The women's health needs study among women from countries with high prevalence of female genital mutilation living in the United States: Design, methods, and participant characteristics.

BACKGROUND: The Women's Health Needs Study (WHNS) collected information on the health characteristics, needs, and experiences, including female genital mutilation (FGM) experiences, attitudes, and beliefs, of women aged 18 to 49 years who were born, or whose mothers were born, in a country where FGM is prevalent living in the US. The purpose of this paper is to describe the WHNS design, methods, strengths and limitations, as well as select demographic and health-related characteristics of participants. METHODS: We conducted a cross-sectional survey from November 2020 -June 2021 in four US metropolitan areas, using a hybrid venue-based sampling (VBS) and respondent-driven sampling (RDS) approach to identify women for recruitment. RESULTS: Of 1,132 participants, 395 were recruited via VBS and 737 RDS. Most were born, or their mothers were born, in either a West African country (Burkina Faso, Guinea, Mali, Mauritania, Sierra Leone, The Gambia) (39.0%) or Ethiopia (30.7%). More than a third were aged 30-39 years (37.5%) with a majority who immigrated at ages ≥13 years (86.6%) and had lived in the United States for ≥5 years (68.9%). Medicaid was the top health insurer (52.5%), followed by private health insurance (30.5%); 17% of participants had no insurance. Nearly half of women reported 1-2 healthcare visits within the past 12 months (47.7%). One in seven did not get needed health care due to cost (14.8%). Over half have ever used contraception (52.1%) to delay or avoid pregnancy and 76.9% had their last pelvic and/or Papanicolaou (pap) exam within the past 3 years. More than half experienced FGM (55.0%). Nearly all women believed that FGM should be stopped (92.0%). CONCLUSION: The VBS/RDS approach enabled recruitment of a diverse study population. WHNS advances research related to the health characteristics, needs, and experiences of women living in the US from countries where FGM is prevalent.

The Need for Standardized Nomenclature in Electronic Documentation of Female Genital Cutting in Health Records.

To evaluate the quality of Electronic Health Record (EHR) documentation practices of Female Genital Cutting (FGC) by medical providers. A retrospective chart review study of 99 patient encounter notes within the University of Minnesota health system (inclusive of 40 hospitals and clinics) was conducted. Extracted data included but was not limited to patient demographics, reason for patient visit, ICD code used in note, and provider description of FGC anatomy. Data was entered into REDCAP and categorized according to descriptive statistics. Out of 99 encounters, 45% used the unspecified code for FGC. The most common reason for patient visits was sexual pain, though many notes contained several reasons for the visit regarding reproductive, urological, or sexual concerns. 56% of visits discussed deinfibulation. 11 different terms for FGC were used, with "female circumcision" being the most common. 14 different terms for deinfibulation were found within 64 notes. 42% of encounters included a description of introitus size in the anatomical description, and only 38% of these provided a metric measurement. This study found significant variation in the quality of FGC documentation practices. Medical providers often used the unspecified FGC code, subjective and/or seemingly inaccurate descriptions of FGC/anatomy, and several different terms for both FGC and deinfibulation. Clearly, more education is needed in clinical training programs to (1) identify FGC type, (2) use the corresponding ICD code, and (3) use specific, objective descriptions (including presence/absence of structures and infibulation status).

"If You Don't Have the Heart to Help, You Cannot Do This Job": The Multidimensional Wellbeing of Community Health Workers Serving Refugees During the COVID-19 Pandemic.

