An integral member of an African refugee's healthcare team: the community health worker

All patients should be seen through a cultural lens however, refugees require this perspective as their past and journey have greater effects on their health. Meaningful evidence has been published regarding refugee patients and their unique circumstances in healthcare. To address these complexities of refugee health, community health workers should be integrated as a member of a refugee patient's healthcare team. Previous evidence supports the role of community health workers in the healthcare field as their shared experiences and cultural knowledge provides a unique perspective that bridges culture and health. This systematic review and subsequent interviews provide meaningful evidence that further sustains this role. METHODS: A systematic review was conducted in which evidence published in the US, 2013-present, using PubMed and Google Scholar search engines was evaluated. A total of 249 were retrieved, 16 articles met the criteria demonstrating evidence of the participation and active role of CHWs in a refugee's healthcare. These articles were further reviewed to analyze the specific roles and effects of CHWs in refugee patients' healthcare. To further understand the effect of CHWs in an African refugee patient's clinical experience, community health workers and healthcare providers were interviewed, and their responses analyzed. RESULTS: The comprehensive review of published literature showed that CHWs are a vital role in refugee patient healthcare by successfully navigating patients through complex healthcare systems, providing culturally appropriate care, and bridging the gap between health and culture. The interviews furthered understanding of CHWs role in a clinical setting specifically while working with African refugee patients. CONCLUSIONS: This project adds to the existing evidence supporting the integration of CHWs into an African refugee's healthcare team. This study reinforces CHWs importance in healthcare as they use their cultural expertise to facilitate trust among patients and facilitate appropriate care.

ABSTRACT BACKGROUND: All patients should be seen through a cultural lens however, refugees require this perspective as their past and journey have greater effects on their health. Meaningful evidence has been published regarding refugee patients and their unique circumstances in healthcare. To address these complexities of refugee health, community health workers should be integrated as a member of a refugee patient’s healthcare team. Previous evidence supports the role of community health workers in the healthcare field as their shared experiences and cultural knowledge provides a unique perspective that bridges culture and health. This systematic review and subsequent interviews provide meaningful evidence that further sustains this role. METHODS: A systematic review was conducted in which evidence published in the US, 2013-present, using PubMed and Google Scholar search engines was evaluated. A total of 249 were retrieved, 16 articles met the criteria demonstrating evidence of the participation and active role of CHWs in a refugee’s healthcare. These articles were further reviewed to analyze the specific roles and effects of CHWs in refugee patients’ healthcare. To further understand the effect of CHWs in an African refugee patient’s clinical experience, community health workers and healthcare providers were interviewed, and their responses analyzed. RESULTS: The comprehensive review of published literature showed that CHWs are a vital role in refugee patient healthcare by successfully navigating patients through ii complex healthcare systems, providing culturally appropriate care, and bridging the gap between health and culture. The interviews furthered understanding of CHWs role in a clinical setting specifically while working with African refugee patients. CONCLUSIONS: This project adds to the existing evidence supporting the integration of CHWs into an African refugee’s healthcare team. This study reinforces CHWs importance in healthcare as they use their cultural expertise to facilitate trust among patients and facilitate appropriate care. iii TABLE OF CONTENTS ABSTRACT ii INTRODUCTION 1 PHASE ONE: SYSTEMATIC LITERATURE REVIEW 4 PHASE TWO: INDIVIDUAL INTERVIEWS 7 INSTRUMENT 7 RESULTS 8 TRUST 8 ROLE OF CULTURE IN HEALTH 9 TRANSCULTURAL V. CULTURALLY 10 CONSONANT PROVIDER COMMUNITY HEALTH WORKERS: 13 SKILLS BEYOND INTERPRETATION DISCUSSION 16 CONCLUSION 17 REFERENCES 19 APPENDICES 23 iv 1 INTRODUCTION Pulling up to the parking lot, I could see Dr. Smith and his staff sitting outside, enjoying their lunch under the awning. Nervous, I walked to them. Dr. Smith welcomed me and introduced me to his staff, “This is Sidnee, she is a medical student at the University of Utah who will be shadowing me today.” The team, consisting of a receptionist and a medical assistant, smiled at me and pulled up a seat. Of course, the formalities began: How old are you? What year are you? What are you studying? My responses: 20, beginning my third year, international studies. My major always seems to shock people. A humanities major? What good will that do you in medical school? Following the usual script Dr. Smith said, “International studies? How interesting. It’s a good thing we have Sammy coming today.” The staff shifted, the receptionist let out a small sigh, “A yes, Sammy.” Failing to hide my puzzled expression, the medical assistant looked at me and said, “Sammy is a refugee from Africa, she is a frequent flyer and is quite