The Immigrant Partnership and Advocacy Curricular Kit: A Comprehensive Train-the-Trainer Curriculum in Immigrant and Refugee Health

ABSTRACT.

The number of immigrants and refugees in the United States is growing, yet many trainees and clinicians feel unprepared to manage the diverse needs of this population. This perspective piece describes the development of the Immigrant Partnership and Advocacy Curricular Kit (I-PACK) by the Midwest Consortium of Global Child Health Educators. I-PACK is an adjunct to the Consortium’s sugarprep.org global health curricular materials. Using Kern’s six-step approach to curriculum development, they developed eight modules in immigrant and refugee health that incorporate interactive learning activities. The I-PACK was launched as an open-access resource in September 2020. As of September 2021, the curriculum has been freely available at sugarprep.org/i-pack and downloaded from educators in 15 countries. The I-PACK curriculum can address a growing need in medical education to empower learners and clinicians to provide competent and compassionate care for immigrants and refugees.

In recent years, the United States has seen a growing population of immigrants and refugees. ¹ A total of 14% of the U.S. population was born outside of the United States, ¹ and as many as one in four children belong to an immigrant family. ² Every healthcare provider in the United States will care for immigrant and refugee families, yet many providers and trainees feel inadequately prepared to do so. ^{3, 4}

In a 2016 study of internal medicine and pediatric residents (N = 199), over half (54%) felt uncomfortable with their knowledge in immigrant and refugee health. ³ Almost all participants (99%) felt that caring for immigrant or refugee patients was more challenging than caring for U.S.-born patients. ³ Similarly, a 2017 survey from the American Academy of Pediatrics found that one-third (33.6%) of pediatric residents, attending physicians, and fellows felt “not at all” or only “slightly” prepared to care for immigrant and refugee families. ⁴

To fill these gaps, there is growing interest in training that addresses the care of immigrant and refugee patients, especially among medical students and residents. Receiving training in immigrant and refugee health is positively correlated with increased comfort in and desire to care for immigrants and refugees. ³ This suggests that not only do learners desire training materials, but that such materials have the potential to increase the number of physicians motivated to care for this at-risk patient population. Furthermore, as the majority of immigrants arriving in the United States are people of color, expanding provider competency in working with immigrant patients and families has potential to reduce racial disparities in care. ¹

Global health training is associated with improved competency in providing immigrant and refugee care. ⁵ The field of global health has a shared foundation with many aspects of immigrant and refugee health, including a strong focus on cultural humility and cross-cultural communication. Our educational collaborative, the Midwest Consortium of Global Health Child Educators, recognized the overlap between the principles of global health and the challenges of immigrant and refugee health in the United States. The Midwest Consortium, founded in 2010, is composed of physicians and educators from seven institutions whose shared mission is to advance global health training in graduate medical education. ⁶ The Midwest Consortium has created several high-quality open-access curricula in global health education, including simulation cases, an online video series for procedural adaptations, and a comprehensive predeparture preparation curriculum, all described in previous publications and freely available online. ^{6 – 10} These have been widely disseminated to over 200 institutions in over 20 countries via the online platform, sugarprep.org.

We recognized an opportunity to connect a growing need in immigrant and refugee health education with the consortium’s ability to leverage an existing successful platform. In this perspective, we describe our experience in the creation and implementation of an open-access curriculum focused on immigrant and refugee health, designed for medical students, residents, and fellows. The curriculum, entitled the Immigrant Partnership and Advocacy Curricular Kit (I-PACK), draws from our experiences in curricular development and content expertise. The I-PACK offers a comprehensive eight-module curriculum in immigrant and refugee health and is available free of cost online (https://sugarprep.org/i-pack/).

Following the model successfully used for our previous curricula, we developed an I-PACK working group for the creation and dissemination of the curriculum. We used Kern’s principles of curriculum development, ¹¹ which describes six steps of curriculum development in medical education. Ethical approval was waived for the evaluation and feedback component of this project by the University of Minnesota Institutional Review Board as activities did not constitute human research.

We sought to create a comprehensive curriculum in immigrant and refugee health for medical educators using the train-the-trainer model that has proven successful in the other sugarprep.org curricula. Workgroup members included members with expertise in global health, immigrant and refugee health, community partnership building, and immigration law. Consortium members identified key content areas for inclusion in the curriculum, which were used to develop eight topic areas that ultimately became I-PACK’s eight modules (Figure 1). We developed a workgroup for each module, and each workgroup created learning objectives and a content outline. We prioritized the principles of cross-cultural communication, cultural humility, advocacy, and collaboration with immigrant and refugee patients and communities. Learning objectives and content were cross-checked to ensure that the modules provided intentional repetition to build on key learning points without redundancy.