Community health workers are members of two groups whose short- and long-term health has been uniquely shaped by the COVID-19 pandemic: health workers and the oft-marginalized populations that they serve. Yet, their wellbeing, particularly of those serving resettled refugees, before and during the pandemic has been largely overlooked. Drawing from a holistic conceptualization of wellness, this study examined the effects of the COVID-19 pandemic on a group of cultural health navigators (CHNs), who serve resettled refugees. We conducted semi-structured individual interviews with CHNs at a southwestern U.S. hospital system between July and August 2020, a critical time in the pandemic. Our analysis produced four themes that encapsulate the effects of the pandemic on CHN wellbeing: (1) "You fear for your life": Chronic risk of COVID-19 exposure takes a toll on physical, emotional, and environmental wellbeing; (2) "It is stressful because it is completely new": Uncertainty diminishes occupational, financial, and emotional wellbeing; (3) "If you don't have the heart to help, you cannot do this job": CHNs remain committed while facing challenges to their occupational wellbeing on multiple fronts; and (4) "Now, you cannot release your stress": Loss of and shifts in outlets integral to social and spiritual wellbeing. The findings deepen empirical understanding of how the pandemic affected the holistic wellbeing of CHNs, as they continued to serve their communities in a time of crisis. We discuss the implications for addressing the multidimensionality of community health worker wellbeing in research, policy, and practice.

African Immigrant Women's Maternal Health Experiences in Clarkston, Georgia: A Qualitative Study.

Introduction: The maternal health experiences of African immigrant women, their utilization of health care services, and the effects on maternal health have received limited attention in research. This research explored the maternal health experiences of African immigrant women residing in Clarkston, Georgia, and their use of health services. Methods: Fourteen African immigrant women responded to semistructured interviews. An adapted version of the Andersen health care utilization model explained the predisposing factors, enabling factors, and need factors, which influence the use of maternal health care for African immigrant women. Results: Findings were presented according to the Andersen health care utilization model. Analysis of the interviews resulted in 11 themes. The themes were as follows: (1) Community social structure, (2) community health beliefs, (3) health organization concerning the use of women, infants, and children, (4) social support at the individual level, (5) limited English proficiency, (6) need for better health education, (7) perception of care, (8) health financing, (9) long wait times and lack of transportation, (10) fear of medication and obstetrical interventions, and (11) impact of Female Genital Mutilation/Cutting. Discussion: Maternal health practices of African immigrant women are impacted by environmental and cultural factors. Public health interventions should be implemented to advance African immigrant women's health care utilization practices through required health education and tailored care, which will translate to positive maternal health experiences.

Female genital cutting (FGC) type: proposing a multifaceted, interactive method for FGC self-assessment.

BACKGROUND: Self-reporting female genital cutting (FGC) status and types by patients and clinicians is often inconsistent and inaccurate, particularly in community settings where clinically verifiable genital exams are not feasible or culturally appropriate. AIM: In this study we sought to discern whether integrating multiple dimensions of participant engagement through self-reflection, visual imagery, and iterative discourse informed the determination of FGC status by a panel of health and cultural experts using World Health Organization (WHO) typology. METHODS: Using community-based participatory research, we recruited 50 Somali women from the Minneapolis-St. Paul, MN, metropolitan area through convenience and snowball sampling to participate in semi-structured interviews. Participants were asked to discuss their recollection of their original circumcision-including the procedure itself and their assessment of the type of circumcision they experienced. Anatomical drawings of uncircumcised and circumcised vulvas were shown to participants to assist them in identifying their FGC type. A panel of health and cultural experts reviewed and independently assessed participant FGC type. Interrater reliability and degree of concordance between participants and panel were determined. OUTCOMES: Outcomes included the following: (1) development of WHO-informed, anatomically accurate visual depictions of vulvas representing FGC typology, (2) development of an iterative, self-reflective process by which participants self-described their own FGC status aided by visual depictions of vulvas, (3) application of WHO FGC typology by a panel of health and cultural experts, and (4) determination of the degree of concordance between participants and panel in the classification of FGC type. RESULTS: High interrater reliability (kappa = 0.64) and concordance (80%) between panel and participants were achieved. CLINICAL TRANSLATION: Incorporation of FGC visual imagery combined with women's empowered use of their own self-described FGC status would optimize clinical care, patient education, and informed decision making between patients and their providers when considering medical and/or surgical interventions, particularly among women possessing limited health and anatomic literacy. STRENGTHS AND LIMITATIONS: Strengths of this study include the incorporation of anatomically accurate visual representations of FGC types; the iterative, educational process by which participants qualitatively self-described their FGC status; and the high interrater reliability and concordance achieved between panel and participants. Study limitations include the inability to conduct clinical genital exams (due to the community-based methodology used), recall bias, and small sample size (n = 50). CONCLUSION: We propose a new patient-informed educational method for integrating anatomically accurate visual imagery and iterative self-reflective discourse to investigate sensitive topics and guide clinicians in providing patient-centered, culturally informed care for patients with FGC.

