Access to Healthcare Among US Adult Refugees: A Systematic Qualitative Review.

Refugees encounter numerous healthcare access barriers in host countries, leading to lower utilization rates and poorer health outcomes. In the US, social inequities and fragmented health systems may exacerbate these disparities. Understanding these factors is necessary to ensure equitable care of refugee populations. A systematic literature review of qualitative studies on US adult refugee healthcare access from January 2000 to June 2021 was performed in accordance with PRISMA. Studies were analyzed deductively and then inductively to incorporate previous findings in other resettlement countries and emergence of US-specific themes. 64 articles representing 16+ countries of origin emerged from the final analysis, yielding nine interrelated themes related to health literacy, cost of services, cultural beliefs, and social supports, among others. The main challenges to refugees' healthcare access emerge from the interactions of care fragmentation with adverse social determinants. Given diverse barriers, integrated care models are recommended in treating refugee populations.

Integrated model of primary and mental healthcare for the refugee population served by an academic medical centre.

Refugees are at increased risk for developing mental health concerns due to high rates of trauma exposure and postmigration stressors. Moreover, barriers to accessing mental health services result in ongoing suffering within this population. Integrated care-which combines primary healthcare and mental healthcare into one cohesive, collaborative setting-may improve refugees' access to comprehensive physical and mental health services to ultimately better support this uniquely vulnerable population. Although integrated care models can increase access to care by colocating multidisciplinary services, establishing an effective integrated care model brings unique logistic (eg, managing office space, delineating roles between multiple providers, establishing open communication practices between specialty roles) and financial (eg, coordinating across department-specific billing procedures) challenges. We therefore describe the model of integrated primary and mental healthcare used in the International Family Medicine Clinic at the University of Virginia, which includes family medicine providers, behavioural health specialists and psychiatrists. Further, based on our 20-year history of providing these integrated services to refugees within an academic medical centre, we offer potential solutions for addressing common challenges (eg, granting specialty providers necessary privileges to access visit notes entered by other specialty providers, creating a culture where communication between providers is the norm, establishing a standard that all providers ought to be CC'ed on most visit notes). We hope that our model and the lessons we have learned along the way can help other institutions that are interested in developing similar integrated care systems to support refugees' mental and physical health.

Advancing COVID-19 Vaccination Equity Among the Refugee Community: An Innovative Multi-Sector Collaborative Outreach Program.

INTRODUCTION: Multi-sector outreach collaborations have the potential to improve COVID-19 vaccine access among underserved populations, including refugees. METHODS: Using a four-pronged strategy, we offered the local refugee community COVID-19 vaccine appointments within the next week. RESULTS: Over a thousand (1,327) individuals from more than 20 countries were identified; mean age 36.5 (SD=16.4); 55% female. Initially, 613 (46%) reported being scheduled/vaccinated prior to outreach efforts; 312 (24%) appointments were scheduled that resulted from outreach efforts. By February 2022, 895 (67.4%) of the 1,327 patients had at least one dose; the majority of these were Pfizer (n=750, 84%). Of 895 with first dose, 843 completed two-dose series (94.2%). Overall completion rate of initial series was 63.5%. Reasons for declining (171, 13%) included wanting to speak with a physician or family member first; pregnancy hesitation; postponing until after Ramadan. DISCUSSION: Although lower than local and state rates, this refugee community's COVID-19 vaccine uptake is on par with the overall population in the United States (65.8%). Because of COVID-19's disproportionately negative impact on refugee and other underserved populations, we offer recommendations for future equity-informed efforts.

College students' intent to intervene with a hypothetical peer exhibiting depression: Leveraging lessons learned during the COVID-19 pandemic.

This study assesses college students' intent to intervene when presented with a hypothetical peer exhibiting depression in one of three scenarios: depression, sadness, and depression in quarantine during COVID-19. Using the Theory of Planned Behavior (TPB), variations in constructs associated with intent were examined by context (external triggers vs. no trigger), knowledge of, and experience with depression. One hundred and sixteen health sciences students read three vignettes and completed an enhanced TPB questionnaire. Intent to intervene was greater when the vignette target was experiencing depression with external stressors. Prior experience with depression and knowing someone with depression were associated with greater intent to connect the hypothetical peer to counseling resources regardless of vignette scenario. Due to increased mental health concerns resulting from the COVID-19 pandemic, efforts promoting awareness of mental illness in peers may benefit from increasing education about stressors and causes of depression that may not be observable.

Maternal Smoking, Alcohol and Recreational Drug Use and the Risk of SIDS Among a US Urban Black Population.