dramatic.” Thoughts flying through my head, I managed to let out a nervous chuckle. A private practice for internal medicine, many of the patients we saw that day acted as old friends, always asking about Dr. Smith’s wife and children. Performing his role as a respected physician, Dr. Smith would complete the appointments in a pleasant manner and carry this attitude to his office to take notes. “He has a knee problem that results in an inability to exercise,” he would say, typing at his computer, “I suspect Type 2 Diabetes will become a problem in the future, but his wife will help keep it in check.” The second audible sigh of the day came around 1:30 PM, “Next is Sammy,” he said. He 2 gathered his materials, walked to his office door, and, before opening it, raised his eyebrows and exhaled, “Here we go.” I’m ashamed to admit, after hearing these reactions from the staff and the doctor, I was nervous. The patient in my head was erratic, pacing the room, demanding answers for their pains and, perhaps, demanding medication. Slowly opening the door, Dr. Smith peaked in his head saying, “Hello Sammy, I have a medical student shadowing me today, would it be alright if she sat in on our appointment?” Although I didn’t hear a reply, Dr. Smith opened the door fully and allowed me in. There was no erratic person in the room. No one demanding answers or drugs. Instead, there was a woman sitting in the plastic chair in the corner. She did not look angry or crazy but she was in pain and she was scared. Speaking slowly with a thick accent, she described a deep pain that shot down her back into her leg. Dr. Smith listened intently and asked an occasional question. Finally, he invited her to the examination table and asked for permission to touch her back. Starting between her shoulder blades. Dr. Smith pressed in and moved down. Pressing into her lower back, Sammy yelped. Dr. Smith continued and her groans grew louder. The exam ended, a plan was made, and we dismissed ourselves. Back in his office, Dr. Smith turned to me and said, “See? She is a bit dramatic.” Sammy was the last patient I saw that day. I left feeling uncomfortable and, frankly, a little sick. That once respectful environment of the office was plagued with negativity when Sammy arrived. Her pain was not seen as a symptom but as an act. This attention seeker was not here for a real problem, unlike the gentleman with onsetting diabetes, instead, she was there to put on her play. Whenever someone spoke of Sammy, they only spoke their gossip, no one told me her story. Where was she raised? What was 3 her primary language? What was her culture like? What circumstance brought her to the United States? What was her story? Maybe Dr. Smith and his staff didn’t know. Or, perhaps they thought it was irrelevant to her healthcare. How many refugee patients experience this? This bias that slashes their emotions into hysteria. This inability to be seen through a cultural lens. All patients should be seen through a cultural lens however, refugees require this perspective as their past and journey have greater effects on their health. A refugee, specifically, is a “sub-set of migrants who are defined by their reasons for displacement and fear of consequences if they return and who are afforded special protection and entitlements by international agreements,” (Matlin, et. al., 2018, p. 2). This definition, provided by authors in their analysis of refugee and migrant health, differentiates the status of a refugee from that of a migrant and begins to highlight the complex backgrounds that must be considered in healthcare. To address these complexities of refugee health, community health workers (CHWs) should be integrated as a member of a refugee patient’s healthcare team. A community health worker, as defined by the American Public Health Association (2022), is “a frontline public health workers who is a trusted member of and/or has an unusually close understanding of the community served.” Integrating CHWs into a refugee patient’s healthcare team is necessary because CHWs help build patients’ trust in their host country’s healthcare system, they act as a bridge and mediator between health and culture, and they decrease provider bias and mistreatment in refugee healthcare. Overall, the integration of CHWs into refugee healthcare will improve the health of refugees and the cultural knowledge of providers. 4 PHASE ONE: SYSTEMATIC LITERATURE REVIEW To further understand the effect of CHWs in the healthcare field, a literature review was conducted to specify the CHWs’ roles when working with refugee patients. This systematic literature review followed Judith Garrard’s (2017) Matrix Method and reviewed literature published in the United States from 2013 up to March 2023, using PubMed and Google Scholar search engines. A Boolean style search was conducted with the phrases, “community health worker OR CHW” and “refugee” in tandem to locate articles that highlighted the complex relationship between CHWs and refugees. In total, 249 titles and abstracts were received however, 227 articles were rejected as they did not satisfy the inclusion criteria including: being published and/or focused in the United States, focusing on CHW roles, and highlighting CHW effects on refugee populations. Refer to Figure 1. The remaining 22 were analyzed and a total of 16 were accepted into the final review following exclusion of duplicates. Refer to Appendix A for full analysis of included articles. 