Teaching the Y-HEALAR: An Innovative Educational Initiative about Refugee Health for Medical Trainees

Background:

Global health--clinical service, research and education that transcend national and cultural boundaries to address resource-limited populations--is an increasingly important component of training; 32% of surveyed pediatric residents desired global health education.^1–3 Pediatric trainees can benefit from domestic global health activities, including care and education of refugees.⁴ We developed Yale Health Education and Literacy for Asylees and Refugees (Y-HEALAR), a community-based health curriculum to enhance health literacy of refugee patients and teach trainees to provide culturally sensitive medical education. We outline program development and assess trainees’ perspectives of the perceived strengths and weaknesses of the program.

Educational Approach and Innovation:

The Y-HEALAR program is a joint effort of pediatric residents and IRIS (Integrated Refugee and Immigrant Services), an agency in New Haven responsible for the resettlement of between 250–550 refugees yearly, with 44% of arrivals from 2013–2017 <18 years.⁵ Countries of origin included Afghanistan (26%), Syria (21%), and Democratic Republic of Congo (12%). Health literacy--the capacity to obtain and understand health information needed to make health decisions--varied widely among resettled refugees, which was a primary motivation for the development of Y-HEALAR.

Utilizing the Kern approach for curriculum development,⁶ we reviewed existing literature, approached refugee community organizations, and conducted a needs assessment of refugees and community organizations.⁷ At the conclusion of this process, our community partners requested programs on health system navigation, breastfeeding, pediatric health, and nutrition. Pediatric residents identified barriers to caring for refugee patients, including limited encounter time and cultural and language differences, and selected additional program topics from their refugee clinic experience (Figure 1). Needs were similar for refugees from the three common countries of origin.

Figure 1.

Logic Model of Development and Implementation of a Novel Health Literacy Curriculum for Refugees (Y-HEALAR)

Pediatric residents developed and launched classes in 2017, and they have since led the program supervised by the Yale Pediatric Refugee Clinic Physician-Director. Participating residents received credit toward advocacy requirements, in which residents have half-day blocks during outpatient rotations to participate in service opportunities. Trainee responsibilities included liaising with IRIS, organizing curricular development sessions, engaging multidisciplinary healthcare providers and trainees (including residents, students, dentists, lactation consultants, nutritionists) to teach the courses, developing pre- and post-session questionnaires for refugee participants, writing grants, and recruiting trainees yearly. Funding was obtained through hospital grants. Volunteer trainees (usually three) developed curricula approximately two months prior to the class, refined them with faculty and IRIS consultation, and taught the prepared curriculum. Paid interpreters recruited refugee participants by phone a week prior to classes, which followed scheduled English classes. Refugees could participate in multiple classes. Many refugee participants (all >18 years old) had children enrolled in the pediatric resident refugee clinic, but this was not required. Separate interpreters simultaneously interpreted the curriculum into the three most common languages: Pashto, Swahili, and Arabic. Trainees obtained verbal and written feedback from refugee participants after each session. Trainees held debriefing sessions and quarterly feedback meetings with participants and incorporated iterative cycles of learning, reflecting, and curricular refinement(Figure 1).

Trainee participants each completed a one-time, cross-sectional, previously validated, Global Health Competency Survey^8–10 over a period of two months to assess:(1)knowledge and interest in global health and equity (3-point Likert scale, 1=not at all confident to 3=very confident) and (2)global health skills in working with patients with different linguistic, educational, socioeconomic, and cultural backgrounds (5-point Likert scale, 1=strongly disagree to 5=strongly agree).¹⁰ The Global Health Competency Survey has been previously shown to have good validity and internal consistency with a Cronbach’s alpha > 0.8 in Canadian family medicine residents.¹⁰ In addition, participants concurrently reported their self-improvement for each component with a 3-point Likert scale (1=no change to 3=greatly improved). The Yale University Institutional Review Board exempted the project.

Results:

Y-HEALAR held 20 classes over 30 months reaching ~200 adult refugees who had been in the US for a median of 12 months (Interquartile Range (IQR), 2.25–30.0). Wide-ranging bimonthly class topics included breastfeeding, pediatric health issues, and smoking cessation (Figure 1). Of 24 trainee respondents (60% response rate), 83% were female, 58% were pediatric residents, and 75% had prior experience with refugees. The trainees participated in an average of 2.3 classes, and had taught a class 1–24 month(s) before(Figure 1). Aggregate median confidence score for global health knowledge (Likert scale 1–3) was 2.21(IQR 2.10–2.45) with self-improvement score (Likert scale 1–3) median of 2.13(IQR 1.96–2.20). Aggregate median confidence score for global health skills (Likert scale 1–5) was 3.27 IQR 2.43–3.69) with a self-improvement score (Likert scale 1–3) median of 1.90(IQR 1.75–1.97). The two areas where trainees reported the least confidence in global health knowledge were (1) access to health care for low income nations and (2) racial stereotyping and clinical decision making. The two areas where trainees reported the least confidence in global health skills were (1) discussing sensitive issues and (2) assisting with realistic health goals for patients with different backgrounds (Supplemental Figure).

Discussion and Next Steps:

We report the development and implementation of a community-academic collaboration to provide health education to refugee families. Trainees had opportunities to learn skills in cultural humility, work with local community organizations to improve their patients’ access to healthcare, and gain comprehension in sociocultural and political factors affecting refugees. Our trainees had similar areas of strengths and weaknesses compared with Canadian family medicine resident counterparts.¹⁰ Survey results reflected a self-perceived improvement in trainees’ global health knowledge and skills following participation.

Limitations include a restricted sample that did not incorporate refugees or partner organizations, lack of survey comparison with other US pediatric trainees, a small sample size, potential for recall and social acceptability biases, lack of a control group, and non-longitudinal data.

These results demonstrate that participation in domestic global health initiatives provides valuable education for trainees and helps trainees to understand challenges that refugees face. These initiatives are increasingly important in the COVID-19 era when global health-based travel is limited. Future work will assess trainees’ experience over time, tailor the curriculum to address gaps in global health competencies, assess the impact of the curriculum on refugee participants, compare improvement with other domestic global health curricular programs, and assess for changes in health outcomes.

What’s New:

This domestic global health initiative supports trainees in providing community-based health education to refugees and asylees while teaching the trainees core global health competencies.