Background: Rates of sudden infant death syndrome (SIDS) are twice as high among Black infants compared to white infants in the US. While the contribution of sleep environment factors to this disparity is known, little is known about the risk of SIDS among Black infants in relation to maternal prenatal smoking, alcohol and drug use as well as infant smoke exposure. Objective: To assess the contribution of maternal substance use during pregnancy and the potential interactions with infant bedsharing in a high-risk, urban Black population. Methods: The Chicago Infant Mortality Study (CIMS) collected data on 195 Black infants who died of SIDS and 195 controls matched on race, age and birthweight. Risk of SIDS was calculated for maternal smoking, alcohol and drug use, adjusting for potential confounding variables and other risk factors for SIDS. Interactions between these substance use variables and bedsharing were also calculated. Results: Infants were more likely to die from SIDS if the mother smoked during pregnancy (aOR 3.90, 95% CI 1.37-3.30) and post-pregnancy (aOR 2.49, 95% CI 1.49-4.19). There was a dose response seen between amount smoked during pregnancy and risk of SIDS. Use of alcohol (aOR 2.89, 95% CI 1.29-6.99), cocaine (aOR 4.78, 95% CI 2.45-9.82) and marijuana (aOR 2.76, 95% CI 1.28-5.93) were associated with increased risk of SIDS. In the final, multivariable model controlling for sociodemographic factors and covariates, maternal smoking (aOR 3.03, 95% CI 1.03-8.88) and cocaine use (aOR 4.65, 95% CI 1.02-21.3) during pregnancy remained significant. There were significant, positive interactions between bedsharing and maternal smoking during pregnancy and post-pregnancy, alcohol use and cocaine use. Conclusion: Maternal use of tobacco, alcohol and cocaine during pregnancy is associated with significantly increased risk of SIDS in a Black, urban population. Reducing substance use and eliminating disparities in SIDS, sudden unexpected infant death (SUID) (also known as sudden unexpected death in infancy or SUDI) and infant mortality need to involve more than individual level education, but instead will require a comprehensive examination of the role of social determinants of health as well as a multi-pronged approach to address both maternal and infant health and wellbeing.

Telemedicine Use in Refugee Primary Care: Implications for Care Beyond the COVID-19 Pandemic.

The expansion of telemedicine during the COVID-19 pandemic offers an opportunity to reach vulnerable refugee communities with limited access to healthcare; however, there are limited data on characteristics of refugee patients that are associated with telemedicine use. We examined primary care encounters between March 2020 and February 2021. We compared telemedicine encounters among refugee and non-refugee patients and examined patient characteristics associated with telemedicine use in refugee patients. Overall, refugees used telemedicine less (aOR = 0.59, p < .001). Among refugee patients, telemedicine encounters were more likely if the patient had hypertension or diabetes, had an activated patient portal, carried private insurance and spoke English as their primary language. Telemedicine may be a useful modality of care management for refugee patients who require many follow-up visits; however, language barriers remain a concern. This is important to consider as telemedicine efforts continue and are expanded.

Improving Depression Screening in Primary Care: A Quality Improvement Initiative.

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

Risk of Postneonatal Infant Mortality Associated With Prior Founded Allegations of Child Abuse.

This study examined the association between prior reports of child abuse and subsequent postneonatal death and differences by cause of death, using data from the Chicago Infant Mortality Study (CIMS). CIMS included all sudden, unexplained infant deaths up to 1 year of age in Chicago (November 1993-April 1996), and age, race-ethnicity, and birthweight-matched living controls. Information on prior child abuse reports and outcomes was obtained through the Illinois Department of Children and Family Services (DCFS) State Central Registry for each case and control. Conditional logistic regression modeling determined the odds of postneonatal death when there was a founded prior allegation. Families with founded allegations were almost 4 times more likely to have a child die during the postneonatal period (aOR = 3.79, 95% CI, 1.56, 9.10). Child protective services involvement is an opportunity for education on safe sleep messaging to help reduce the incidence of potentially preventable infant deaths.

Depression, burnout, and professional outcomes among PAs.

OBJECTIVE: This study examined the effect of depression and burnout on PA professional fulfillment and medical errors. METHODS: Eight hundred eighty PAs completed an online survey containing the Professional Fulfillment Index, PHQ-2, GAD-7, and demographic questions. Two serial mediation models examined the relationship between depression, burnout, and professional outcomes. RESULTS: Burnout fully mediated the relationship between depression and outcomes in both models and the present research indicates that burnout plays a stronger role in job satisfaction than symptoms of depression. CONCLUSIONS: Understanding the underpinnings of professional satisfaction may mitigate clinician turnover, which in turn may lead to cost savings for the organization, better resilience and mental health for clinicians, and potentially better patient outcomes.