5 Figure 1 The remaining articles suggest that CHWs are vital to refugee health outcomes as most studies assessed that CHW-led interventions were indispensable to delivering culturally focused and effective programs that address unmet health/social needs within refugee communities. Overall, authors reported an improvement in prevention, treatment adherence, follow-ups, access to care, trauma-informed care, mental health care, and addressing social determinants of health. An overview of all articles included in this analysis can be reviewed in Appendix A. In regard to the CHWs’ specific role in the refugee’s healthcare, authors highlighted translation services, resource connection, community education, advocacy, and social support/patient navigation. Refer to Figure 2. All findings from this systematic literature review were compiled in a poster format and can be reviewed in Appendix B. 6 Figure 2 However, it is clear more research needs to be done in order to further understand the role of CHWs on refugee health outcomes therefore, Phase Two of this project will aim to extend this knowledge in identifying the role of community health workers within a clinical setting when supporting refugee patients. Although all refugee populations encompass unique health circumstances that result in complexities in health treatments, African refugee patients will be the focus in Phase Two of this project as the African continent encompasses over 50 countries with a vast variety of cultures and languages. Over the past 30 years, several countries within Africa have been victims to war, famine, and genocide; all resulting in mass exoduses of people trying to find safety. In fact, the United States’ Refugee Processing Center (RPC) has reported over 432,000 refugee admissions to the U.S. from Africa since 1975 (2023). Therefore, the remainder of this project will focus on new Americans with African refugee backgrounds and their experiences in the United States’ healthcare system and the specific effects of community health workers on this experience. 7 PHASE TWO: INDIVIDUAL INTERVIEWS In order to further understand the effect of CHWs on an African refugee patients’ clinical experience, the thoughts and narratives of those community health workers serving the African refugee community were sought in addition to healthcare providers and African refugee patients. Each interviewee was recruited through the University of Utah’s Department of Family & Preventive Medicine networks with eligibility requirements including an age of at least 20 years, acceptable English proficiency, and residency in the United States for at least one year. INSTRUMENT An interview guide was created focusing on each individual’s personal experience in a clinical setting including, but not limited to: African refugee patients specific needs, healthcare provider training, effect of CHWs, and the triangular relationship between African refugee patients, healthcare providers, and CHWs. The interview guide can be reviewed in Appendix C. All interviews were conducted and recorded via Zoom, then transcribed without identifiable information for further analysis. On average, each interview lasted approximately 25 minutes. In total, three healthcare providers and two community health workers were interviewed. Unfortunately, no individuals identifying as African refugee patients were successfully recruited for this project. As proposed by one community health worker, African refugee patients may not have felt comfortable using English in the interview, did not have time after working 2-3 jobs to make a living, or did not feel their participation 8 would reap any benefit. Despite the absence of a patient’s perspective, the information received from the interviews provided meaningful evidence that further sustains the value of CHWs in an African refugee’s clinical experience. RESULTS Participants provided their thoughts and experiences when serving the African refugee community in a clinical setting. Specifically, providers focused on the overarching themes they learned from serving African refugee patients, their training, and their feelings toward the inclusion of community health workers in the examination room. Conversely, CHWs provided insight on their specific role and effects when they are present in a clinical setting. Despite their different experiences, providers and CHWs alike highlighted the complexities and importance of culture in health as well as trust between the patient and the healthcare team. All findings are detailed below in sections including trust, role of culture in health, transcultural v. culturally consonant provider, and community health workers: skills beyond interpretation. All participants are named under their pseudonym. TRUST When speaking about trust, all participants expressed its importance in the examination room between the patient, the provider, and in certain situations, the community health worker. “I think trust is everything. I think trust is the most integral part of [the patientprovider] relationship. I think if a patient doesn’t trust you they’re not going to 9 listen to everything that you have to say. They might hear you but, they’re not going to take it to heart. If they don’t trust you, they are not going to tell you everything that is going on with them. If they feel like you’re judging them they’re going to be guarded.” Taylor, physician assistant Likewise, a community health worker stated: “Trust is huge, trust is very very important. I mean we saw it with the COVID issues. There were certain communities that were very hesitant with getting the COVID vaccine due to a lack of trust due to a past history and due to how their ancestors were treated, so they were very