Disease Management and Practice Guidelines

Polycystic Ovarian Syndrome amongst Refugee Populations from Middle Eastern and North African Countries (April 2024) Mira Bagous

Polycystic ovarian syndrome (PCOS) affects an estimated 8-13% of premenopausal women yet remains undiagnosed in up to 70% of this population. While few studies have been conducted, it appears there may be an increased prevalence as well as a variable phenotype amongst those from Middle Eastern and North African (MENA) countries. The refugee population at present has a large representation from several countries in this region, including Afghanistan, Iran, Iraq and Syria. Refugee patients coming from MENA countries may have experienced significant stressors or trauma that can exacerbate or increase susceptibility to PCOS.

An Overview of Congenital and Rheumatic Heart Disease in Refugee Children (January 2024) Mara Weigner

Congenital heart disease (CHD) exists on a spectrum and impacts approximately 1% of children born worldwide. Refugee children with CHD are often disproportionately impacted due to tumultuous circumstances and lack of access to consistent or adequate healthcare during early life. This lack of access to healthcare also increases the risk of rheumatic heart disease, which has been largely eradicated in developed countries. Overseas medical examinations and new arrival health screenings by a primary care clinician are crucial to identify children with known or previously unidentified heart disease and to efficiently coordinate both acute and long-term care. In addition to providing routine childhood health maintenance, a primary care clinic also serves as a medical home and can help families navigate the many challenges of an unfamiliar healthcare system.

Special considerations for cervical cancer screening among refugee women of diverse religious and cultural backgrounds (October 2023) Philip Grotz

Historically, cervical cancer (CC) has been a leading cause of cancer-related death in women, ranking as the fourth highest in cancer-related deaths worldwide. To combat this high-disease burden, preventive and early detection screening for precancerous lesions with regular Papanicolau exams, or pap smears, is universally recommended by both the United States Preventive Services Task Force and the American College of Obstetrics and Gynecology for women ages 21-65. Pap smears detect cellular atypia that is almost always a result of altered gene expression caused by infection with human papillomavirus (HPV), which in the case of cervical infection, is almost always sexually transmitted. Despite its known mechanism of transmission, no special considerations currently exist within guidelines for alternative screening for women who deny sexual activity. Reasons to explain the lack of differing recommendations for these women may include unreliability of history taking, high incidence of sexual activity among the general population, and the benefit of screening for cervical cancers not caused by HPV. This paper intends to quantify the risk of cervical cancer for the general population of sexually inactive women, as well as contextualize the risks of refugees in particular by examining the individual risks of different kinds of sexual activity and the possibilities of underreporting or unknown exposures. Further, it intends to weigh these risks against the increased risk of refugee women for the above-mentioned poor outcomes and offer solutions that may help decrease their occurrence and improve the overall utility of the test.

Vitamin D Deficiency in the Afghan Refugee Population (October 2022) Miyabi Saito

Vitamin D is an important micronutrient for many processes in the body. Deficiency can range from asymptomatic to osteomalacia and rickets, which increase the probability of bone fractures. In countries where vitamin D rich or fortified foods are not easily accessible, deficiency has become a major healthcare crisis. Afghan refugees, especially women and children, have been found to have disproportionately high prevalence of vitamin D deficiency compared to other refugee populations. Cultural practices, socioeconomic status, and other environmental factors may play a large role in contributing to the high prevalence. As supplementation and screening protocols are not standardized for this population, all the contextual factors must be taken into consideration when assessing vitamin D status.

Vaccine Hesitancy in Refugee Communities (March 2022) Jacqueline Carson

Vaccine Hesitancy is seen as one of the world’s most pressing global health threats. Fueled by lack of confidence, complacency, and inconvenience, Vaccine Hesitancy is present globally. However, refugees and displaced persons are particularly at risk due to a unique set of barriers, such as lack of access to vaccination centers, lack of distributed information about vaccines, lack of nearby medical care, and misinformation. Specific examples from the Somali, Russian-speaking, and Afghan populations are offered to demonstrate the causes and effects of Vaccine Hesitancy. Tackling Vaccine Hesitancy successfully in refugee and displaced populations can only be completed by multidisciplinary efforts coordinated by government and community organizations.

