Neighborhood characteristics and ataque de nervios: the role of neighborhood violence

Abstract

Ataque de nervios is a Latina/o idiom of distress that may occur as a culturally sanctioned response to acute stressful experiences, particularly relating to grief, threat, family conflict, and a breakdown in social networks. The contextual factors associated with ataque de nervios have received little attention in research. This study examined the association between neighborhood factors and the experience of ataque de nervios among a sample of Latinas/os participating in the Latino Health and Well-Being Project in the northeastern United States. We examined the association between neighborhood cohesion, safety, trust, and violence and ataque de nervios. In multivariate logistic regression models, neighborhood violence was associated with ataque de nervios (p = .02), with each unit increase in the neighborhood violence scale being associated with 1.36 times greater odds of experiencing ataque de nervios. None of the other neighborhood variables were significantly associated with ataque de nervios. The positive association between neighborhood violence and the experience of ataque de nervios makes a further case for policy efforts and other investments to reduce neighborhood violence.

Keywords

ataque de nervios idioms of distress Latinas/os neighborhood violence

Introduction

Idioms of distress, defined as “particular ways in which members of sociocultural groups express affliction” (Hinton & Lewis-Fernández, 2010, p. 210), have received increased attention in the past four decades due to the growing overall awareness of cultural differences in mental health outcomes, both in the US and internationally (Keys, Kaiser, Kohrt, Khoury, & Brewster, 2012; Nichter, 1981; Parsons & Wakeley, 1991). Examples of idioms of distress include Han (a Korean expression of regret or resentment), Hozun (a Darfuri expression of deep sadness), and sıkıntı (a Turkish expression of trouble or oppression) (Borra, 2011; Rasmussen, Katoni, Keller, & Wilkinson, 2017; Saint Arnault & Kim, 2008). Research on these idioms of distress suggests that they are used by individuals responding to stressful situations, such as warfare or immigration to a new country (Borra, 2011; Hinton & Lewis-Fernández, 2010; Lewis-Fernández et al., 2005; Rasmussen et al., 2017). Parsons (1984) found that idioms of distress in Tonga were adaptive coping mechanisms against personally or culturally stressful experiences, while Desai and Chaturvedi (2017) found that Indian idioms of distress, such as Dhat (anxiety and weakness associated with semen discharge), arose from interpersonal and cultural conflicts and were layered with both personal and cultural meaning. Idioms of distress were thus understood as culturally sanctioned responses to various stressors, such as abuse and the loss of loved ones, which bind people together in times of stress and permit individuals to share their distressful experiences without fear of social isolation (Hinton & Lewis-Fernández, 2010; Vazquez, Sandler, Interian, & Feldman, 2017).

Ataque de nervios, a Latino idiom of distress, is receiving renewed attention in the United States, beyond work in medical anthropology, where it has traditionally been studied (Fernandes, Iqbal Hasmi, & Essau, 2015; Guarnaccia et al., 2010; Sanchez & Shallcross, 2012). Guarnaccia and colleagues view ataque de nervios as a “culturally sanctioned response to acute stressful experiences, particularly relating to grief, threat, and family conflict” (Guarnaccia et al., 1989, p. 158). Guarnaccia and colleagues add that ataque de nervios is oftentimes characterized by uncontrollable shaking or crying, heart palpitations, and feeling out of control in one’s life, generally in response to hearing news of upsetting occurrences such as the illness or death of a loved one. Subsequent studies both support this view and emphasize the role of interpersonally distressing events in the etiology of ataque de nervios, involving a breakdown in social networks (Fernandes et al., 2015; Keough, Timpano, & Schmidt, 2009; Lewis-Fernández et al., 2002a; Loue & Sajatovic 2008; Schechter et al., 2000). Ataque de nervios may present clinically as an overwhelming and distressing sense of being out of control, with additional symptoms that include crying, uncontrollable shouting, heat rising into the head, and in some cases, seizure-like body tremors and suicidal thoughts (Keough et al., 2009). Ataque de nervios can occur once in the lifetime of an individual who experiences acute stress, and not be associated with preceding or subsequent pathology (Alcántara, Abelson & Gone, 2012; Schechter et al., 2000). Episodes of ataque de nervios often start in childhood and share the same sociodemographic correlates as those found among adults, such as being more common among females than males (Guarnaccia et al., 2003; Livanis & Shick-Tryon, 2010; López et al., 2011). This occurrence across the lifespan highlights the need to identify factors associated with ataque de nervios.