hesitant.” Charlie, CHW Consequently, healthcare providers and CHWs alike believe that culture has serious impacts on health and it cannot be ignored. In addition, both parties believe that, without trust, any medical visit can be unsuccessful resulting in poor health of the patient. ROLE OF CULTURE IN HEALTH Despite their differing roles, all participants shared common themes regarding culture, health, and trust. When asked about the connection between culture and health, all participants expressed that culture had a large impact on health. “There are cultural beliefs specifically around health. For example, maybe not putting a lot of faith into Western healthcare and maybe being more trusting in somebody who is a traditional healer but absolutely culture plays a big role into health decision making and even understanding diseases processes, etc.” Alex, nurse practitioner 10 Similarly, another participant suggested that culture not only impacts the food patients eat but even people’s living situations: “I think even thinking about things like their living situation like if someone has a respiratory virus and your like, ‘Oh, you need to isolate,’ but they are living in a multi-generational household with six other people, you can’t just tell them, ‘Oh, just stay away from people,’ because that’s part of who they are.” Sloan, CHW CHWs agreed saying that the connection between health and culture was “essential” as culture could influence many aspects of a person’s health. TRANSCULTURAL V. CULTURALLY CONSONANT PROVIDER All providers reported serving African refugees as their patients. Alex, for example, has been practicing as a nurse practitioner in family practice for over seven years and reported that “80% - 90% of [their] patient panel are refugees; many from Africa, although really from all parts of the world.” In addition, Blake has been a registered nurse for 25 years and treats Tuberculosis in patients, many which identify as African refugee. Although they have only been a licensed physician’s assistant for almost two years, Taylor offers a unique insight as they themselves identify as an African and serve African refugee patients in primary care. Despite their varying backgrounds, every provider reported receiving some form of cultural humility or cultural competency training that would help them treat patients from a background different from their own. In fact, Alex and Taylor explained it was a part of their role to deliver these trainings to their networks. When asked if these cultural humility trainings were applicable to real scenarios Taylor answers, “Absolutely, 11 especially if you are someone who values being able to provide care that is culturally sensitive that values the person and values their contribution to their own health, it has to be something that’s high yield for you.” Despite these trainings, all providers admitted the difficulty to practice complete cultural sensitivity. “We always have to recognize that our lived experiences are going to influence how we perceive the world around us and I don’t think any amount of training can like train that out of us and so I think we can strive to be open-minded and generally be so but … there’s maybe not a full understanding of the other person’s perspective or we don’t even recognize that maybe we’re not understanding the experience of another person or the beliefs of another person.” Alex, nurse practitioner When asked specifically about African refugee patients, no providers reported major confrontations or conflicts when serving them. However, all providers indicated an overall lack in understanding and health literacy among these patients. “[When meeting with African refugee patients] we haven’t had any confrontations or things like that I would say there is a decrease in understanding what we are asking of them. Normally, we are offering to treat them for latent tuberculosis (TB), which is a dormant stage of TB and they can take a prophylactic treatment but a lot of these places have a culture where taking medication when you are not sick is not something they are really fond of and mistrust of the government doesn’t help that very much. I would say, on average, maybe 30-40% of all refugees start latent TB treatment versus the 100% being offered to start the treatment.” Blake, registered nurse 12 Blake continued adding that only 5-10% of those infected with latent TB will activate which can lead morbidity and mortality. Yet, many of their patients do not understand the health benefits of this prophylactic treatment and decide to live with their latent TB despite the risk of health implications. In addition, Taylor supplemented this narrative describing the difficulty with their patient’s decreased health literacy. “Typically, before we have a visit, the patient will let us know what their preferred language is and then we try to set up an interpreter for that visit. I’m realizing that sometimes there are issues that go beyond just interpretation, sometimes there are issues surrounding health literacy where it’s not just straight interpretation. Where even though the patient might have an interpreter, their level of health literacy or just their education foundation, in general, might create a barrier for them to understand the information even though it is being presented in a language that’s their preferred language.” Taylor, physician assistant This misunderstanding, in turn, would result in patients not taking their medication correctly or feeling dissatisfied and overlooked in the visit ultimately resulting in their decreased appearance in future visits. Despite this