Cancer Screening Among Refugees and Potential Interventions to Increase Screening Rates (August 2021) Nichole Stelling, MS4

Screening for colorectal, cervical, and breast cancer is an important aspect of primary care for all individuals, including refugees. However, rates of screening for these cancers are lower among refugees than among individuals born in the United States for several reasons including difficulty accessing care and differing sociocultural perspectives regarding cancer screenings. This paper aims to outline the factors leading to lower rates of screening and discuss several strategies for improving screening rates which have been proposed and studied in prior literature.

An Exploration of Barriers and Strategies for Effective Delivery of Point-of-Care Patient Education in the Refugee Population (October 2020) John Kalmanek

In this paper we will explore several common barriers that make it difficult to tap into the opportunity for health education in clinic, and discuss strategies and resources that healthcare teams can use to help their refugee patients bridge the health knowledge gap necessary for them to better manage their health.

Refugee Oral Health: An Overview for U.S. Primary Care Providers (March 2020) Haley Smith

Refugee populations are disproportionately affected by common oral diseases, including dental caries and periodontal disease. This paper seeks to synthesize the currently available literature on oral health in refugee populations and to identify key knowledge gaps. The paper specifically discusses the multifactorial causes of oral health disparities seen in refugee populations, and outlines the known barriers to dental care for refugees resettled in the United States. The paper additionally discusses the negative consequences of poor oral health in refugee populations, and identifies the role general medical practitioners can play in addressing oral health disparities, including recommendations on oral health preventive practices for U.S. primary care physicians caring for refugee patients and families.

The Prevalence of Elevated Blood Lead Levels in Foreign-Born Refugee Children Upon Arrival to the U.S. and the Adequacy of Follow-up Treatment (March 2019) Sarah Seifu, Kawai Tanabe, Fern R. Hauck

This study sought to evaluate the prevalence of blood lead levels (BLL) in refugee children upon arrival to the U.S. and deter-mine whether they received BLL screening and follow-up according to CDC guidelines. 301 refugee children ages 6 months to 16 years were seen at the International Family Medicine Clinic from 2003 to 2016. Data were collected on BLL, treatment, age, gender, English proficiency, native language, anemia, malnutrition, and microcytosis. Bivariate analyses were conducted to determine the association between these variables and BLL. The prevalence of elevated blood lead levels (EBLL), defined as ≥ 10 µg/dL before June 2012 and ≥ 5 µg/dL from June 2012, was observed in 13% (n = 39). Male sex (p = 0.033), young age (p = 0.003), and microcytosis (p = 0.009) were significantly associated with EBLL. Follow-up and treatment for EBLL were lower than the recommended CDC guidelines for BLL and greater education of healthcare providers is needed.

Keywords: Lead poisoning, Elevated blood lead levels, Refugee children, Foreign-born, Follow-up

Evaluating the Effects of Refugee Experiences on Cognitive and Social-Emotional Development in Refugee Children in the Primary Care Setting (July 2018) Emily Schutzenhofer

The prevalence of developmental disability among refugee children is unknown. However, the disruption of families and education, in addition to the witnessed traumatic events, that often accompany the refugee and resettlement experience are known to impact cognitive, social, emotional, and physical child development. Pre-migration traumatic exposures and post-migration stressors are explored in order to give context to the factors negatively affecting cognitive and social-emotional development of refugee children resettled in high-income countries. Traumas and stressors affect the cognitive development and mental health of refugee children through an interwoven multitude of mechanisms. Unusual patterns of language acquisition in new bilingual environments complicate cognitive development as well as assessment of both language and cognitive development. In order to promote cognitive and social-emotional developmental screening and early intervention for refugee children, family perspectives of development and developmental screening must be understood and incorporated into screening implementation. Culturally and linguistically-appropriate methods of developmental screening of refugee children, including the Parents’ Evaluation of Developmental Status (PEDS), may be utilized in the primary care setting to most accurately identify refugee children at risk for developmental delays.

