Refugee Health and the Kentucky Global Health Center

In this University of Louisville Grand Rounds lecture, Drs. Rahel Bosson and Ruth Carrico give an overview of the real struggle of the refugee population and provide an update of the current state of refugee health in Kentucky. They also provide an overview of the Global Health Initiative at University of Louisville, which includes the follow programs: HIV/AIDs, Refugee Health and Immunization, Vaccine and International Travel and Global Health Research Support. The talk concludes looking to the future with a comprehensive Global Health Center composed of improving refugee orientation and EMR, healthcare worker education, developing guidelines, and bettering our surveillance and epidemiology surrounding global health populations

Treating Latent Tuberculosis Infection in Newly Arriving Refugees: An Advanced Practice Nurse Initiative at the University of Louisville Global Health Center

Background: A review of newly arriving refugees referred to the local health department for latent tuberculosis infection (LTBI) treatment during 2013-2015 revealed a treatment gap of 73%, supporting the need to identify new approaches to treat vulnerable populations and mirrored results in the literature. Objectives: 1) Describe an advanced practice registered nurse (APRN) led alternative approach to LTBI treatment in the refugee population; and 2) evaluate the impact of a 12-week regimen for LTBI on treatment acceptance, adherence and completion. Methods: During the initial health screening visit, treatment options were provided for those identified with LTBI consisting of either a 12-week regimen requiring weekly directly observed therapy (DOT) or the traditional 9-month treatment. Results: During March-December 2016, 50 refugees were referred and 24/50 were offered a 12-week regimen of Rifapentine and Isoniazid, administered with DOT. 23 of the 24 or 96% completed the entire treatment course. Conclusions: The new LTBI clinic process resulted in an increase in treatment acceptance and completion compared with the historic rate of 27%. Implications for Nursing: APRN initiatives such as this can result in positive benefits to patients and communities while serving to advance the nursing profession in all practice setting

Evaluating Mental Health in Cuban Refugees: The Role of the Refugee Health Screener-15

The Refugee Health Screener-15 (RHS-15) is widely used in refugee populations, but the psychometric properties and clinical utility have not been evaluated in Cuban refugees and entrants. The current study explored results from the Spanish version of the RHS-15 in a sample of 53 Cuban entrants and refugees, and of these, 17.6% screened positive for a mental health concern. Analyses suggested that a positive screening was significantly related to symptoms of anxiety, depression, and posttraumatic stress disorder; however, it was not associated with demographic variables such as gender, mode of transport, or the number of countries through which a refugee traveled before arriving in the United States. A factor analysis of the measure revealed a 4-factor solution is most appropriate when used with Cuban individuals. Results provide preliminary evidence regarding the measure’s psychometric properties, and demonstrate that the Spanish version of the RHS-15 is an appropriate screening tool for the mental health of newly arrived Cuban entrants and refugees. Future studies should further validate the Spanish version RHS-15 in Cuban entrants and refugees, and explore its efficacy amongst Latino refugees of other nationalities

Refugee-Centered Medical Home:A New Approach to Care at the University of Louisville Global Health Center

Refugees arrive to the United States with a full spectrum of health conditions, many of which involve intense case management requiring significant financial investments and use of healthcare resources. Kentucky receives more than 3,000 new refugees each year and ranked 10th in the nation for numbers of new arrivals resettled during 2015. These refugees arrive from diverse countries representing different cultures and speaking different languages. In addition, they arrive with diverse health conditions and medical needs. The aims of this paper are to share experiences from the University of Louisville Global Health Center regarding conceptualization, implementation and evaluation of a new care model. This model focuses on the complexities of caring for refugees from diverse populations and backgrounds. The foundation for this model aligns with the patient-centered medical home approach outlined by the Agency for Healthcare Research and Quality. Recognizing the need for a new paradigm for care, a refugee-centered medical home model was designed and implemented as an ideal approach