Some studies have found considerable overlap between ataque de nervios and panic attacks, while other studies have found that only a small proportion of patients with ataque de nervios meets criteria for panic disorder (Hinton, Lewis- Fernández &. Pollack, 2009; Lewis-Fernández et al., 2002b; Vazquez et al., 2017). Additional studies with Latinos/as have found that ataque de nervios often coexists with depressive, panic, and anxiety symptoms (Lewis-Fernández et al., 2002b; Hinton, Chong, Pollack, Barlow, & McNally, 2008; Lewis-Fernández & López, 2016; Lewis-Fernández et al., 2002; Vazquez et al., 2017). However, ataque de nervios is distinct from these other manifestations of emotional distress; for example, compared to panic attacks, individuals who experience ataque de nervios report more dissociative symptoms, sensations of heat rising into the chest and head, a slower crescendo into a full-blown attack, and fewer unprovoked episodes (Guarnaccia et al., 2002; Keough et al., 2009). While ataque de nervios includes anxiety as a symptom, ataque de nervios covers a broader range of symptoms than does general anxiety disorder (Guarnaccia et al. 2010; Hinton et al. 2008).

The social norms that shape the development of ataque de nervios are what make it a unified category. Indeed, a dissociative lack of agency in the expression of ataque de nervios highlights the contrast between an undesired state of intense distress and a fear of losing control (Hinton et al., 2009); the resistance to communicating distress and suffering to others; and the fear of “negative” emotionality that may result from expressing distress (Fernandes et al., 2015; Hinton et al., 2009; Lewis-Fernández & López 2016; Lewis-Fernández et al., 2002a). For example, Tolin and colleagues (2007) found that interpersonal conflict was associated with ataque de nervios, while Guarnaccia and colleagues (1989) observed that experiencing episodes of ataque de nervios generated support from the individual’s social support network, which in turn assisted the individual in returning to their pre-episode functioning.

To date, research on ataque de nervios has primarily examined and identified socio-demographic risk factors for ataque de nervios. People who report ataque de nervios tend to be women, less educated (a high school diploma or less), and previously married (divorced, separated, or widowed) (Hinton et al., 2008; Lewis-Fernández, Guarnaccia, Patel, Lizardi, & Díaz, 2005; Vazquez et al., 2017). Identified triggers have included divorce, death, child illness, the experience of domestic abuse, and long-standing disagreements with family members, among others. (Lewis-Fernández & López, 2016; Tolin, Robison, Gaztambide, Horowitz & Blank, 2007; Ortega, Goodwin, McQuaid, & Canino, 2004). While this literature provides a preliminary understanding of individual-level risk factors for ataque de nervios, a broader understanding of the etiology of ataque de nervios is needed.

Little research has been conducted to examine the association between contextual and environmental factors and ataque de nervios. The neighborhood environment, in particular, may be important, especially in light of the significance of interpersonal relationships in Latino/a populations and their role in the experiences of ataque de nervios (Tolin et al., 2007). Previous studies have found that Latinos/as rely on neighbors for social and professional connections. They also note the importance of the neighborhood environment for this population, including its role in protecting against emotional distress (Cagney et al., 2007; Elliott & Sims 2001; Kim et al., 2011). Negative neighborhood variables (e.g., the presence of violence) increase the risk of depression, anxiety, substance abuse, and PTSD in residents (Buu et al. 2009; Hong, Zhang & Walton, 2014; Perez et al. 2015; Wright 2015). Vega and colleagues (2011) found that neighborhood social cohesion served as a protective factor against depressive symptomology among Latino immigrants (n = 1,468). Hong and colleagues (2014) found that neighborhood cohesion mediated the negative relationship between neighborhood poverty and general mental health outcomes among Latinos. Similarly, Perez and colleagues (2015) found that neighborhood social cohesion and depressive symptomology were inversely related among different Latino/a populations, particularly in neighborhoods in which individuals utilized parks and recreational facilities. Hongong and colleagues (2014) found that neighborhood cohesion attenuated depression and anxiety outcomes associated with discrimination among Latinos.Thus far, the relationship between the neighborhood environments and ataque de nervios has not been studied.