Keywords: Development, Refugee Children, Resettlement, Mental Health, Screening Tools

Assessing Developmental Delay in Refugee Children (July 2016) Tamara Saint-Surin

Refugee children may face a number of challenges to their developmental process, including neglect, poverty, exposure to trauma, poor health, lack of education, and behavioral disturbances. In addition, cultural background differences and parental language barriers may make it difficult to evaluate childhood development and milestones using many standard United States screening tools such as the Ages & Stages Questionnaire. Age determination may be difficult, and education level may vary among these patients. A thorough history obtained about each child can help inform further evaluation and is especially important as early as possible in the refugee child’s healthcare encounter. This paper provides helpful questions to discover risk factors for developmental delay, and explores challenges for each part of the medical history. Cultural and religious views often play a role in the family’s perception of any form of developmental delay or disability, and understanding each family’s view is especially important in discussing prognosis and a treatment plan.

Keywords: Refugee Children, Development, Milestones, Screening Tools, Medical History, Cultural Background, Poverty, Religious Views


Diet and Exercise: Major Factors Leading to Weight Gain in Refugees (June 2016) Audrey Nguyen

Weight gain and obesity are common problems seen among refugee patients who are often thin and underweight prior to arrival in the United States. This problem often develops over several years and is especially prominent in refugee children. This paper uses the case of a 10-year-old girl seen in the IFMC as a starting point in exploring the factors that lead to significant weight gain in refugee populations. Poor diet and lack of exercise are the primary causes of significant weight gain and its related morbidity, which may be preventable with appropriate education and motivation early in the resettlement process. Effective prevention of these problems requires language-appropriate and culture-appropriate fitness and nutrition interventions in order to reach this unique population.  Additional resources provided include an Appendix: “Visual Aids in Spanish, French, Dari, Nepali, and Swahili for How to Eat Healthy: Portioning Your Plate.”

Keywords: Diet, Exercise, Weight Gain, Obesity, Portioning Your Plate, Visual Aids, Spanish, French, Dari, Nepali, Swahili


B12 Deficiency in Bhutanese Refugees (June 2016) Nicele Puente

Nutrient deficiencies, which are common among refugee populations, are important for healthcare providers to understand, detect, and treat in order to prevent long-term medical complications. Providers should also promote balanced nutrition as part of their treatment plan. Vitamin B12 deficiency, which is seen in the United States in the elderly, gastric surgery patients, and strict vegans, can lead to significant neurologic morbidity. This paper describes the recognition of several Bhutanese patients with histories of Vitamin B12 deficiency and neuropathy who lacked the common US risk factors, prompting investigation of the greater trend of B12 deficiency in the Bhutanese population. The paper explains the physiologic importance of Vitamin B12, explores the history of Bhutanese refugees and resettlement in the United States dating back to 2008, and presents a literature review identifying the trend and possible causes of this vitamin deficiency with proposed management strategies for these patients. Recognizing a lack of consensus in this area, potential interim solutions are proposed while further research is pursued. Additional appendix references include: Minnesota Department of Health “Recommended Protocol for Vitamin B12 Testing in Bhutanese Refugees;” Counseling Aid and Visual Shopping Guide to foods high in Vitamin B12 content with Nepali translations.