barrier to care for African refugee patients, majority of providers presented uncertainty when asked about the effect of community health workers in the examination room with them and their patient. Although these providers had not yet had a CHW present in the clinical room, all expressed their willingness to have one present if the situation called for it. However, majority of providers expressed that the overall effectiveness of the community health worker in the visit would be dependent on the CHW themselves and the skills they employ, the patient, as well as the provider 13 themselves. The minority of providers, on the other hand, had already had a CHW present in the examination room with their patient and could speak to the effects they saw. “I think they are very effective in the fact that they are not just interpreters. I think the beauty of a having a community health worker is that that person understands the culture of that community that that person is coming from and they can actually explain things in a way that’s not just medical… [Also,] having someone from [the patient’s] community like automatically builds a sense of safety. It’s like going to a party and you don’t know anybody there versus going to a party with your best friend, you guys don’t know anybody there but at least you are together, right? It creates a sense of safety for me as well because I feel like I’m able to actually communicate with the patient… in a way that they understand and then being able to say that I have someone that I can reach out to if I need to provide additional information to the patient.” Taylor, physician assistant Taylor concluded the interview saying the relationship between CHWs and providers was important as CHWs were “bridging that divide between healthcare providers and refugee patients.” COMMUNITY HEALTH WORKERS: SKILLS BEYOND INTERPRETATION As a community health worker, Sloan has served the African refugee population for over 18 years. When asked what their motivations to become a CHW they responded: “I don’t think I chose to become a community health worker. I think the field chose me because I came here as a refugee and at that time there were not many 14 refugees from those countries that we serve… I realized that there was a need for me to serve my community. People are struggling in different ways, you know, starting from integration they are struggling with interpretation since many of them did not speak English so there was a need to bridge the gap between the American system and being a new arrival in this country so that’s when I decided to become a community health worker, so I can help my community to navigate and understand different systems that they couldn’t understand.” Sloan, CHW Within their job, Sloan reported that approximately 30% of their time as a CHW was spent in the examination room with their patients. Charlie, on the other hand, has been a CHW for five years and, similar to Sloan, chose to pursue their career due to the gaps they noticed between their community and the healthcare system. Unlike Sloan, Charlie does not spend much time in the clinical room but rather spends their time completing health promotion and community education. In terms of their specific role in the examination room, Sloan and Charlie say their presence is to make the patient feel comfortable. “One of the things my patients struggle with is not being comfortable when they go to see the providers. For example, they often feel intimidated, and respond, “Yes, sir. Yes. Yes. Yes,” to everything they are being told and, afterward, they don’t really understand. You have people come and say, “What did the doctor say?” and they’ll say “Oh, I don’t know” … I feel like, having a community health worker in that setting will really help, especially if that person relates to their patient and can make the patient feel more comfortable and also help the 15 doctor to help pass on his message and his message will be well understood.” Charlie, CHW By feeling the support of someone from their community, patients can have an ally and feel safe to share their experiences with their provider. In addition to adding a sense of comfort to the visit, CHWs’ presence can be a resource for the provider. “Providers having community health workers that they are working with will be really great because that community health worker can serve as a liaison especially if that community health worker can understand the culture of the patient… it’s a win-win for the provider because he has somebody there that understands his patient well. He can also work with the community health worker to listen to what his patient is saying and try to tailor whatever practice he has towards their belief to try to help the patient.” Charlie, CHW There can be a bidirectional sense of discomfort when one does not fully understand a culture and it can seem more intimidating to ask a person what is culturally appropriate for them but, as described, “Ask the question directly rather than ending up offending someone every time they come to visit.” Thus, a community health workers presence in the examination room can be a resource to the patient and the provider. 