Abstract
Healthcare providers may be ill-equipped to address the specific care needs of refugee/immigrant (RI) patient populations. We assessed continuing education (CE) training interests among HIV/AIDS, STD, and Hepatitis C (HASH) providers in New York State (NYS), United States, who serve RI patients from Latin America and the Caribbean (LAC). An online survey was completed by 156 HASH providers during a three-month period in Spring 2018. HASH providers serving LAC patients indicate interest in additional training to address the unique needs of the RI community. We noted a strong interest for more tailored learning opportunities in issues that impact refugee health.
Keywords: Immigrant Health, Refugee, HIV/AIDS, Latin America, Caribbean, Training, Continuing education, Hepatitis, STD
1. Introduction
The mix of people served by many health care systems shifts in response to global population movements.1,2 The forces underpinning these movements range from catastrophic weather phenomena or socio-political events that impact a particular region, to intentional migration to new locales.2 As a result, these population movements may lead to changing - and sometimes unpredictable - population patterns. Healthcare providers often struggle to understand how to address the particular healthcare needs faced by these new and evolving migrant populations, such as refugees and immigrants (RI). The circumstances related to the migration patterns of patient populations may have a potential impact on their health outcomes upon arrival at their new destination.2 In the United States, New York State (NYS) is a destination and resettlement location for immigrants from all parts of the world; the largest portion of immigrants to the state, however, are from Latin America and the Caribbean,3 who form an increasingly larger portion of clinical practice clientele.
In a recent study, physicians in Canada were given a survey to assess their strategies for accommodating immigrant patients and their level of training in immigrant care.4 The study highlights the growing importance and the need for healthcare providers who are trained in addressing the needs of diverse cultures, and providing appropriate care. Continuing education (CE) for providers is an important source of learning and sharing best practices in clinical care; reaching clinicians through CE mechanisms online or in-person can help support addressing new or unforeseen needs, such as cultural competency needed to address the healthcare needs of new residents.5
1.1 Objectives and Aims
Providing healthcare can be a challenging endeavor, especially when differences in culture can influence patients’ conceptions of health, illness, and healthcare practices.6 Specified training andidance tailored to the needs of patients help healthcare professionals to improve their clinical practice, level of cultural competence, and confidence.6 With the appropriate training, healthcare providers may be better able to address the healthcare needs of their patients, accounting for cultural differences in “new” populations with which they may not be familiar. Continuing Education trainings that are not tailored to help providers remain current on health conditions, approaches, and treatments addressing their patients’ needs may be detrimental to the communities that health providers serve.6 The objective of this study was to assess the CE training interests among HIV/AIDS, STD, and Hepatitis C providers in New York State, United States, who serve refugee and immigrant patients from Latin America and the Caribbean, with the aim of developing future trainings tailored to provider interests and practice needs. This information will help inform the development of future CE offerings targeting these providers.
2. Methods
2.1. Study Data Collection
HIV/AIDS, STD, and Hepatitis C (HASH) healthcare providers were asked about refugee and immigrant (RI) health-related topics and training interests as part of the New York State AIDS Institute’s Clinical Education Initiative’s (CEI) Annual Assessment (an electronic-based survey (e-survey)). The annual survey was conducted using REDCap®, a HIPAA-compliant application used to electronically capture and manage research and clinical study data. Providers included physicians, nurses, dentists, and pharmacists, and questions ascertained details about their clinical practice, priorities, and training interests; interests in Pre-exposure prophylaxis (PrEP), Post-exposure prophylaxis (PEP), and opioid overdose. HASH providers were asked if they served RI populations, and from which regions of the world the RI populations they served came, including the Latin America and the Caribbean (LAC) region.
2.2. Data Analysis
The statistical programming software R was used for data analysis. LAC-serving healthcare providers were compared with other health providers regarding priorities, screening/treatment, and training interests. Logistic regression was used to generate odds ratios as measures of association with 95% confidence intervals, adjusting for the providers’ primary professional discipline/occupation. The University of Rochester’s Research Subjects Review Board determined that this evaluation (RSRB00062100) did not meet the federal definition of research and was, therefore, exempt. This assessment was conducted in accordance with the Helsinki Declaration.
3. Results
3.1. Overall Result
Our assessment included 156 HASH providers, with 53 providers (33.9%; including 41 males (26.5%) and 114 females (73.5%)) indicating they served LAC populations. Most providers responding were nurses (60.3%), physicians (33.3%), and pharmacists (6.4%). Primarily, the practice settings were hospital/hospital clinic (21.4%), state/local health department/clinic (20.8%), community health center (20.1%), and a range of other organizations (37.7%). However, in total, there were less LAC serving providers in all practice settings (33.8%) than Non-LAC serving providers (66.2%).