The present study examined the association between neighborhood factors and the experience of ataque de nervios among a sample of Latinos/as residing in a largely Latino city in the northeastern United States. We hypothesized that neighborhood violence is associated with a greater likelihood of experiencing ataques de nervios and that neighborhood cohesion, safety, and trust predict lower likelihood of ataque de nervios. Determining the associations between neighborhood variables and ataque de nervios may provide further insight into risk factors for this syndrome and will provide directions for interventions and policy.

Methods

Study design and sample

We analyzed baseline data from the original cohort study, the “Latino Health and Well-Being Project”, which was conducted between 2011 and 2013 (Granberry et al., 2016; Lopez-Cepero, Frisad, Lemon, & Rosal, 2018; Silfee, Rosal, Sreedhara, Lora & Lemon, 2016). The study recruited patients from the Greater Lawrence Family Health Center (GLFHC), a federally qualified community health center in Lawrence, MA, which serves approximately 80–85% of the city’s Latino population. Inclusion criteria were: Latino ethnicity, Spanish or English speaking, between 21 and 85 years of age, no plans to move out of the area within the one-year study period, no cognitive impairments precluding participation (i.e., able to answer verbally administered questions for oneself), and able and willing to give informed consent. Proportional sampling was employed within specified age ranges (21–34, 35–54, 55–85) and gender strata: using electronic patient records, patients were randomly selected who might meet the first three inclusion criteria. A total of 3,067 individuals were selected, of which 602 agreed to participate in the study. Ninety percent (n = 540) of the interviews were conducted in Spanish.

Assessment procedures

Selected individuals were contacted via a mailed letter signed by the health center’s chief medical officer. The letter described the study and stated that a study coordinator would call patients to provide additional information, assess their eligibility to participate, and inquire about interest in participating. It also provided a toll-free number for individuals to call if they did not wish to participate. Within two weeks of the mailing, trained bilingual/bicultural community coordinators contacted individuals by phone. Eligible and interested individuals were invited to participate in the study and scheduled for a study visit, with transportation provided if needed. During the participant’s visit, trained staff obtained written informed consent and conducted assessments. Individual assessments took place at the Lawrence Senior Center, a community site easy to access for participants, and lasted approximately 2.5–3 hours. Participants were remunerated $50 for their participation.

The Institutional Review Board of the University of Massachusetts Medical School approved this study.

Measures

Ataque de nervios

Ataque de nervios was measured using the National Latin American and Asian American Survey (NLAAS) Ataque de Nervios questionnaire, the only survey assessment of ataque de nervios available at the time of the study and validated in Spanish (Alegría, Molina & Chen, 2004). While the original NLAAS questionnaire includes a question on suicidality, the community oversight board for the Latino Health and Well-Being Project decided against including this question in the survey, given that the study was conducted in a community setting and the interviewers were non-clinical staff. The 15-question survey was completed in two steps. First, participants were asked “Have you ever had an episode or nervous attack (ataque de nervios) when you felt totally out of control?” (translation of Spanish version). If participants answered negatively, the survey ended. If participants answered positively, they were then asked if they had experienced any of 14 symptoms: anger or rage, aggression, hysteria, dizziness, seizures, heart palpitations, chest tightness, fainting, shouting a lot, having crying attacks, feeling very scared or frightened, having a period of amnesia, and trembling. Participants were considered as having met ataque de nervios criteria if they both answered positively to the screener question in part one and reported at least four of the 14 symptoms (Guarnaccia et al., 2010). The final item asked if they had experienced an episode/ataque de nervios in the previous two weeks; this last question was not used to assess the presence of ataque de nervios but was instead used as a follow-up to the rest of the survey.

Neighborhood variables

The Mujahid Neighborhood Scale was used to assess four neighborhood factors of interest: neighborhood safety, social cohesion, trust, and violence. Responses for the neighborhood safety, social cohesion, and trust subscales range from 1 (strongly agree) to 5 (strongly disagree); responses for the neighborhood violence subscale ranged from 1 (often) to 4 (never). Subscale items were averaged, and all items were reverse-coded so that higher scores indicated higher perceived neighborhood safety, with the exception of neighborhood violence (a higher violence score indicates higher levels of neighborhood violence). This scale has high internal consistency (Cronbach’s alpha range 0.73–0.83) and test-retest reliability (range 0.60–0.88) (Mujahid et al. 2007). The neighborhood safety subscale includes three questions that ask participants whether they felt safe walking in their neighborhoods day or night, whether violence was a problem in their neighborhoods, and whether their neighborhoods were safe from crime. The neighborhood social cohesion subscale includes four questions that ask participants if they felt that neighbors were willing to help one another, get along with one another, and whether people in their neighborhood share the same values. The neighborhood trust item comprises one question that assesses whether participants felt that people in their neighborhoods could be trusted. The neighborhood violence subscale includes four questions which assesses specific activities of violence in the participant’s neighborhood in the past six months.