16 DISCUSSION Just as with Sammy and Dr. Smith, Charlie told a similar story. Speaking of common stereotypes African refugees face in the healthcare sphere, Charlie told the story of their close friend who went to the emergency room due to unbearable pain. However, due to the false notion that the African refugee community would too commonly go to medical institutes to retrieve pain medication, the friend was turned away because “he did not look like someone who was in pain.” They were told to go home and schedule an appointment the next morning. Unfortunately, the friend passed away before that night, without proper medical attention. While it is clear there is no “one-size” medical care when it comes to treating African refugee patients, the history and culture of each individual can affect how they view medical care. At this critical intersection of the sciences and the humanities, community health workers can elevate a provider’s understanding and empathy for patients that do not belong to their own cultural group. Although unintentional, providers may develop a blindfold to humanity and begin looking at patients only as data points or test results. As a member of the healthcare team, community health workers can reorient the provider to caring for human beings. Additionally, the healthcare team should be extended to incorporate community health workers to bridge this gap between science and the human experience because it is this disconnect between the science and humanities that leaves culture overlooked and promotes negative health outcomes in African refugee healthcare. 17 CONCLUSION This extension to community health workers should not require the CHW to be present during each medical visit nevertheless, CHWs should be held in high regard as a resource for patients and providers alike as they bridge this gap between culture and health. Although they had never had a community health worker present in the examination room, Blake explained that, as a part of their cultural training, refugee agencies will provide lessons with individuals from those countries that will share and introduction to background and cultural traits. In response, Blake and their team train the refugee agencies about Tuberculosis so they can better educate their clients once they arrive. It is this collaboration between community and healthcare that will lead to the decrease of health determinants amongst African refugee populations. Although healthcare providers, whether they be DNPs, MDs, or PAs, and CHWs have vastly different experiences and roles, each party’s overall goal is the same: to ensure the best health for all patients. Unfortunately, CHWs are often overlooked as a resource but their role in healthcare continues to gain attention yet, the uncertainty among providers can withhold their advancement. When asked what they wanted healthcare providers to know about their role, CHWs insisted that providers know they are not present to cause stress to the provider but, to provide comfort to all parties. “I know we are not there to speak on [the patient’s] behalf. We are not there to make decisions for them… I want providers to know that we are not there to watch or supervise them because they know what they are doing, they are experts in this area. We are just there to provide support and ensure the patient feels comfortable.” Sloan, CHW 18 Together, CHWs and healthcare provides can decrease health inequalities faced by African refugee patients. Although, it is clear more research needs to be done in this realm of refugee and community health. The effect of community health workers on underserved populations must be studied further in order to decrease the ever-growing gaps in healthcare. It is crucial to note that this project failed to receive a community voice besides that of the participating CHW although, it will be these community voices that will further sustain the role of CHWs for not only African refugee populations, but for all underserved communities in the United States. 19 REFERENCES American Public Health Association. (2022). 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J Community 22 Health, 41(3):526-34. Doi: 10.1007/s10900-015-0126-x. Zhang, M., Gurung, A., Anglewicz, P., Yun, K. (2021). Covid-19 and Immigrant Essential Workers: Bhutanese and Burmese Refugees in the United States. Public Health Rep, 136(1):117-123. doi: 10.1177/0033354920971720. 24 of Two Syrian Women in Rhode Island Toll E, Goldman RE. Co-creating a Theory of Change to advance COVID-19 testing and vaccine uptake in underserved communities Stadnick NA, Cain KL, Oswald W, Watson P, Ibarra M, Lagoc R, Ayers LO, Salgin L, Broyles SL, Laurent LC, Pezzoli K, Rabin B. Wagner J, Kong S, Kuoch T, Scully MF, Tan HK, BermudezMillan A. Patient Reported Outcomes of 'Eat, Walk, Sleep': A Cardiometabol ic Lifestyle Program for Cambodian Americans Delivered by support; translator communication, challenges accessing governmental benefits, navigating medical system Advocacy; cultural competence training; administrati ve planning of public health policy Increased mortality and morbidity from covid Non-specified Increased uptake of testing and vaccine usage increase access to governmental benefits, increase access to medical system Increased uptake of testing and vaccine usage Cardiometaboli Home visits; c lifestyle patient program education; translation Increased diabetes and hypertension, PTSD, MDD, depression, etc. Cambodian Refugees High satisfaction from patients; increased knowledge of cardiometabol ic prevention measures; improved preventive health High satisfaction from patients; increased knowledge of cardiometabol ic prevention measures; improved preventive health Testing and Vaccine Uptake in Underserved Communities transition period 25 Community Health Workers Self-reported pain among Cambodian Americans with depression: patientprovider communicatio n as an overlooked social determinant. COVID-19 and Immigrant Essential Workers: Bhutanese and Burmese Refugees in the United