College student attitudes and strategies for intervention with a hypothetical peer exhibiting disordered eating.

OBJECTIVE: The present study assesses stigma, attitudes, and strategies of college students in intervening with peers demonstrating disordered eating behaviors. METHOD: Four hundred and eighty nine college students (384 women) completed questionnaires that assessed eating disorder symptoms and bystander attitudes adapted for disordered eating. Participants read one of three vignettes of a 20-year-old hypothetical peer displaying symptoms of disordered eating aligned with bulimia nervosa, anorexia nervosa, or binge-eating disorder; participants then described whether the vignette subject had a problem, what the problem was, and strategies for intervention. Relationships among eating disorder history, bystander attitudes, demographics, and intention to intervene in disordered eating were assessed using descriptive and regressive analyses; peer intervention strategies were organized and evaluated for frequencies of responses. RESULTS: Demographics (female-identification) and familiarity with disordered eating were associated with likelihood to intervene in disordered eating. Most students recognized that the peer had a problem, but fewer than half believed the problem was disordered eating; nearly a quarter (22%) of the students stated that they would be uncomfortable talking to a peer about disordered eating. The majority of students cited vague or nonproblem-related intervention strategies (62%), followed by emotion-focused strategies (22.5%), or body and behavior-focused strategies (15%). DISCUSSION: College students, particularly women and those with previous exposure to eating disorders, are likely to intervene peers disordered eating. However, students tend to use vague or body-focused intervention strategies. Bystander intervention training that provides rationale and rehearsal for supportive communication strategies is needed to address students' lack of intervention skills, particularly among men.

Does Perpetrator Occupation Affect Classification of Sexual Assault?

Classification of sexual assault varies based on the characteristics of the victim, perpetrator, and event. However, most studies focus on the individual characteristics of participants asked to classify the assault, the victims' characteristics, or the event; few have examined variations in the perpetrator. Therefore, this study examined whether the occupation of the perpetrator affected the classification of the event as sexual assault. Participants included a primarily White female sample of undergraduate students (n = 401) at a south-Atlantic university. They completed a paper-and-pencil survey containing an ambiguous sexual assault encounter where the occupation of the perpetrator (athlete, reporter, college student, or politician) was randomly varied. Participants were asked to classify whether the encounter was sexual assault and what an appropriate punishment might be. Additional measures included the Illinois Rape Myth Acceptance Scale (IRMA) and questions about personal experience with sexual assault. Overall, most participants labeled the encounter as sexual assault, indicating that college students are aware of the legal parameters for providing consent. However, this classification occurred differentially based on the occupation of the perpetrator. Participants were most likely to label the athlete as committing sexual assault, followed by the college student, politician, and reporter, respectively. Females and those who reject rape myths were more likely to label the scenario as sexual assault. A "personal apology" and a "sexual rehabilitation program" were the most common punishments selected for the perpetrator. These findings highlight potential concerns and the need for additional training when college students adjudicate sexual assault reports and determine appropriate consequences.

Women's Empowerment as a Mitigating Factor for Improved Antenatal Care Quality despite Impact of 2014 Ebola Outbreak in Guinea.

Improving maternal outcomes and reducing pregnancy morbidity and mortality are critical public health goals. The provision of quality antenatal care (ANC) is one method of doing so. Increasing women's empowerment is associated with positive women's health outcomes, including the adequate timing and amount of ANC use. However, little is known about the relationship between women's empowerment and quality ANC care. Despite a history of political instability, low women's equality and poor maternal health, the Republic of Guinea has committed to improving the status of women and access to health. However, the 2014 Ebola outbreak may have had a negative impact on achieving these goals. This study sought to examine factors in the relationship between women's empowerment and the receipt of quality ANC (indicated by the number of health components) within the context of the Ebola outbreak. This study conducted multiple logistic regressions examining associations between covariates and the number of ANC components received using data from the 2012 and 2018 Guinea Demographic Health Surveys. Several aspects of women's empowerment (healthcare decision-making, literacy/access to magazines, monogamous relationship status, contraceptive use, socio-economic status/employment) were significantly linked with the receipt of a greater number of ANC components, highlighting the importance of women's empowerment in accessing quality maternity care.

Variation and multilevel selection of SARS-CoV-2.