Covariates

Consistent with previous research (Guarnaccia et al., 1989, 2010; Guarnaccia, Rubio-Stipec & Bravo, 1993; Lewis-Fernández et al., 2002b, 2005) that identified variables significantly associated with ataque de nervios, the covariates measured in this study include self-reported age, sex, education, marital status, and perceived adequacy of income. Age was analyzed categorically (21–34, 35–54, ≥ 55 years). Sex was measured as male or female. Education levels were grouped into two categories: “less than high school or high school graduate” and “some college or college graduate”. Perceived adequacy of income was measured with a single item that asked, “In general, would you say you (and your family living in the same household) have more money than you need, just enough money for your needs, or not enough money to meet your needs?” Response options were collapsed to “not enough” and “just enough or more than enough” due to low responses in the “more than enough” category. This measure of perceived income was selected over annual household income because annual household income is prone to participant non-responsiveness. Marital status was measured with a single item with response options including: married, cohabitating, divorced, separated, and single. Responses were grouped into three categories: married/cohabitating, divorced/separated, and single (never married). All covariates were entered in the models run for this study.

Statistical analyses

Descriptive statistics included frequencies for categorical variables and means and standard deviations for continuous variables. We used chi-square tests to examine statistically significant differences between each categorical covariate and ataque de nervios status. We ran multivariate logistic regression models to evaluate the association between the four neighborhood variables (neighborhood safety, social cohesion, trust, and violence) with ataque de nervios, adjusting for the risk factors that have been associated with ataque de nervios in the literature (Guarnaccia et al. 2002, 2010; Hinton et al. 2008; Lewis-Fernández and López 2016): age, sex, education, perceived income, and marital status. Because we hypothesized collinearity among the four neighborhood sub-scales a priori, we ran models for each of the four neighborhood variables separately. Collinearity was examined and confirmed with basic association analysis. Significance was set at p < 0.05 for all statistical tests, and STATA version 14.1 was used for all analyses.

Results

Table 1 displays the demographic description of the sample (N = 602), both overall and according to ataque de nervios status.

Table 1.

Characteristics of study participants in the total sample and according to lifetime ataque de nervios status. Data from Latino Health and Well-being Study 2011–2013.

	Meets criteria for ataque de nervios
	Total		No		Yes
Variable	n	%	n	%	n	%	p-value(degree of freedom)
Gender							.07 (1)
Female	308	51.2	215	49.3	93	56
Male	294	48.8	221	50.7	73	44
Statistic value	3.3755
Age group							.13 (2)
21–34	183	30.4	129	29.6	54	32.5
35–54	207	34.4	143	32.8	64	38.6
55+	212	35.2	164	37.6	48	28.9
Statistic value	4.0844
Education level							.69 (1)
Some high school or high school graduate	428	71.1	308	70.6	120	72.3
Some college or college graduate	174	28.9	128	29.4	46	27.7
Statistic value	0.1587
Perceived income							.04 (1)
Enough to meet needs	290	48.5	200	46	90	55.2
Not enough to meet needs	308	51.5	235	54	73	44.8
Statistic value	4.0510
Marital status							.21 (1)
Married or cohabitating	344	57.1	256	58.70	88	53
Never married	119	19.8	81	18.60	38	22.9
Separated or divorced	139	23.1	99	22.7	40	24.1
Statistic value	1.5970

The ‘statistical value’ is the df for each variable.