Health Profiles of Newly Arriving Refugees in Kentucky, 2016: Data from the University of Louisville Global Health Program

Objectives: Refugees resettling in the United States bring with them a number of health conditions, the majority chronic. These health conditions may impact their ability to be successful with disease self-management and employment, and acculturate and thrive in their new communities. Knowledge of health conditions present in individual refugee populations can be of benefit to healthcare providers in the community and public health. The objective of this manuscript is to describe the state of health among refugees newly arriving in the US and resettling in Kentucky during 2016. Methods: Using data from the domestic health screens, immunization clinics, and the Centers for Disease Control and Prevention Electronic Disease Notification, a database entitled Arriving Refugee Informatics Surveillance and Epidemiology (ARIVE) was developed and the Research Electronic Data Capture (REDCap) system used as the platform. Results: A total of 1495 adult and pediatric refugees were screened during January-June 2016 in Louisville, Lexington, Owensboro, and Bowling Green, Kentucky and data entered into ARIVE. Results from those domestic health screenings identified dental abnormalities (60%), obesity (23%), decreased visual acuity (14%), hyperlipidemia (14%), and elevated blood lead levels in child refugees (12%). Latent tuberculosis infection was identified in 13% and more than 32% had evidence of at least one intestinal parasite. Conditions of social importance included tobacco use among 16%. Mental health issues were evident as 15% had a positive Refugee Health Screener (RHS-15) result and more than 13% indicated they had witnessed or experienced torture. Conclusions: This analysis shows that the main health conditions facing refugees after arriving in the US are chronic conditions that require long‐term medical management and support services. Upon review of these results, a systematic approach to solving the problem of long‐term follow‐up needs to be established for refugees in order to address and decrease the impact of chronic health conditions. Using information from this Kentucky assessment may promote interest in a national refugee health database as a means of developing population-based and population-specific interventions to improve overall health

Use of Emergency Department for Care Access by Refugees Resettling in Kentucky, 2015: Findings from the University of Louisville Global Health Center

Background: Kentucky is one of the largest rural resettlement areas for refugees in the US welcoming more than 3,000 refugees and other entrants during 2015. Refugees arrive with a number of chronic health conditions that require ongoing management in a healthcare system where they lack knowledge and ability to navigate. This may encourage them to seek care that is easy to access but episodic and fragmented. The objective of this study was to determine the frequency and reasons for accessing care via a local emergency department by resettling refugees during their first twelve months of resettlement. Methods: Using data from domestic health screening, crossmatching was done with the Emergency Department (ED) database of a local university medical center. Records were reviewed to determine If the ED was accessed for care, day and time care was accessed, chief complaint at the time of ED arrival, discharge diagnosis and final disposition. Results: Of 2616 refugees seen for health screening during 2011-2015, 77 (3%) sought care in the ED at least one time during the twelve months following their arrival, encompassing a total of 96 unique ED visits. Of the 96 ED visits, 83 (86%) were seen and discharged with the remaining 13 (14%) being admitted to ULH or referred for admission to another facility (e.g., mental health). Of the 83 discharged visits, 51 (61%) were determined to be preventable ED visits. Care was accessed more frequently on Monday (19%), Sunday (18%) and Thursday (17%). 57 of the 83 discharged visits (69%) occurred during hours that reflect those common for routine business in a clinic setting (8 AM - 4 PM). Of ED visits during those routine business hours, 34 (60%) were determined to be preventable ED visits. Discussion: This study represents the first published data regarding ED use by refugees resettling into a single community. These data provide insight into the use of an ED as a point of care access and the role that access plays in refugee healthcare, especially during the earliest phase of resettlement. Conclusions: These data may serve to inform development of a refugee-centered medical home with the objective to improve access to coordinated and comprehensive care

Designing the Arriving Refugee Informatics Surveillance and Epidemiology (ARIVE) System: A Web-based Electronic Database for Epidemiological Surveillance