States. Berthold SM and Feinn R and BermudezMillan A and Buckley T and Buxton OM and Kong S and Kuoch T and Scully M and Ngo TA and Wagner J Zhang M and Gurung A and Anglewicz P and Yun K Pain management Conducted surveys Difficulty understanding healthcare provider and depressive symptoms Cambodian Refugees COVID19 Community health leaders Lack of interventions addressing risk factors from COVID19 Bhutanese and Burmese refugees behavior; decreased barriers to care Healthcare institutions should receive the resources necessary to secure patients' rights to clear communicatio n including trained community health workers. behavior; decreased barriers to care Higher pain scores were higher difficulty understanding healthcare provider predictors of lower addressed social determinants of health Lack of larger studies that include Asian immigrant subgroups, as well as immediate attention to protecting immigrant essential “We found that working in essential industries was associated with an increased risk of COVID-19 infection among Bhutanese and 26 Systematic review of the evidence on the effectiveness of sexual and reproductive health interventions in humanitarian crises. Early Medical Students' Experiences as System Navigators: Results of a Qualitative Study. workers during the COVID-19 pandemic. Sexual education needed including CHWs as a main part of the interventions Warren E Sexual and Post N reproductive and Hossain health M and Blanchet K and Roberts B Female community health workers referral to reproductive clinics Limited use of controls and inadequate attempts to address bias. Non-specified Qua K and Gullett H and WilsonDelfosse A and Thomas P and Singh M Patient navigators Providing early medical study’s system navigators skills Newly arrived Engage in refugee systems families thinking and systems analysis to identify advocacy opportunities for different levels of patient and health care team needs. Education to Medical students/Syste m navigation Burmese refugees.” Limited and lack of evidence base for SRH interventions Health Systems Science (HSS), emerging as critical content in medical education 27 Counting the Unsung by Promoting Participation in the 2020 US Census: A Survey of Migrant Workers in Washington State. PonceGonzalez I and Rodriguez CM and Cheadle A and Torrance S and Parchman M Systematic survey Deliver the interviews Migrants and refugees are a group particularly threatened by being undercounted, Hispanic migrant/ refugee nonspecific A Novel Strategy to Increase Identification of AfricanBorn People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 20122014. Help-Seeking Behavior and Health Care Navigation by Chandrasek ar E and Song S and Johnson M and Harris AM and Kaufman GI and Freedman D and Quinn MT and Kim KE A hepatitis education and prevention program Chain referrals Hepatitis B virus (HBV) African Refugees Yun K and Paul P and Subedi P and Kuikel L and Health care barriers, access to care Evidence based programs Lack of knowledge to navigate the health system Bhutanese refugees Involve oneon-one structured conversations, radio telenovelas, and community conversations organized by the trusted leaders. Chain referral strategy to implement HBV testing and identify many Africanborn people with chronic HBV infection Understandin g of the knowledge and attitudes of migrants toward the U.S. census. Sustained and repeated social modeling is required to Center-based model may not be feasible for refugees dispersed Need to develop HBVrelated education, screening, and linkage-tocare strategies that target African-born people 28 Bhutanese Refugees. Nguyen GT and Barg FK A Multicompone nt Health Education Campaign Led by Community Health Workers to Increase Influenza Vaccination among Migrants and Refugees. Cancer Community Education in Somali PonceInfluenza Gonzalez campaign IM and Perez K and Cheadle AD and Jade M and Iverson B and Parchman ML Workshops Health education in Influenza vaccine Latinx migrant/refug ee WatanabeGalloway S and Alnaji N and Grimm B Community education Female reproductive anatomy; breast and cervical cancer Somali Education program promote selfefficacy, particularly for community members with very limited literacy or cognitive challenges cause by age or illness. CHW-led workshops can be an effective way to increase knowledge about influenza and influenza vaccine. across suburban or rural areas where telephone or home visiting programs may be necessary. Improve education Improve education Significant improvements in all questions about the definition of influenza, symptoms, and risks 29 Refugees in Nebraska. and Leypoldt M Uptake of cancer screenings among a multiethnic refugee population in North Texas, 2014-2018. Raines Milenkov A and Felini M and Baker E and Acharya R and Longanga Diese E and Onsa S and Fernando S and Chor H Rogers HJ and Hogan L and Coates D and Homer CSE and Henry A Responding to the health needs of women from migrant and refugee backgroundsModels of maternity and postpartum care in highincome Prevention program Community education Literature review /access to care Patient navigators knowledge and screening; hepatitis C and liver cancer; and preparing for a health screening visit. Identifying differences in demographic and screening behaviors and acceptance among different refugee groups Displacement, resettlement, and migration may exacerbate health inequities Myanmar, Central Africa, Bhutan, Somalia, Arabic Speaking Countries, Pregnant Refugee non- specific Ailing to recognize the diversity within refugee communities and adapting to their specific cultural and linguistic needs with outreach, Demonstrate improvements in maternal and infant health outcomes, the interventions provide evidence of service elements that Overall, higher uptake of all types of cancer screenings was observed Obtain a greater understanding of socioeconomi c and cultural factors, health beliefs and practices that impact on service access. 