towards the basic tenets of social medicine and provide global discussions around structural competency with innovative ways of thinking about health education, health care and spatiality. We believe that our results may be useful for comparing structural competency training initiatives in global health.

State Immigration Policy Contexts and Racialized Legal Status Disparities in Health Care Utilization Among U.S. Agricultural Workers.

Research links restrictive immigration policies to immigrant health and health care outcomes. Yet most studies in this area focus on the impact of single policies in particular years, with few assessing how broader state-level immigration policy contexts affect groups by nativity, race/ethnicity, and legal status. Linking data from the National Agricultural Workers Survey (2005-2012) with information on state immigration policies, we use an intersectional approach to examine the links between policy contexts and health care utilization by nativity, race/ethnicity, and legal status. We also assess the associations between two specific types of state immigration policies-those governing immigrant access to Medicaid and driver's licenses-and health care utilization disparities. We find that state-level immigration policy contexts are associated with health care utilization among U.S.-born and naturalized U.S. citizen non-White Latinx agricultural workers, who report lower levels of health care utilization and greater barriers to care-seeking in more restrictive policy contexts. By contrast, we find little evidence that state policies shaped health care utilization among undocumented workers. These findings advance understanding of the impact of "policies of exclusion" on the lives of marginalized groups and underscore the importance of racialized legal status in considering the links between sociopolitical contexts and health and health care disparities.

Forty Years of Molecular Diagnostics for Infectious Diseases.

ABSTRACTNearly 40 years have elapsed since the invention of the PCR, with its extremely sensitive and specific ability to detect nucleic acids via in vitro enzyme-mediated amplification. In turn, more than 2 years have passed since the onset of the coronavirus disease 2019 (COVID-19) pandemic, during which time molecular diagnostics for infectious diseases have assumed a larger global role than ever before. In this context, we review broadly the progression of molecular techniques in clinical microbiology, to their current prominence. Notably, these methods now entail both the detection and quantification of microbial nucleic acids, along with their sequence-based characterization. Overall, we seek to provide a combined perspective on the techniques themselves, as well as how they have come to shape health care at the intersection of technologic innovation, pathophysiologic knowledge, clinical/laboratory logistics, and even financial/regulatory factors.

Assessing Health Care Use Trajectories After the Onset of Functional Disability: Application of a Group-Based Trajectory Model.

While older adults with activity limitations have high levels of health care use, we do not know how this varies over time. We aimed to assess trajectories of Emergency Department (ED) use and hospitalization after the onset of receipt of help with self-care or mobility. We used the 2011-2017 National Health Aging Trends Study (NHATS) linked to Medicare claims to identify a cohort of older adults who began to receive help with self-care or mobility in the past year. Primary outcome was the quarterly rates of ED use and/or hospitalization over the 24 months following the onset of receiving help. We fit a Group-Based Trajectory Model to identify the trajectories of ED use or hospitalization and assessed the association of characteristics preceding and concurrent to the onset of help with trajectory group membership. Among 1,687 NHATS respondents newly receiving help with self-care/mobility, health care use escalated and then immediately fell. We found distinct trajectories of ED use and hospitalization: delayed rise (13.5%), falling (26.2%), and persistent (60.4%). Trajectory group membership was predicted by clinical, economic, and regional characteristics; and the individuals in each group differed in terms of concurrent new illnesses and degree of disability. While activity limitations are a strong predictor of health care use among older adults, trajectories of health care use are heterogeneous. Along with clinical characteristics, potentially modifiable household and regional factors shaped health care trajectories, indicating that addressing these factors could potentially shift health care use patterns.

Exploring the Role of Social Networks in Facilitating Health Service Access Among Low-Income Women in the Philippines: A Qualitative Study.

Despite efforts to implement universal health care coverage (UHC) in the Philippines, income poor households continue to face barriers to health care access and use. In light of recent UHC legislation, the aim of this study was to explore how gender and social networks shape health care access and use among women experiencing poverty in Negros Occidental, Philippines. Semi-structured interviews were conducted with women (n = 35) and health care providers (n = 15). Descriptive statistical analyses were performed to report demographic information. Interview data were analyzed thematically using a hybrid deductive-inductive approach and guided by the Patient-Centred Access to Health Care framework. Women’s decisions regarding health care access were influenced by their perceptions of illness severity, their trust in health care facilities, and their available financial resources. Experiences of health care use were shaped by interactions with health professionals, resource availability at facilities, health care costs, and health insurance acquisition. Women drew upon social networks throughout their lifespan for social and financial support to facilitate healthcare access and use. These findings indicate that social networks may be an important complement to formal supports (eg, UHC) in improving access to health care for women experiencing poverty in the Philippines.

13th Annual Evidence-Based Practice/Research Conference Nurses Shaping Health Care: Retaining the Nursing Workforce November 5, 2021

PODIUM PRESENTATIONS ### Nicole Nedd, EdD, APRN; Deborah Rugs, PhD #### Veterans Health Administration, U.S. Department of Veterans Affairs Background: The Department of Veterans Affairs Veterans Health Administration (VHA) is the largest employer of nurses in the United States. Currently VHA

Listening for bridges: Developing a culturally responsive, transdiagnostic approach to psychotherapy for Bhutan.

The increasing global need for mental health care has led to a search for efficient, effective treatments that are based on both local cultural healing traditions and scientific evidence. In this article, I describe the development of a brief, culturally responsive, transdiagnostic approach to psychotherapy for common mental disorders in Bhutan, a rapidly changing culture firmly grounded in Vajrayana Buddhism. Buddhist-Informed Therapy for Bhutan (BT-B) supports Bhutan's goals of preserving traditional culture, improving psychological well-being for its citizens, and integrating Buddhism into solutions for contemporary social issues. More broadly, BT-B extends the range of culturally responsive treatment approaches in several ways. First, BT-B is innovative in its identification and therapeutic use of conceptual links between specific Western evidence-based principles of therapeutic change and core Buddhist principles. Listening empathically to the client's narrative, the therapist identifies an evidence-based principle to address and uses conceptually linked deeply rooted Buddhist beliefs to guide the client in applying their own cultural wisdom to resolve problems. Second, the model illustrates the value of an ecological approach to culturally responsive treatment development that takes into account local cultural beliefs, practices, and institutions, including those that shape health care delivery and use. Third, evidence from case examples adds to the growing body of literature that supports the utility of transdiagnostic therapeutic approaches across cultures and in settings where resources are limited.