Objectives: We design and implement the Arriving Refugee Informatics surVeillance and Epidemiology (ARIVE) system to improve the health of refugees undergoing resettlement and enhance existing health surveillance networks. Materials and Methods: Using the REDCap electronic data capture software as a basis we create a refugee health database incorporating data from the Center for Disease Control and Prevention’s Electronic Disease Notification (EDN) system and domestic screening data from refugee health care providers. Results: Domestic screening and EDN refugee health data have been integrated for 13,824 refugees resettled from 35 different countries into the state of Kentucky from the years 2013-2016. Discussion: A flexible software solution like REDCap provides a way to implement the core of a health surveillance network in a way that is sustainable and cost-effective and REDCap’s data dictionary standard provides an easy way to share and improve the database structure of a health surveillance network

Mental and physical health profile of Syrian resettled refugees

BACKGROUND: Newly arriving Syrian refugees can present with specific health characteristics and medical conditions when entering the United States. Given the lack of epidemiological data available for the refugee populations, our study examined the demographic features of Syrian refugees resettled in the state of Kentucky. Specifically, we examined mental and physical health clinical data in both pre-departure health screenings and domestic Refugee Health Assessments (RHA; Kentucky Office for Refugees, n.d.) performed after resettlement. METHOD: The current study adopted a cross-sectional research design. We analyzed outcome data collected from participants from 2013 and 2015. Specifically, a comparative cross-sectional analysis was performed using clinical data from Syrian refugees who underwent an RHA as part of the resettlement process between January 2015 and August 2016. Those data were compared to data derived from refugees from other countries who resettled in Kentucky between 2013 and 2015. RESULTS: Mental health screenings using the Refugee Health Screener (RHS-15; Hollifield et al., 2013) found that 19.5% (n = 34) of adult Syrian refugees reported signs and symptoms from posttraumatic stress, depressive symptoms, and/or anxiety, and nearly 40% (n = 69) reported personal experiences of imprisonment or violence, and/or having witnessed someone experiencing torture or violence. Intestinal parasites and lack of immunity to varicella were the most prevalent communicable diseases among Syrian refugees. Dental abnormalities and decreased visual acuity account for the first and second most prevalent non-communicable conditions. When comparing these results to all refugees arriving during the same years, significant differences arose in demographic variables, social history, communicable diseases, and non-communicable diseases. CONCLUSION: This study provides an initial health profile of Syrian refugees resettling in Kentucky, which reflects mental health as a major healthcare concern. Posttraumatic stress and related symptoms are severe mental health conditions among Syrian refugees above and beyond other severe physical problems

Traumatic Experiences and Mental Health Risk for Refugees

Refugees who settle in Western countries exhibit a high rate of mental health issues, which are often related to experiences throughout the pre-displacement, displacement, and post-displacement processes. Early detection of mental health symptoms could increase positive outcomes in this vulnerable population. The rates and predictors of positive screenings for mental health symptoms were examined among a large sample of refugees, individuals with special immigrant visas, and parolees/entrants (N = 8149) from diverse nationalities. Logistic regression analyses were used to determine if demographic factors and witnessing/experiencing violence predicted positive screenings. On a smaller subset of the sample, we calculated referral acceptance rate by country of origin. Refugees from Syria, Iraq, and Afghanistan were most likely to exhibit a positive screening for mental health symptoms. Refugees from Sudan, Iraq, and Syria reported the highest rate of experiencing violence, whereas those from Iraq, Sudan, and the Democratic Republic of Congo reported the highest rate of witnessing violence. Both witnessing and experiencing violence predicted positive Refugee Health Screener-15 (RHS-15) scores. Further, higher age and female gender predicted positive RHS-15 scores, though neither demographic variable was correlated with accepting a referral for mental health services. The findings from this study can help to identify characteristics that may be associated with risk for mental health symptoms among a refugee population