Figure 1.

I-PACK modules.

Modules are designed to be used in a self-guided, train-the-trainer format, offering educators the background knowledge to facilitate each module as well as the necessary tools to easily implement the curriculum. Minimal learner prework or knowledge is required, and resources are provided to allow educators to modify the content to meet the needs of the institution, learners, and local community. The I-PACK curriculum was designed to be modular and modifiable, so that the curriculum could be delivered as stand-alone individual modules or in a daylong intensive workshop, depending on the needs and time constraints of educators and trainees. I-PACK intentionally includes a variety of educational strategies and integrates suggestions for modifications based on learner type and level (Table 1).

Table 1.

Educational strategies

Train-the-trainer model	• I-PACK is designed for educators, rather than a curriculum packaged directly to learners. I-PACK includes a comprehensive curriculum that experienced educators can use as a scaffold. • I-PACK also contains background materials and detailed instructions to best equip educators to deliver the content.
Modular	• I-PACK can be taught as a comprehensive curriculum with all eight modules, or educators can select single modules or even stand-alone elements within a module. • Modular elements allow single modules to be taught as half-day seminars or broken into smaller blocks of time to be used at morning or noon conferences longitudinally, maximizing flexibility.
Modifiable	• Educators can choose which components of I-PACK they wish to use to meet specific learning goals, and materials can be adapted as needed. • Each instructor guide includes an overview of each activity, learning objectives, and the required time and related materials to help educators meet an institution’s individual learning needs.
Active learning	• In addition to didactic and reading materials, I-PACK uses active learning activities including case-based discussion, instructions for panels, and hands-on advocacy work such as letter and resolution writing.
Adaptable to learner level	• Each module has suggestions to adapt for different learner levels, such as medical students, residents, and advanced learners, including practicing providers.

I-PACK = Immigrant Partnership and Advocacy Curricular Kit.

Immigrant Partnership and Advocacy Curricular Kit is built on educational principles of adult learning, and consists primarily of interactive learning activities designed to retain information and promote critical thinking and relies heavily on Kolb’s experiential learning and Schön's reflection in action conceptual frameworks. ^{12, 13} Interactive activities are contained in each module, including implementing panel discussions, letter writing, stakeholder mapping, and action planning, empowering learners to engage their knowledge in action.

The COVID-19 pandemic led us to adapt and develop I-PACK for virtual and distance learning. In 2020 to 2021, I-PACK modules were presented as part of virtual global health education sessions for residents enrolled in pediatric global health pathways nationwide at seven institutions. The curriculum was also distributed to a wider audience via our e-mail listserv for individuals who had previously downloaded other curricula on the sugarprep.org website. As of September 2021, the curriculum download pages have been visited 1,386 times, with downloads from users in 15 countries.

Each I-PACK module is packaged with its own pre- and postassessment surveys, which are linked within the PDF downloads of the curriculum text. Survey questions used Likert scales to assess learners’ familiarity with module’s content, effectiveness, and quality of modules in achieving learning objectives, and willingness to recommend a module to a friend. Pilot data has shown promising results: thus far, 155 trainees have completed the preassessment surveys and 66 have completed both pre- and postassessment surveys. Among the 66 participants who completed both pre- and postsurveys, all rated the modules as either excellent (57.6%) or “good” (42.4%), and nearly all (98.5%) of respondents indicated that they would recommend the modules to a colleague. Because the curriculum has been disseminated widely, we do not have access to the total number of trainees who have participated in I-PACK modules so far. Users demonstrated an improvement in average comfort with learning objectives, as measured on a 4-point Likert scale using unpaired pre-and postsurvey data (P < 0.0001).

Future steps in evaluation will include paired pre- and postsurveys to assess paired changes in comfort before and after the modules. We plan to complete a qualitative analysis of the open responses in the postsurveys, allowing participants to specifically comment on areas of the modules either in need of improvement or particularly effective. We will also plan to seek further input from experts and committees in immigration health for updates and revisions to ensure accuracy and relevance of information provided in the modules. The author team will continue monitoring the evaluation data from facilitators and trainees to facilitate periodic updates and improvements to the curriculum.

In the face of a growing need for competent and compassionate care for immigrants and refugees, the free I-PACK curriculum can help address an important gap in medical education by empowering educators and providers to prepare themselves, their learners, their institutions, and their communities to better partner with immigrant families. I-PACK is adaptable and well suited for advocacy electives, community health rotations, and domestic global health experiences in both virtual and in-person formats. The modules are well suited to both adult and distance learning, as they do not require in-person attendance, and complement current teleconferencing modalities. Next steps for this project include further web-based launches of the material, ongoing assessment of content efficacy, and continued modification of the materials.