LAC-serving providers indicated that the health issues they addressed within their refugee/immigrant patients such as physical health (35.8%), infectious diseases (39.6%), and social problems (43.4%), differed from their non-refugee patients. LAC-serving providers also indicated that the mental health issues they addressed in their refugee/immigrant patients differed from their other patients (22.6%).
In addition, LAC serving providers were more likely than non-LAC serving providers to provide STD screening/testing services (aOR: 4.6, 95% CI: 1.3-16.42) and STD treatment (aOR: 4.3, 95%CI: 1.41-16.15) within their practices. No significance was found among the two comparison groups related to HIV screening and treatment. Professional discipline was identified as a confounding variable in our analysis and so adjusted odds ratios were calculated for our results.
3.2. Main Specific Result
Among LAC serving providers, 84.8% indicated that they were interested in receiving additional training in refugee health (Table 1). In addition, LAC serving providers were 4 times more likely to request refugee health training when compared to non-LAC providers (aOR:4.2; 95%CI:1.7-10.4).
Table 1.
Additional Clinical Education Initiative’s (CEI) training needs indicated by LAC-serving providers and Non-LAC-serving providers
| N(%) | |||||||
|---|---|---|---|---|---|---|---|
| Additional CEI Training | Preference | LAC –serving provider | Non-LAC-serving provider | Total | Adjusted Odds Ratio | 95% C.I. | P-value |
| Refugee Health Issues | Yes | 39 (84.8%) | 55 (57.3%) | 94 (66.2%) | 4.2 | 1.7–10.4 | < 0.001 |
| Screening/Testing for HIV | Yes | 35 (76.1%) | 75 (78.9%) | 110 (78.0%) | 0.9 | 0.4–1.2 | 0.72 |
| Screening/Testing for HCV | Yes | 334 (73.39%) | 69 (75.8%) | 102 (75.0%) | 0.8 | 0.4–1.9 | 0.67 |
| Screening/Testing for STDs | Yes | 38 (82.6%) | 79 (84.0%) | 117 (83.6%) | 0.8 | 0.3– 2.2 | 0.73 |
| Latest Developments on Treatment Options for HIV/HCV/STD | Yes | 46 (93.9%) | 91 (91.0%) | 137 (91.9%) | 1.5 | 0.4–5.9 | 0.55 |
| PrEP | Yes | 42 (89.4%) | 82 (85.4%) | 124 (86.7%) | 1.5 | 0.5–4.3 | 0.5 |
| PEP | Yes | 39 (83.0%) | 85 (85.9%) | 124 (84.9%) | 0.8 | 0.3–2.1 | 0.7 |
| ETE (End the Epidemic) | Yes | 31 (98.9%) | 74 (77.1%) | 105 (74.5%) | 0.7 | 0.3–1.5 | 0.3 |
| Undetectable =Untransmutable (U=U) | Yes | 35 (77.8%) | 81 (84.4%) | 116 (82.3%) | 0.7 | 0.3–1.6 | 0.4 |
| Addressing Stigma | Yes | 36 (81.8%) | 79 (83.2%) | 115 (82.7%) | 0.9 | 0.4–2.4 | 0.9 |
| LGBT Health | Yes | 42 (89.4%) | 85 (85.9%) | 127 (87.0%) | 1.4 | 0.5–4.2 | 0.5 |
| Taking a Sexual History | Yes | 37 (78.7%) | 79 (81.4%) | 116 (80.6%) | 0.9 | 0.4–2.0 | 0.7 |
| Behavior Counseling for STD/HIV Risk Reduction | Yes | 39 (86.7%) | 89 (89.9%) | 128 (88.9%) | 0.7 | 0.3–2.2 | 0.6 |
| STD Clinical Management | Yes | 41 (89.1%) | 89 (91.8%) | 130 (90.9%) | 0.8 | 0.2–2.4 | 0.6 |
| Medical Marijuana | Yes | 38 (80.9%) | 70 (71.4%) | 108 (74.5%) | 1.7 | 0.7–4.2 | 0.2 |
| Workplace Gun Violence | Yes | 30 (66.7%) | 64 (68.1%) | 94 (67.6%) | 0.9 | 0.4–1.9 | 0.8 |
| Harassment in the Workplace | Yes | 27 (60.0%) | 58 (63.0%) | 85 (62.0%) | 0.8 | 0.4–1.8 | 0.6 |
| Linkage to Care Options | Yes | 33 (75.0%) | 75 (79.8%) | 108 (78.3%) | 0.7 | 0.3–1.7 | 0.4 |
| Smoking Cessation | Yes | 33 (71.7%) | 79 (82.3%) | 112 (78.9%) | 0.5 | 0.2–1.2 | 0.1 |
| Opioid Overdose | Yes | 34 (77.3%) | 87 (90.6%) | 121 (86.4%) | 0.5 | 0.2–1.2 | 0.1 |
3.3. Summary of Findings
This study found that providers who serve LAC patients observe the multi-faceted health issues experienced by the LAC community. At present, LAC patients may have more serious – and different - healthcare needs than non-LAC patients. This finding suggests that there may be factors impacting the level of health status and healthcare for LAC patients that warrant further study. Importantly, providers are interested in additional training to address these serious refugee and immigrant health issues.