30 countries: A systematic scoping review. align with women's 32 Appendix C Community Health Worker Background: As a community health worker, which community do you represent? How long have you been a community health worker? Why did you choose to become a community health worker? CHWs in a clinical setting How much of your time is spent helping patients in a clinical setting? How would you describe your role when helping patients in a clinical setting? Is there anything you wish providers knew about your role as a community health worker? Is there anything you wish your patients knew about your role as a community health worker? Culture and Health (cultural humility) In your opinion, how important is cultural humility for providers? In your experience, what can go wrong if a provider does not exhibit proper cultural humility? As a member of your community, what common stereotypes and biases do you face? Have these thoughts affected your health or your experience in healthcare? As a community health worker, have you actively “fought” cultural stereotypes and biases for the sake of your patients? How important, in your opinion, is the connection between health and culture? As a community health worker, how do you bridge this connection between health and culture in a clinical setting? Trust In your opinion, how important is trust in a patient-provider relationship? In your experience, what types of things can strain this trust between African refugee patient and provider? How do you build trust with your patients? How do you build trust with the providers? As a community health worker, how do you build the patient-provider relationship in a clinical setting? 33 African Refugee Patients Background Where are you from? How long have you been in the United States? How long have you been in Utah? Can you tell me a little bit of your experience coming to the United States? Since your time in the United States, have you seen a provider at the clinic (hospital, private office, etc.)? Do you share your culture with your provider? Culture and health (cultural humility) In your opinion, what is the relationship between culture and health? Do you feel it is important for providers to know their patient’s culture? Do you feel it is realistic for providers to know their patient’s culture? In your opinion, does your culture affect your health? As a member of your community, what common stereotypes and biases do you face? Have these thoughts affected your health or your experience in healthcare? What do you wish providers knew about your culture? Trust During your clinical visit(s), did you feel you could thoroughly trust your provider? Have you/will you continue seeing the same provider? In your opinion, how difficult is it to build a patient-provider relationship? What types of things strain this trust in a patient-provider relationship? Community health workers Are you familiar with community health workers? (if Yes) Have you had a community health worker present in a clinical setting? (If Yes) How did their presence affect your visit? Specifically, how did their presence affect your trust in your healthcare team? Would you say your visit was successful due their presence? Would you recommend community health workers to others in your community? (If No) Do you think the presence of a community health worker would affect your clinical visit? In what ways? (If No) [describe CHW and their roles] How do you think the presence of a CHW would affect your healthcare experiences? 34 Provider (white, African American providers, immigrant) Background How long have you been practicing in Utah? What is your specialty? Have you had any African refugee patients? Did you know anything about their culture/background before hand? Were there any difficulties during the visit? Culture and health (cultural humility) How important, in your opinion, is the connection between health and culture? How can a patient’s culture affect their health and treatment? Have you had any cultural humility (cultural competency) training? Were these trainings effective in practice? Have you experienced any biases (implicit or explicit) that have affected your visit with a patient? Is it realistic to expect complete cultural humility from providers for all patients? What about for African refugee patients? Trust In your opinion, how important is trust in a patient-provider relationship? In your experience, what types of things can strain this trust between African refugee patient and provider? How do you build trust with your patients? Community health workers Are you familiar with community health workers? (If Yes) Have you ever had one present during a visit with a patient? (If Yes) How did their presence affect your visit? (If No) Would you be willing to have a community health worker present when you visit with your patient? Do you feel the presence of a community health worker would affect your visit positively or negatively? Why? (If No) [describe CHW and their roles] Would you be willing to have a community health worker present when you visit with your patient? Do you feel the presence of a community health worker would affect your visit positively or negatively? Why? Name of Candidate: Sidnee Myers Date of Submission: May 03, 2023