Health advocacy for refugees

Abstract

PROBLEM BEING ADDRESSED

Canadian family physicians serve a patient population that is increasingly diverse, both culturally and linguistically. Family medicine needs to take a leadership role in developing social accountability and cultural sensitivity among physicians.

OBJECTIVE OF PROGRAM

To train medical students to work with newly arriving refugees, to foster competence in handling cultural issues, to raise awareness of global health, and to engage medical students in work with underserviced populations in primary care.

PROGRAM DESCRIPTION

The program is composed of an Internet-based training module and a self-assessment quiz focused on global and refugee health, a workshop to increase competence in cultural matters, an experience working with at least 1 refugee family at a shelter for newly arriving refugees, family physician mentorship, and a debriefing workshop at the end of the experience. Students who complete this program are eligible for further electives at a refugee health clinic.

CONCLUSION

The program has been received enthusiastically by students, refugees, and family physicians. Working with refugees provides a powerful introduction to issues related to global health and competence in cultural matters. The program also provides an opportunity for medical students to work alongside family physicians and nurtures their interest in working with disadvantaged populations.

Social accountability is an important new principle in medical education.¹ Family physicians work with a range of communities, many of which are socially disadvantaged, which makes advocacy an important principle in family medicine.² We need to attract medical students to family practice and we need to attract family physicians to work with underserviced and marginalized populations. Training programs that can integrate development of global health skills with meaningful community activities can affect students’ and physicians’ future career choices.³

Immigration is dramatically increasing the cultural and linguistic diversity of the Canadian population.⁴ Preparing for this diversity requires that we equip future family physicians with cultural competence and provide them with a practical understanding of the effects of language and cultural barriers on patients.⁵ This paper describes an innovative program that introduces global health and cultural competence to medical students and provides family medicine mentorship in the context of a shelter for newly arriving refugees.

Refugees are a special subgroup of immigrants because, by definition, their sometimes perilous migration history can put them at risk of a number of health problems, and they frequently encounter barriers to care.^6,7 Without adequate primary health care, refugees’ acute and chronic health issues can go unrecognized. A recent systematic review suggested that cultural mediation improves the quality of care for socially disadvantaged populations.⁸

The objectives of this program are to introduce medical students to refugee health and cultural competence and to assist refugees with early integration into primary health care (Table 1). Health advocacy in this program focuses on facilitating communication, providing access to information and primary health care, and exchanging knowledge. Medical students and family physician teachers collaboratively designed, pilot-tested, and evaluated the student-delivered prevention outreach program at a local shelter for newly arriving refugees. This program built on the enthusiasm of medical students early in their careers and provided them with meaningful exposure to health advocacy and cross-cultural interviewing without the need for advanced diagnostic skills. The program currently qualifies as an elective course at the University of Ottawa in Ontario.

Table 1.

Learning objectives

After completing this program, participating medical students will meet the following standards: be able to describe the refugee settlement process within Canada, be able to describe what is meant by a cross-cultural encounter, understand basic skills for conducting an interview using an interpreter, appreciate the value of advocacy for vulnerable patient populations, and be interested in learning more about refugee and global health.

Program

The program blends training in cultural competence with a community prevention outreach program at a shelter for government-assisted refugees. Many of the refugees have come directly from camps in Chad, the Sudan, Uganda, the Congo, and the Thai-Myanmar border area. The students are often the first Canadian health care workers to greet the refugees. All participating students receive training in refugee health, consisting of an Internet-based training module focusing on refugees’ experiences and a self-assessment quiz,⁹ and a cultural sensitivity workshop provided by medical faculty with expertise in refugee health.

In the prevention outreach activity, a team of 2 medical students meets a newly arriving refugee family and helps them complete a medical summary (cumulative patient profile), including their demographics, current illnesses, medical histories, allergies, and current medications, as well as a brief checklist of symptoms. The team then provides them with written information on the health system and preventive services. The students instruct the families to give their medical summaries and refugee-tailored prevention guidelines to their subsequent community family physicians.

We evaluated this prevention outreach program using a follow-up interview with students, family physicians, and refugees. We pilot-tested the prevention outreach program on 5 refugee families (15 individuals) at a shelter. We then interviewed a convenience (non-random) sample of refugees (1 family), 5 medical students, and 4 primary health care professionals taking part in the pilot program. During the interviews, participants were asked to evaluate the session in terms of content, aspects of cultural competence, and credibility. The semistructured face-to-face interviews were conducted by one of the authors (S.H.), who played a role in program development. The family of 5 sent 1 representative to meet one-on-one with the interviewer. We analyzed the data qualitatively for evidence of acceptability, harm, and usefulness. Ethics approval was obtained from the Research and Review Ethics Boards at the Élisabeth Bruyère Research Institute.