Approximately half of the sample (51.2%) was female. The sample was distributed almost equally among the three age groups (30.4%, 34.4%, 35.2%). The majority of the study participants (71.1%) had at least some high school education. In total, 166 participants (27.6%) reported having experienced an ataque de nervios. In bivariate analysis, we found that ataque de nervios status was not significantly associated with the majority of covariates under investigation (age, sex, education level, and marital status). Of those who had experienced ataque de nervios, a higher percentage reported having enough money to meet their needs vs. not enough (52.2% vs. 44.8%, p = .04), while the opposite was true among those who had not experienced ataque de nervios (46% vs. 54%, p = .04). Regarding ataque de nervios symptomology, we took the mean of the 14 symptoms measured as a proxy for ataque severity; the minimum cutoff for having an episode of ataque de nervios was ever having had 4 out of 14 symptoms throughout the participant’s lifetime. Participants reported experiencing, on average, 4.53 symptoms (SD = 4.2).

Multivariate regression models examining the association between ataque de nervios and neighborhood variables are described in Table 2.

Table 2.

Summary of multivariate logistic models providing the associations of neighborhood variables and lifetime timeframe of ataque de nervios, adjusted for risk factors.¹

Neighborhood variable	Odds ratio	95% Confidence Interval	Standard error	p-value
Cohesion score	0.84	0.66–1.05	0.10	.13
Safety score	0.88	0.72–1.07	0.09	.19
Trust score	0.90	0.74–1.10	0.09	.31
Violence score	1.36	1.05–1.78	0.18	.02

The neighborhood variables were adjusted for gender, age, education status, perceived income, and marital status.

We adjusted for gender, age, education level, perceived income, and marital status, and observed that neighborhood violence was associated with ataque de nervios (p = .02), with each unit increase in the neighborhood violence scale being associated with 1.36 times greater odds of experiencing ataque de nervios. None of the other neighborhood variables (neighborhood cohesion, safety, or trust) were significantly associated with ataque de nervios in multivariate models.

Discussion

The purpose of this paper was to examine the association between perceived neighborhood social environmental factors and ataque de nervios in a Latino/a sample. To our knowledge, this is the first analysis of the association between ataque de nervios and perceived neighborhood social environment factors. Our hypothesis that neighborhood violence would be significantly associated with greater likelihood of experiencing ataque de nervios was supported by our findings. However, our hypotheses that neighborhood cohesion, safety, and trust would also be associated with lower likelihood of ataque de nervios were not supported. Experiencing ataque de nervios also was not associated with the demographic risk factors of gender, age, education, and marital status.

The results of this study are in line with previous research showing that neighborhood violence is associated with emotional distress, such as depression and anxiety, among Latinos/as (Alegría et al., 2002; Clark et al., 2008; Hong et al., 2014; Kataoka et al., 2003). Our study adds to existing evidence that neighborhood violence is associated with ataque de nervios in this population as well. Neighborhood violence also has been associated with trauma, stress, and anxiety among Latinos/as (Epstein-Ngo, Maurizi, Bregman & Ceballo, 2013; Jennings-Bay et al., 2015; Kataoka et al., 2003; Kennedy & Ceballo, 2013). Clark and colleagues (2008) found that Latina women who witnessed neighborhood violence were twice as likely to experience symptoms of depression and anxiety compared to those who did not. Mair and colleagues (2010) found that neighborhood violence was positively and significantly associated with depressive symptoms among Latino men and women. Both studies suggested that neighborhood violence was a risk factor for depressive and anxiety symptoms in their respective Latino/a cohorts. However, neither these nor other studies (Alegría et al., 2002; Hong et al., 2014; Kataoka et al., 2003; Tolin et al., 2007) examined the association between neighborhood violence and ataque de nervios. With ataque de nervios identified as a cultural expression of personal stress (Alcántara, Molina & Ichiro Kawachi, 2015, Alcántara et al., 2012; Kohrt et al., 2014; Lewis-Fernández & López, 2016), neighborhood violence should be considered a potentially influential factor in the etiology of ataque de nervios.

The findings of this study add to the growing literature on idioms of distress understood as cultural expressions of personal stress (Borra, 2011; Desai & Chaturvedi, 2017; Parsons, 1984). Specifically, the association between ataque de nervios and neighborhood violence contributes to the literature on the relationship between neighborhood characteristics with additional indicators of suffering. Ataque de nervios is an indicator of intense individual-level distress among Latinos/as that can be used by clinicians in assessing and treating Latino/a patients. Neighborhood violence remains an environment-level stressor found to be associated with ataque de nervios in this study.