Keywords: Vitamin B12 Deficiency, Bhutanese, Resettlement, Literature Review, Management Strategies, Testing Protocol, Counseling, Visual Shopping Guide


Growth Charts in an Ethnically Diverse Refugee Population (April 2016) Taylor Williams

Growth trends and appropriate growth chart usage among refugee populations are a sometimes controversial area of refugee healthcare. This paper presents a patient case that introduces questions about growth chart utility across ethnically diverse populations, presenting a brief history of growth charts, the benefits and risks of growth charts, and a discussion of growth in international populations. This includes a literature review detailing some of the controversy surrounding what parameters are most appropriate for various ethnic groups, and an example of how looking beyond the CDC and WHO growth charts may prove helpful for a provider seeing patients who do not fit the expected growth trend. The paper further explores challenges in applying growth charts to individual patients and concludes that further research is needed to provide adequate data for proper patient evaluation and growth chart use. Additional resources include growth chart data for Thailand, Myanmar, Turkey, India, and Iran, as well as a composite comparative chart of these growth curves superimposed on the CDC charts.

Keywords: Growth Charts, History of Growth Charts, Literature Review, Thailand, Myanmar, Burma, Turkey, Iran, CDC, WHO


Management of TB in Refugee Populations (January 2012) Galina Boyarinova

Tuberculosis (TB) is one of the common diseases seen in refugee populations, and despite pre-arrival screening, refugees have exhibited a high post-arrival TB incidence, suggesting that the low-sensitivity screening done before arrival may be inadequate. This paper reviews appropriate screening methods, general treatment and medication regimens, and many challenges and successes related to TB management. Both local and global resources are considered for their importance in the fight against TB. Treatment in refugee camps is compared to treatment in local community settings, with challenges of refugee camp treatment listed and explained. The paper asserts that screening must be improved, but also suggests that the real solution is in decreasing TB in endemic areas and preventing spread by fighting the disease.

Keywords: Tuberculosis, TB, Screening, Treatment, Medication Regimens, Refugee Camps, Local Community, Global Resources


Hepatitis B Overview (2010) Jason Huang

Hepatitis B is a common disease affecting refugee populations. This overview includes a summary of the virology of Hepatitis B Virus (HBV) and the epidemiology of Hepatitis B infection worldwide. It also provides a bulleted outline-style overview and review of the serologic diagnosis of HBV infection, transmission of HBV, natural history of HBV infection, long-term sequelae of chronic HBV infection, and treatment of HBV. In reviewing the management of immigrants from a country with intermediate to high rates of HBV infection, the paper also addresses key questions including when to monitor for hepatocellular carcinoma and when to provide suppressive therapy.

Keywords: Hepatitis B, HBV, Virology, Epidemiology, Diagnosis, Transmission, Sequelae, Treatment, Monitoring, Hepatocellular Carcinoma, Suppressive Therapy


Survey Methodology of International Patients: Preliminary Report of International Patient Satisfaction (September 2004) Jiakai Zhu

This pilot study was designed to develop a methodology for collecting patient satisfaction information from limited-English proficient patients in the International Family Medicine Clinic (IFMC). The research is intended to be the first step in finding ways to determine patient satisfaction among an international population, promoting increased quality and efficiency of healthcare for these patients as a result of the findings. A 20-question survey was generated by physicians experienced in caring for international patients, including questions about satisfaction with the provider, barriers during visits, demographic information, satisfaction with interpretation services, and difficulty paying for healthcare and medications. The survey was administered through in-person, formal interviews in the IFMC immediately after the patient’s experience. A total of 51 patients were approached, and 46 agreed to the survey. This preliminary research determined that the survey methodology used was successful as an efficient and cost effective procedure to gather information with a limited refusal rate. Additional conclusions include: using professional interpreters improves communication and leads to increased satisfaction; patient satisfaction may be linked to expectation, but further study with a negative control is needed to provide greater insight; the patients surveyed were satisfied with their care but complained about expenses, which finding could also be further characterized by using a negative control of native local patients. Tables 1 – 4 contain specific data from the surveys conducted.

Keywords: Survey Methodology, Patient Satisfaction, Survey, Interpretation, Patient Expectations