Beautiful vulvas: expanding illustrative visual imagery of female genital cutting types.

BACKGROUND: Visual imagery has been used to educate healthcare providers, patients, and the lay public on female genital cutting (FGC) typology and reconstructive procedures. However, culturally inclusive, diverse, and anatomically accurate representation of vulvas informed by women possessing lived experience of FGC is lacking. AIM: We sought to apply World Health Organization (WHO) FGC typology to the development of type-specific visual imagery designed by a graphic artist and culturally informed by women with lived experience of FGC alongside a panel of health experts in FGC-related care. METHODS: Over a 3-year process, a visual artist created watercolor renderings of vulvas with and without FGC across varying WHO types and subtypes using an iterative community-based approach. Somali women possessing lived experience of FGC were engaged alongside a team of clinician experts in FGC-related care. Women and clinicians provided descriptive input on skin color variation, texture, and skin tone, as well as the visual depiction of actions necessary in conducting a genital examination. OUTCOMES: A series of vulvar anatomic illustrations depicting WHO FGC typology. RESULTS: FGC types and subtypes are illustrated alongside culturally informed descriptors and clinical pearls to strengthen provider competency in the identification and documentation of FGC WHO typology, as well as facilitate patient education, counseling, shared decision making, and care. CLINICAL IMPLICATIONS: Ensuring equitable representation of race, gender, age, body type, and ability in medical illustrations may enhance patient education, counseling, and shared decision making in medical and/or surgical care. FGC provides a lens through which the incorporation of patient-informed and culturally relevant imagery and descriptors may enhance provider competency in the care of FGC-affected women and adolescents. STRENGTHS AND LIMITATIONS: The strengths of this study include the development of visual imagery through an iterative community-based process that engaged women with lived experience of FGC alongside clinicians with expertise in FGC-related care, as well as the representation of historically underrepresented bodies in the anatomical literature. Study limitations include the lack of generalizability to all possible forms or practices of FGC given the focus on one geographically distinct migrant community, as well as the reliance on self-report given the inability to clinically verify FGC status due to the community-based methodology employed. CONCLUSION: Patient-informed and culturally representative visual imagery of vulvas is essential to the provision of patient-centered sexual health care and education. Illustrations developed through this community-engaged work may inform future development of visual educational content that advances equity in diverse representation of medical illustrations.

Rates of Cervical Cancer Screening and Dysplasia Among Refugees in a Health Care Safety Net System.

Refugees may be at higher risk of cervical dysplasia. The prevalence of screening, pathology, risk factors, and management of patients in our Refugee Women's Health Clinic (RWHC) was assessed. A retrospective review of RWHC patient records between 2009 and 2015 assessed demographic factors, medical history, initial chief complaint, prevalence of screening, HPV status, and loss to follow-up. We reviewed 696 charts; 84.2% (n = 586) were successfully screened. Prevalence of dysplasia was 6.8% (n = 40). Among those, 5% (n = 2) had high-grade dysplasia, equivalent to 0.34% of the screened population. Only 43.6% received indicated colposcopy. FGM/C was associated with non-statistically significant higher rate of dysplasia, at 11.3%. HIV was associated with a statistically significant higher rate of dysplasia at 36.8% (p < 0.001). The rate of high-grade cervical dysplasia among refugees in RWHC is similar to their home countries. RWHC patients were screened at a higher rate than the general Arizona population.

Health outcomes and female genital mutilation/cutting: how much is due to the cutting itself?