Given our finding that neighborhood violence was associated with ataque de nervios, more research is needed on the role of this idiom of distress as a coping mechanism. Future studies on ataque de nervios also should examine neighborhood-level factors of Latinos/as across the lifespan, including childhood. As we did not find any significant associations between ataque de nervios and the other neighborhood-level variables, namely social cohesion, safety, and trust, more research is needed on the association between the lack of social cohesion and ataque de nervios in community-level settings. One possible explanation for the lack of association between ataque de nervios and social cohesion, safety, and trust is that, since this study was conducted with neighborhood-level variables in a community setting, these predictive variables might have been taken for granted by individuals who have lived in that community for an extended period of time or who otherwise assume that communities are supposed to provide safety and trust, and would therefore not be consciously aware of these factors (Cagney et al., 2007; Elliott & Sims, 2001; Kim et al., 2011; Tolin et al., 2007). As neighborhood violence is a deviation from neighborhood trust, safety, and overall cohesion, it would indeed cause emotional distress.

Our failure to find associations between most socio-demographic variables and ataque de nervios has a potential explanation. Our finding that demographic factors were not associated with ataque de nervios in this study could be explained by the relatively homogeneous characteristics of the study population. For example, the City of Lawrence (population 80,209) is 77% Latino/a; 46% of the Latino/a population live below the US federal poverty line (compared to 29% of the overall population in Lawrence) and Latinos are 50% less likely to graduate from a community or four-year college as are White students (Barber, 2017). Demographics are not consistently associated with increased (or decreased) risk of ataque de nervios (Guarnaccia, Lewis-Fernandez & Rivera Marano, 2003; Hinton et al. 2009), and demographics that might otherwise cause mental upset, such as lack of employment or prejudice due to being a visible minority, are protected against by the relative homogeneity of the population. The only demographic variable (perceived income) that met statistical significance (p = .04) can be theorized as being outside of participants’ control, as it pertains to factors like employment availability, the price of household necessities (like food and rent), and access to affordable health care options.

Keeping in line with Kohrt and colleagues’ (2014) recommendations about the need to recognize idioms of distress when developing treatment and policy options for mental health, the positive association between neighborhood violence and the experience of ataque de nervios can further make a case for policy efforts and other investments in improving neighborhood quality to reduce neighborhood violence. For example, previous studies have found that public transit and well-tended parks and recreation centers reduce neighborhood violence by 75% (Cerdá et al., 2012; Murillo, Echeverria & Vazquez, 2016; Perez et al., 2015). Our analysis suggests that, among other benefits, such investments could potentially improve emotional well-being, particularly ataque de nervios, among Latino/a community members.

In this study, we hypothesized that three neighborhood variables (namely, cohesion, safety, and trust) would predict a lower rate of ataque de nervios. However, this hypothesis was not supported. Our findings do not preclude the possibility that other neighborhood factors not assessed by this study could be protective against ataque de nervios. A more thorough understanding of protective factors is needed to support the development of more holistic treatment and prevention efforts that are accessible and sustainable at the neighborhood level.

Limitations

This study has several limitations. Our inability to establish causality/temporality in the study design precludes us from being able to determine whether participants who experienced/witnessed neighborhood violence are more likely to experience ataque de nervios. Due to the exploratory nature of this study, we did not conduct more in-depth analyses, such as mediational models or analyses. Such models could be the topic of future research. Furthermore, we did not run multivariate logistic regression models with ataque de nervios symptom severity. While previous studies (Guarnaccia et al., 2003; Hinton et al., 2008, 2009) have measured ataque de nervios severity, in this study we first wanted to establish a general correlation between ataque de nervios and neighborhood variables. We would like to look at severity in subsequent studies. Our measures relied on self-report surveys, which may be prone to recall bias and potentially social desirability bias. The Mujahid Neighborhood Scales used in this study (i.e., cohesion, safety, trust, and violence) have not been validated in Spanish, thus the results need to be replicated.

Of note as well is that the study sample was composed of Latino/a patients from a large community health center, and constituted 21.6% of a randomly selected age/sex-stratified group of patients. As such, the results might have limited generalizability. While this is a limitation of the study and could limit applicability of the findings to larger populations, previous studies have reported similar recruitment rates. For example, Kanuch and colleagues (2016) had a 34% recruitment rate for their study on serious mental illness and diabetes, while Carmichael and colleagues (2016) had a 38% response rate for their study on clinicians’ attitudes toward participants in mental health studies.