The evolution of SARS-CoV-2 remains poorly understood. Theory predicts a group-structured population with selection acting principally at two levels: the pathogen individuals and the group of pathogens within a single host individual. Rapid replication of individual viruses is selected for, but if this replication debilitates the host before transmission occurs, the entire group of viruses in that host may perish. Thus, rapid transmission can favor more pathogenic strains, while slower transmission can favor less pathogenic strains. Available data suggest that SARS-CoV-2 may follow this pattern. Indeed, high population density and other circumstances that favor rapid transmission may also favor more deadly strains. Health care workers, exposed to pathogenic strains of hospitalized patients, may be at greater risk. The low case fatality rate on the Diamond Princess cruise ship may reflect the founder effect-an initial infection with a mild strain. A vaccine made with one strain may confer limited immunity to other strains. Variation among strains may lead to the rapid evolution of resistance to therapeutics. Finally, if less pathogenic strains are largely associated with mild disease, rather than treating all SARS-CoV-2 positive individuals equally, priority could be focused on testing and contact tracing the most seriously symptomatic patients.

Assessing Burnout and Interest in Wellness Programs in Physician Assistant Students.

PURPOSE: Burnout among health care professionals and preprofessional health care students is of growing concern because of its detrimental effects on performance, mental health, and physical health. Research to date has focused primarily on physicians and medical students. The purpose of this study was to assess burnout and the quality of life among physician assistant (PA) students and gauge their interest in specific wellness interventions that address those issues in their PA program. METHODS: An online survey consisting of validated measures for burnout and quality of life was completed by 320 PA students from all 8 Virginia PA programs (n = 8). Additionally, student interest in various wellness interventions was assessed, including preferences for timing and delivery, to inform development of a tailored well-being component in the PA curriculum to reduce burnout. RESULTS: We found burnout to be prevalent among PA students, with 79.69% reporting high levels of emotional exhaustion; 56.56% of students met the criteria for cynicism. Survey participants rated stress reduction (n = 290, 90.63%) and burnout (n = 299, 93.44%) as primary issues that need to be addressed in the PA student population. Furthermore, 77.50% of participants expressed interest in participating in a wellness intervention designed to reduce burnout. CONCLUSION: Given the high prevalence of burnout in the PA students surveyed, resources and potential interventions that reduce burnout need to be identified. The current study identified PA students' perceived needs and interest in various aspects of potential wellness interventions in the PA program. Students preferred an emphasis on stress reduction and burnout, which can be used to develop a tailored well-being curriculum to promote work-life balance and stress management for PA students.

Evaluating antenatal care in Liberia: evidence from the demographic and health survey.

Liberia has one of the highest maternal mortality ratios worldwide. Using quality antenatal care (ANC) can prevent maternal mortality. Indicators of quality ANC include: (1) timing of care initiation; (2) number of ANC visits (4+); and (3) ANC with recommended components. The purpose of this study was to examine factors associated with quality ANC in Liberia. Data from the 2013 Liberia Demographic and Health Survey were used (n = 5,348). Factors associated with quality ANC were assessed using multiple logistic regression. The majority of women attended at least four ANC visits (76.13%) and initiated care in the first trimester (66.5%); however, only 30% received care with all recommended components. Intended pregnancy, contraceptive use, and receiving ANC at a health facility with skilled providers were significantly associated with quality care. The lack of quality ANC may contribute to the high maternal mortality in Liberia. Facilitating access to health facilities and skilled ANC providers could improve the quality of care and potentially improve maternal outcomes over time. Additionally, focusing on empowering women with respect to access to birth control and control over pregnancies may increase the use of quality care.

Impact of a Hand Hygiene Curriculum and Group Handwashing Station at Two Primary Schools in East Africa.

Proper handwashing reduces the transmission of deadly, preventable diseases. Schools, even those with limited resources, have the power to promote handwashing through simple, effective interventions. This study evaluated the impact of a school-based handwashing program consisting of two interventions: a hand-hygiene curriculum and group handwashing station. Quantitative and open-ended pre/postintervention surveys were administered to students at one primary school in Kenya ( n = 38) and at one primary school in Uganda ( n = 57). Matching procedures were followed at each school. Paired ttests for pre/postsurveys demonstrated an increase in students' knowledge ( p < .001) and frequency of handwashing ( p < .001). After 6 months, students were still engaging in daily group handwashing. The curriculum increased knowledge, and the handwashing station enabled students to translate their knowledge into action. This study supports educational interventions combined with built environmental interventions should be used to promote handwashing behaviors and emphasizes the role of group handwashing stations.

Extreme body messages: themes from Facebook posts in extreme fitness and nutrition online support groups.