While Female Genital Mutilation/Cutting (FGM/C) continues to garner global attention, FGM/C-affected migrant communities, who are often racialized minorities in the U.S., face additional challenges which may impact their physical and mental health and well-being. It has been proposed that an overly narrow focus on the female genitalia or FGM/C status alone, while ignoring the wider social experiences and perceptions of affected migrant women, will result in incomplete or misleading conclusions about the relationship between FGM/C and migrant women's health. A cross-sectional study was conducted across two waves of Somali and Somali Bantu women living in the United States, (n = 879 [wave 1], n = 654 [wave 2]). Socio-demographics, self-reported FGM/C status, perceived psychological distress, and self-reported FGM/C-related health morbidity was examined against self-reported experiences of everyday discrimination and perceived psychosocial support. In statistical models including age and educational attainment as potentially confounding socio-demographic variables, as well as self-reported FGM/C status, self-reported discrimination, and perceived psychosocial support, self-reported discrimination was the variable most strongly associated with poor physical health and psychological distress (i.e., FGM/C-related health morbidity and psychological distress), with greater perceived psychosocial support negatively associated with psychological distress, when controlling for all the other variables in the model. FGM/C status was not significantly associated with either outcome. Discrimination, more frequently reported among 'No FGM/C' (i.e., genitally intact or unmodified) women, was most frequently perceived as linked to religion and ethnicity. Our findings are consistent with views that discrimination drives negative outcomes. In this population, discrimination may include the 'quadruple jeopardy' of intersecting relationships among gender, race, religion, and migration status. We find that self-reported experiences of discrimination-and not FGM/C status per se-is associated with adverse physical and mental health consequences in our sample drawn from Somali migrant communities living in the United States, and that social support may help to mitigate these consequences. Our findings thus reinforce calls to better contextualize the relationship between FGM/C and measures of health and well-being among Somali women in the United States (regardless of their FGM/C status), taking psychosocial factors more centrally into account.Clinical Trials.Gov ID no. NCT03249649, Study ID no. 5252. Public website: https://clinicaltrials.gov/ct2/show/NCT03249649.

Influence of Female Genital Mutilation/Cutting on Health Morbidity, Health Service Utilization and Satisfaction with Care among Somali Women and Teenage Girls in the United States.

INTRODUCTION: There is scant evidence on the health morbidities experienced by Somali women and girls affected by female genital mutilation/cutting (FGM/C) and their resultant health-seeking behavior in the USA as compared to those who have not undergone the procedure. To fill this gap, we conducted a comprehensive examination of health morbidity among women and teenage girls with and without FGM/C in a Somali migrant community. METHODS: Using a comprehensive community-based participatory research approach, a cross-sectional survey was administered to 879 Somali women and teenage girls in Phoenix and Tucson, Arizona. We employed Chi-square and analysis of variance to disentangle health and healthcare use among those with and without FGM/C. RESULTS: The majority of respondents had undergone FGM/C (79%). Respondents with FGM/C experienced significantly more health concerns compared to uncut women and girls, with those possessing Type III FGM/C experiencing significantly more obstetric, gynecologic, sexual, and mental health morbidity than those with Type I or Type II. Rates of service use, while varied, were low overall, particularly for mental health services, even with health insurance. The majority of respondents who sought care indicated that their concerns were resolved, and they were satisfied with the healthcare received. CONCLUSIONS: Community-engaged strategies that build upon satisfaction with care of women who seek care to enhance trust, nurture community embeddedness and facilitate peer navigation, while equipping health and social service providers with the competency and tools to provide respectful, trauma-informed care, will be critical to advance health equity for FGM/C-affected communities.

Attitudes and Experiences Surrounding Female Genital Mutilation/Cutting in the United States: A Scoping Review.