4. Discussion and Global Health Implications
Refugees and immigrants are a significant segment of society with complexities including social health needs,4 which is important to healthcare providers who serve them. This study shows that providers perceive that significant and different health issues face their patients from Latin America and the Caribbean. LAC-serving providers show a strong desire for additional training in immigrant and refugee health issues to address their ability to effectively identify and manage their patients.
Limitations
Because of the anonymous nature of this assessment, responding clinicians may or may not be representative of all HASH clinicians in NYS who provide care to RI populations. While the regions of the world are consolidated into categories such as “LAC,” these regions are heterogenous with distinctive cultural, health, and lifestyle variations that exist among and within the countries in each classification.
Recommendation for Further Studies
Understanding the needs identified by NYS HASH providers helps continuing education content generators develop culturally relevant training for providers on elements and quality of care for refugee and immigrant communities.7 In so doing, future studies can explore the necessity for, and impact of, training that addresses the unique cultural variations of immigrant populations (for instance, the LAC region) and how these cultural variations can impact provider practices.7 Potentially, providing more culturally appropriate care could help impact HIV/AIDS, STDs, and Hepatitis C in these populations.
As a result of shifting global populations, healthcare providers have to identify new trends and barriers to provide the best appropriate care for the patients they serve. Therefore, culturally-relevant training is imperative for HASH providers so that they can continue to offer appropriate healthcare to their patients, setting a precedent that can be replicated in healthcare institutions worldwide.
Key Messages.
HIV/AIDS, STD, and Hepatitis C providers serving the Latin American and Caribbean communities of New York are more likely to provide screening, testing, and treatment for STDs in their patient communities than do other non-LAC-serving providers.
HIV/AIDS, STD, and Hepatitis C providers indicate that the physical, infectious, and social health challenges facing their patients from Latin America and the Caribbean differ from their other patient populations.
HIV/AIDS, STD, and Hepatitis C providers serving the LAC population indicate a strong interest in obtaining more training in refugee and immigrant health issues.
Compliance with Ethical Standards
Conflict of Interest: The authors declare no relevant conflict of interest.
Financial Disclosures: The authors declare that there were no financial disclosures to make for this study.
Funding/Support: Funded by the New York State AIDS Institute Clinical Education Initiative Resource Center of Excellence (University of Rochester; C029086 TD Dye, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AIDS Institute or the New York State Department of Health.
Ethical Approval: The University of Rochester’s Research Subjects Review Board determined that this evaluation (RSRB00062100) did not meet the federal definition of research.
References
- 1.Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education:a call for more training and opportunities. Academic Medicine. 2007;82(3):226–230. doi: 10.1097/ACM.0b013e3180305cf9. [DOI] [PubMed] [Google Scholar]
- 2.Torres JM, Wallace SP. Migration circumstances, psychological distress, and self-rated physical health for Latino immigrants in the United States. American journal of public health. 2013;103(9):1619–1627. doi: 10.2105/AJPH.2012.301195. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Office of the New York State Comptroller. A portrait of immigrants in New York. NYS Office of Budget and Policy Analysis. New York: Albany; 2016. [Google Scholar]
- 4.Papic O, Malak Z, Rosenberg E. Survey of family physicians'perspectives on management of immigrant patients:attitudes, barriers, strategies, and training needs. Patient education and counseling. 2012;86(2):205–209. doi: 10.1016/j.pec.2011.05.015. [DOI] [PubMed] [Google Scholar]
- 5.Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes:an updated synthesis of systematic reviews. Journal of Continuing Education in the Health Professions. 2015;35(2):131–138. doi: 10.1002/chp.21290. [DOI] [PubMed] [Google Scholar]
- 6.Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for health professionals providing primary healthcare for refugees and asylum seekers in high-income countries:a systematic review and thematic synthesis of qualitative research. BMJ open. 2017;7(8):e015981. doi: 10.1136/bmjopen-2017-015981. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kleinman A, Eisenberg L, Good B. Culture, illness, and care:clinical lessons from anthropologic and cross-cultural research. Focus. 2006;88(1):251–149. doi: 10.7326/0003-4819-88-2-251. [DOI] [PubMed] [Google Scholar]