Another potential limitation has to do with the sample population, as all participants were recruited from the patient population of a large community health center. However, 80-85% of the Latino/a population in the city where the study was conducted seek health care services at this health center (Barber 2017).

Conclusion

This study provides evidence that ataque de nervios occurs in response to negative life events, especially at the neighborhood level. The results are important on several levels. They highlight the need for a deeper understanding of neighborhood contexts for ataque de nervios. In light of the association between neighborhood violence and ataque de nervios, more attention should be paid to contextual factors, such as the patient’s perception of neighborhood characteristics, when assessing ataque de nervios in the clinical setting and developing prevention and treatment programs. As our results add to extant research by finding ataques to be associated with one neighborhood-level variable, identifying ataque de nervios might help healthcare providers and policymakers address the underlying social issues. The association between neighborhood violence and ataque de nervios reinforces the need to invest resources into policies that decrease neighborhood violence.

Footnotes

Acknowledgments

We would like to thank Christine Foley Frisard for her valuable assistance with the statistical analyses. We acknowledge the contributions of our community partners and organizations who made this research possible: the Lawrence Mayor’s Health Task Force, the Lawrence Senior Center (Martha Velez, Martha Cruz, and Angelina García), the YWCA (Vilma Lora and Esther Alburquerque), the Greater Lawrence Family Health Center (Dean Cleghorn, Ph.D., Carlos Cappas-Ortíz, Jeffrey Geller, MD, Mary Kay, MD, and Donna Rivera, MSW) and our University of Massachusetts Medical School colleagues (Ira Ockene, MD and Lisa Fortuna, MD), students (Kate Pellegrini and Jessica Long) and staff (Karen Ronayne, Christine Frisard, and Dane Netherton). Funding: This research was generously supported grants from the National Institute of Mental Health (R01 MH085653), the Centers for Disease Control and Prevention (U48 DP005031-01), and the National Institute of Minority Health and Health Disparities (1 P60 MD006912-02).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Shir Lerman Ginzburg

Shir Lerman Ginzburg, PhD, MPH, is a research fellow in the Department of Public Health Sciences at UConn Health. Her research interests focus on mental health outcomes and food insecurity among underserved communities, particularly ethnic minorities. She is also currently conducting research on environmental health and air pollution. She is trained as a medical anthropologist and public health professional, and has conducted research on syndemics, mental health, chronic illness, obesity, diabetes, the Zika virus, Puerto Rico, and the United States. She has coedited three books, Gender, Health, and Society in Contemporary Latin America and the Caribbean, Foundations of BioSocial Health: Stigma and Illness Interactions, and Stigma Syndemics: New Directions in BioSocial Health, and has also published original research articles in journals such as Medical Anthropology, Medical Anthropology Theory, and PLOS One.

Stephenie C. Lemon, PhD, is Professor and Chief of the Division of Preventive and Behavioral Medicine in the Department of Population and Quantitative Health Sciences. She serves as Co-Director of the UMass Worcester Prevention Research Center and Director of the Community Engagement Core of the UMass Center for Clinical and Translational Science. Dr. Lemon is a recognized leader in chronic disease prevention and control research, implementation science, and community engagement in research. Dr. Lemon serves as Co-Director of an NCI-funded postdoctoral training program in implementation science and as Co-Director of an NHLBI-funded institutional K12 program in implementation science.

Milagros Rosal, PhD, is a clinical research psychologist and Professor in the Division of Preventive and Behavioral Medicine, and a faculty member in the Ph.D. Program in Clinical and Population Health Research, UMMS. She is Co-PI of the NIMHD-funded Center for Health Equity Intervention Research (CHEIR), and Associate Director of the CDC-funded Worcester County Prevention Research Center (PRC). The primary goals of Dr. Rosal’s research are to improve scientific knowledge of root causes of health disparities and to develop effective interventions to eliminate them. Her expertise is in the areas of prevention and management of obesity, diabetes, and cardiovascular disease; gestational weight gain and postpartum weight loss; patient adherence to cancer screening recommendations; and influence of psychosocial factors on health behavior change. Dr. Rosal is particularly interested in culturally responsive and literacy sensitive interventions tailored to Latino and African American/Black groups.

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