Program results

Results indicated that the intervention was favourably received by all 3 target groups: refugees, health professionals, and medical students. Refugees reported that the outreach allowed many of their questions to be answered, helped them understand Canada’s health care system, and made their first visits to doctors’ offices easier. Physicians reported that families who had gone through the preventive outreach interview had a better understanding of the system and in turn were more interested in preventive services and more trusting of physicians. Students reported an improvement in their knowledge and skills for brokering cross-cultural health care. Students found it disheartening at times to discover that so few physicians were accepting new patients and emphasized the importance of clinical backup and mentorship within the program.

Conducting health interviews with refugee families opened my eyes to the numerous and complex health care needs dealt with by refugees. It’s one thing to read or hear about the health needs faced by this group of people, but it is more powerful to hear it when sitting directly across from them. It makes you want to make a difference. (Medical student)

I think this questionnaire will be very useful. It is a 1-page summary of the patient’s health care needs. It will help focus the interview on issues that patients have identified, which is especially important when there may be language barriers and cultural differences. (Health care professional)

I think [the outreach prevention session] affected [my first visit to a doctor’s office] positively because I was clear on some questions and what the doctor was going to ask me in advance. (Refugee patient)

Discussion

This outreach program helped students in their first and second years of medical school gain an understanding of the importance of cultural competence and community family physicians. Rather than teaching students a “cookbook” type of approach to dealing with patients from different backgrounds, it used a refugee-focused framework to guide inquiry.¹⁰ Many students reported that this program represented the first time in medical school that they felt they had actually made a difference in someone’s life.

The students faced several challenges in addition to dealing with the cultural and linguistic differences of newly arriving refugees. During interviews, students sometimes identified potentially urgent health care concerns, but with their limited medical knowledge and the limited medical knowledge of the supporting settlement staff, it was difficult to determine accurately how urgent these concerns were. A protocol was put in place to ensure that when students came across certain problems, they could count on family physician medical backup and access to urgent care services. This on-call service then led to urgent care visits at the shelter with family medicine mentors that served to debrief students and ensure high-quality care for the refugees. All students participated in a post-intervention group workshop to discuss medical and ethical challenges encountered during their experience.

In their health advocacy and educator roles with the refugee families, students learned the importance of comprehensive family medicine and preventive health assessments. They often found it disheartening, however, to experience first-hand with their refugee families how very hard it is to find family physicians who are accepting new patients. Most of the families were eager to participate in taking care of their health, yet as newcomers, they found it difficult to access the primary health care system.

As with electives in international health, the process of working with newly arriving refugees at a community shelter was a powerful learning experience that brought global health inequities to life.³ In addition to appreciating refugees’ vulnerability, students experienced the practical limitations of the Canadian health system. The combination of community-focused health advocacy and cross-cultural interviewing provided a rich learning environment for medical students and positive results for refugee families.

Shelters for newly arriving refugees exist in large urban centres across Canada. With the collaboration of family physicians with expertise in refugee medicine and medical students with an interest in refugees, similar programs could be implemented in medical schools across the country. For anyone interested in starting a program, we would recommend starting slowly with a small group of committed students and building a core group of mentor physicians and settlement workers.

We initially received funding from the University of Ottawa for a Summer Research Student Grant and recruited other student volunteers to pilot-test the program. Key implementation challenges included focusing the student intervention on advocacy and not clinical assessment, ensuring that we had interpreters or language compatibility, ensuring timely physician backup for managing refugees who were ill, and providing physicians for student mentorship. Given the complexity of working in a shelter with refugees, we would also recommend contacting us early in the process for training and evaluation resources and further helpful hints for implementing a program. We are continually refining our educational resources and our ongoing evaluation materials.

Conclusion

Programs that build social accountability have a valuable role in medical education. This program has emerged with the active support of students and family physician mentors and with the help of summer student research funding. Working at a community refugee shelter provided a powerful learning experience for students and enhanced their perspective on the importance of primary care and cultural competence skills. Last year, 45 first- and second-year students speaking 15 different languages participated in the program at the University of Ottawa.

This socially accountable training program combined the following:

• health advocacy and community-based education,

• engagement in a community shelter for refugees,

• activity relevant to the community through helping newly arriving refugees, and

• student leadership with family physician mentorship.

EDITOR’S KEY POINTS

• Given the change in Canada’s population, family physicians need to be socially accountable and sensitive to cultural differences.

• This paper describes an innovative program that introduces these ideas to medical students, along with family medicine mentorship, in the context of a shelter for newly arriving refugees.

• Initial evaluation of the program indicates that it was well received by medical students who reported improvement in their knowledge and skills for managing cross-cultural health care.

POINTS DE REPÈRE DU RÉDACTEUR

• Compte tenu des changements dans la population du Canada, les médecins de famille doivent avoir une attitude de responsabilité sociale et d’ouverture aux différences culturelles.

• Cet article décrit un programme innovateur qui présente ces notions aux étudiants en médecine, avec un mentorat en médecine familiale, dans le contexte d’un centre d’assistance pour réfugiés nouvellement arrivés.

• Une première évaluation du programme indique qu’il est reçu favorablement par les étudiants en médecine, qui disent avoir amélioré leurs connaissances et habiletés en matière de soins de santé multiculturels.