BACKGROUND: Extreme fitness and nutrition programs, that are said to "jump start" a healthy lifestyle, are becoming more pervasive. While some research has explored the harmful impact of fitspiration, thinspiration, and pro-anorexia/bulimia websites, no studies have examined the content associated with these extreme programs that advertised as promoting a healthy lifestyle. The objective of this study was to analyze posts found on extreme fitness and nutrition program support pages on Facebook. As these programs have become more popular, along with Facebook platforms for their participants, examining online user-generated posts related to these programs can provide information about the types of messages being promoted, and whether these can contribute to disordered eating and other harmful health behaviors. METHODS: User data were selected from one month from public posts on two popular Facebook fitness groups. Both groups were short-term programs that set extreme guidelines for fitness and nutrition. Researchers examined the data for harmful health messages using an individual coding strategy with inter-rater reliability (Kappa =0.92). RESULTS: Majority (88.6%) of messages analyzed promoted harmful health messages. Common categories of messages included losing weight/fat, promoting dieting/restraint, and harmful body messages, which promoted unsafe ways to attain certain body types. CONCLUSIONS: The data analyzed in this study represent overwhelmingly negative commentary relating to harmful health and body messages. Messages in this study normalized dysfunctional behaviors and promoted fixating on certain body parts and objectifying bodies. These Facebook groups, though intended to be a sort of online support forum, provide an open space for body negativity and promotion of extreme behaviors for the sake of thinness. Most concerning, participants of these programs, which are advertised as promoting health, are expressing unhealthy thoughts and behaviors surrounding food, exercise, and body image. Given the ease of accessibility to this content using online platforms, these harmful messages can reach large groups of people and continue adding to a culture that values physical appearance to the detriment of health.

Predictors of exclusive breastfeeding across three time points in Bangladesh: an examination of the 2007, 2011 and 2014 Demographic and Health Survey.

Background: The objective of this study was to explore predictors of exclusive breastfeeding (EBF) in Bangladesh using data from 2007, 2011 and 2014, specifically focusing on potential reasons why rates of EBF changed over those time periods. Methods: Data on mother/infant pairs with infants <6 months of age were examined at the three time points using the Bangladesh Demographic and Health Survey. The EBF prevalence, changes in EBF since the previous survey and determinants of EBF at each time period were examined using t-tests, χ2 and multilevel logistic regression. Results: The prevalence of EBF was 42.5, 65 and 59.4% in 2007, 2011 and 2014, respectively. The age of the child was significantly associated with EBF across all time points. The largest changes in EBF occurred in the 3- to 5-month age group. Predictors of EBF in this specific age group were similar to overall predictors (e.g. age of the child and region). Participation of the mother in household decisions was a significant predictor in 2014. Conclusions: EBF prevalence in Bangladesh increased between 2007 and 2011 and then decreased between 2011 and 2014. The increase in 2011 may have been the result of widespread initiatives to promote EBF in that time frame. Due to the unexplained decrease in EBF between 2011 and 2014, there is still a need for interventions such as peer counselling, antenatal education and community awareness to promote EBF.

Antenatal HIV Testing in Sub-Saharan Africa During the Implementation of the Millennium Development Goals: A Systematic Review Using the PEN-3 Cultural Model.

This study systematically explored the barriers and facilitators to routine antenatal HIV testing from the perspective of pregnant women in sub-Saharan Africa during the implementation period of the Millennium Development Goals. Articles published between 2000 and 2015 were selected after reviewing the title, abstract, and references. Twenty-seven studies published in 11 African countries were eligible for the current study and reviewed. The most common barriers identified include communication with male partners, patient convenience and accessibility, health system and health-care provider issues, fear of disclosure, HIV-related stigma, the burden of other responsibilities at home, and the perception of antenatal care as a "woman's job." Routine testing among pregnant women is crucial for the eradication of infant and child HIV infections. Further understanding the interplay of social and cultural factors, particularly the role of women in intimate relationships and the influence of men on antenatal care seeking behaviors, is necessary to continue the work of the Millennium Development Goals.

Determinants of contraceptive use among Nigerian couples: evidence from the 2013 Demographic and Health Survey.

BACKGROUND: Nigeria remains a focus for increasing contraceptive use, as it is one of the most populous countries in Sub-Saharan Africa. The objective of the current study was to investigate determinants of contraceptive use in Nigeria couples. METHODS: Using the 2013 Nigeria Demographic and Health Survey, we estimated the likelihood of contraceptive use based on concordance with male partner desire for family size, male and female fertility preferences, female decision making power, and male partner attitudes toward contraceptive use. RESULTS: Male partner perception that decisions regarding health should be made jointly or primarily by women was positively associated with use. Women were less likely to use contraceptives in couples in which male partners had greater earning power. Finally, men who viewed contraceptives as an enabler for promiscuity had female partners less likely to use contraceptives. CONCLUSIONS: These findings highlight the importance of male partners in women's contraceptive decision making.