To identify research and gaps in literature about FGM/C-related attitudes and experiences among individuals from FGM/C-practicing countries living in the United States, we conducted a scoping review guided by Arksey and O'Malley's framework. We searched Medline (OVID), Embase (OVID), PubMed, and SCOPUS and conducted a grey literature search for studies assessing attitudes or experiences related to FGM/C with data collected directly from individuals from FGM/C-practicing countries living in the United States. The search yielded 417 studies, and 40 met the inclusion criteria. Findings suggest that women and men from FGM/C-practicing countries living in the United States generally oppose FGM/C, and that women with FGM/C have significant physical and mental health needs and have found US healthcare providers to lack understanding of FGM/C. Future research can improve measurement of FGM/C by taking into account the sociocultural influences on FGM/C-related attitudes and experiences.

Classifying Refugee Status Using Common Features in EMR.

Automated and accurate identification of refugees in healthcare databases is a critical first step to investigate healthcare needs of this vulnerable population and improve health disparities. In this study, we developed a machine-learning method, named refugee identification system (RIS) to address this need. We curated a data set consisting of 103 refugees and 930 non-refugees in Arizona. We compiled de-identified individual-level information including age, primary language, and noise-masked home address, state-level refugee resettlement statistics, and world language statistics. We then performed feature engineering to convert language and masked address into quantitative features. Finally, we built a random forest model to classify refugee and non-refugees. RIS achieved high classification accuracy (overall accuracy=0.97, specificity=0.99, sensitivity=0.85, positive predictive value=0.88, negative predictive value=0.98, and area under receiver operating characteristic curve=0.98). RIS is customizable for refugee identification outside Arizona. Its application enables large-scale investigation of refugee healthcare needs and improvement of health disparities.

A Scoping Review of Social Support Research among Refugees in Resettlement: Implications for Conceptual and Empirical Research.

This study reviewed social support research with refugees in resettlement by assessing the scope of scholarship and examining methodological approaches, definitions, theoretical frameworks, domains, and sources of support. The scoping review followed a systematic approach that retained 41 articles for analysis. The findings indicate that refugee resettlement studies seldom conceptualizes social support as a central focus, defines the concept, draws from related theory, or examines multifaceted components of the construct. The review nevertheless yielded promising findings for future conceptual and empirical research. The analysis identified a wide range of relevant domains and sources of social support, laying the foundation for a socio-ecological model of social support specific to refugee experiences in resettlement. The findings also indicate an imperative to examine and theorize social support vis-à-vis diverse groups as a main outcome of interest, in connection to a range of relevant outcomes, and longitudinally in recognition of the temporal processes in resettlement.

A cross-sectional analysis of factors associated with stress, burnout and turnover intention among healthcare workers during the COVID-19 pandemic in the United States.

In 2020, healthcare workers faced the COVID-19 pandemic amidst other salient sociopolitical stressors. This study, therefore, set out to examine associations between personal, work-related and contextual factors and three outcomes - stress, burnout and turnover intention - at a critical juncture in the pandemic. In December 2020, we recruited a broad array of healthcare workers (n = 985) in a public safety net healthcare system serving socially and economically marginalised communities in the Southwest region of the United States using a cross-sectional online survey. The results indicated that more health problems were associated with higher stress and burnout symptoms. While seeking emotional support and using drugs or alcohol to cope were associated with higher stress, a positive social outlook was associated with lower stress. Lower quality of work-life was associated with higher burnout symptoms and turnover intention. Negative effects of the pandemic on wellbeing and higher number of COVID-19-related concerns were associated with higher stress and burnout symptoms. Contrary to the original hypotheses, self-care was not associated with any of the three outcomes, and effects of the political climate and issues of racism on wellbeing were not associated with stress, burnout or turnover intention. However, identifying as a Person of Colour was associated with higher stress, as well as lower burnout. The findings on worker health, social outlook, quality of work-life and race/ethnicity, in particular, suggest a critical need for healthcare systems to address the wellbeing of workers through equitable organisational policy and practice.

Racism, COVID-19, and Health Inequity in the USA: a Call to Action.

The current national COVID-19 mortality rate for Black Americans is 2.1 times higher than that of Whites. In this commentary, we provide historical context on how structural racism undergirds multi-sector policies which contribute to racial health inequities such as those highlighted by the COVID-19 pandemic. We offer a concrete, actionable path forward to address structural racism and advance health equity for Black Americans through anti-racism, implicit bias, and cultural competency training; capacity building; community-based participatory research (CBPR) initiatives; validated metrics for longitudinal monitoring of efforts to address health disparities and the evaluation of those interventions; and advocacy for and empowerment of vulnerable communities. This necessitates a multi-pronged, coordinated approach led by clinicians; public health professionals; researchers; social scientists; policy-makers at all governmental levels; and local community leaders and stakeholders across the education, legal, social service, and economic sectors to proactively and systematically advance health equity for Black Americans across the USA.

Severe acute respiratory syndrome coronavirus 2: a canary in the coal mine for public safety net hospitals.

BACKGROUND: The coronavirus disease 2019 pandemic has exposed disproportionate health inequities among underserved populations, including refugees. Public safety net healthcare systems play a critical role in facilitating access to care for refugees and informing coordinated public health prevention and mitigation efforts during a pandemic. OBJECTIVE: This study aimed to evaluate the prevalence ratios of severe acute respiratory syndrome coronavirus 2 infection between refugee women and nonrefugee parturient patients admitted to the hospital for delivery. Here, we suspected that the burden of infection was disproportionately distributed across refugee communities that may act as sentinels for community outbreaks. STUDY DESIGN: A cross-sectional study was conducted examining parturient women admitted to the maternity unit between May 6, 2020, and July 22, 2020, when universal testing for severe acute respiratory syndrome coronavirus 2 was first employed. Risk factors for severe acute respiratory syndrome 2 positivity were ascertained, disaggregated by refugee status, and other clinical and sociodemographic variables examined. Prevalence ratios were calculated and comparisons made to county-level community prevalence over the same period. RESULTS: The positive test percentage at the county-level during this study period was 21.6%. Of 350 women admitted to the hospital for delivery, 33 (9.4%) tested positive for severe acute respiratory syndrome 2. When refugee status was determined, 45 women (12.8%) were identified as refugees. Of the 45 refugee women, 8 (17.8%) tested positive for severe acute respiratory syndrome 2 compared with 25 nonrefugee patients (8.19%) who tested positive for severe acute respiratory syndrome 2 (prevalence ratio, 2.16; 95% confidence interval, 1.04-4.51). In addition, 7 of the refugee women who tested positive for severe acute respiratory syndrome coronavirus 2 were from Central Africa. CONCLUSION: The severe acute respiratory syndrome coronavirus 2 outbreak has disproportionately affected refugee populations. This study highlighted the utility of universal screening in mounting a rapid response to an evolving pandemic and how we can better serve refugee communities. Focused response may help achieve more equitable care related to severe acute respiratory syndrome 2 among vulnerable communities. The identification of such populations may help mitigate the spread of the disease and facilitate a timely, culturally, and linguistically enhanced public health response.

Methodological and Ethical Considerations in Research With Immigrant and Refugee Survivors of Intimate Partner Violence.

To promote safe and positive health outcomes by utilizing culturally relevant evidence-based interventions for immigrant and refugee women survivors of intimate partner violence, their active participation in research is critical. With 43.6 million immigrants and refugees living in the United States, there is a need for research studies to eliminate health disparities in these populations. However, barriers to recruiting and retaining these populations in research prevent the provision of quality and culturally informed services to meet their needs. The aim of this article is to discuss the recruitment and retention strategies employed and analyze the methodological and ethical challenges in the context of the weWomen Study. The use of a multifaceted approach informed by best practices maximized recruitment efforts and active participation that generated high numbers of immigrant and refugee women participants. The study also substantiated the need for more community-based participatory approaches to engage community members in the development of culturally appropriate approaches that instill a sense of ownership over the research process. Active research participation of immigrant and refugee survivors will help investigators understand their unique needs and facilitate the implementation of targeted evidence-based interventions.