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The COVID-19 pandemic has disproportionately affected refugee, immigrant, and migrant populations. Vaccines are essential for decreasing transmission and severity of COVID-19 infection. Understanding differences in vaccination coverage based on preferred language is crucial for focusing efforts to decrease COVID-19–related disparities. Four sites in the Minnesota Center of Excellence in Newcomer Health collaboratively evaluated completion of primary COVID-19 vaccination series on or before December 31, 2021, for patients who were 12 years or older on June 30, 2021, by preferred language. The non-English/non-Spanish speaking population included 46,714 patients who spoke 174 languages; COVID-19 vaccination coverage by language ranged from 26.2% to 88.0%. Stratifying vaccination coverage by specific language is a critical first step toward dismantling disparities and shaping interventions that best meet the needs of communities served.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has had a disproportionate impact on Black, Hispanic, and other individuals of color, although data on the effect of a person’s language on SARS-CoV-2 infection are limited. Considering the barriers suffered by immigrants and non-English-speaking families, we tested whether children with a preferred language other than English was associated with SARS-CoV-2 infection. Children from families with a preferred language other than English had a higher predicted probability of SARS-CoV-2 test positivity (adjusted odds ratio, 3.76; 95% CI, 2.07–6.67) during the first wave of the pandemic. This discrepancy continued into the second wave (adjusted odds ratio, 1.64; 95% CI, 1.10–2.41), although the difference compared with families who prefer to speak English decreased over time. These findings suggest that children from non-English-speaking families are at increased risk of SARS-CoV-2 infection, and efforts to reverse systemic inequities causing this increased risk are needed.

Refugees in the United States are believed to be at high risk of COVID-19. A cross-sectional study design was utilized to collect anonymous, online surveys from refugee communities in the United States during December 2020 to January 2021. We invited bilingual community leaders to share the survey link with other refugees aged ≥18 years. We identified factors associated with COVID-19 infection and measured the distribution of contact tracing among those who tested positive. Of 435 refugees who completed the survey, 26.4% reported testing positive for COVID-19. COVID-19 infection was associated with having an infected family member and knowing people in one's immediate social environment who were infected. Among respondents who tested positive, 84.4% reported that they had been contacted for contact tracing. To prepare for future pandemics, public health authorities should continue partner with refugee community leaders and organizations to ensure efficient programs are inclusive of refugee communities.

Objective Little is known about COVID-19 vaccination intentions among refugee communities in the United States. The objective of this study was to measure COVID-19 vaccination intentions among a sample of refugees in the United States and the reasons for their vaccine acceptance or hesitancy. Methods From December 2020 through January 2021, we emailed or text messaged anonymous online surveys to 12 bilingual leaders in the Afghan, Bhutanese, Somali, South Sudanese, and Burmese refugee communities in the United States. We asked community leaders to complete the survey and share the link with community members who met the inclusion criteria (arrived in the United States as refugees, were aged ≥18, and currently lived in the United States). We compared the characteristics of respondents who intended to receive the COVID-19 vaccine with those of respondents who did not intend to receive the vaccine or were unsure. We then conducted crude and adjusted logistic regression analysis to measure the association between employment as an essential worker and COVID-19 vaccine acceptance. Results Of 435 respondents, 306 (70.3%) indicated that they planned to receive a COVID-19 vaccine. Being an essential worker (adjusted odds ratio [aOR] = 2.37; 95% CI, 1.44-3.90) and male sex (aOR = 1.87; 95% CI, 1.12-3.12) were significantly associated with higher odds of intending to receive a COVID-19 vaccine. Among respondents who intended to receive a COVID-19 vaccine, wanting to protect themselves (68.6%), family members (65.0%), and other people (54.3%) were the main reasons. Conclusion Many refugees who responded to the survey, especially those who worked in essential industries, intended to receive a COVID-19 vaccine. Community organizations, health care providers, and public health agencies should work together to ensure that vaccine registration and vaccination sites are accessible to refugees.

Restrictive immigration policies are important social determinants of health, but less is known about the health implications and health-related content of protective immigration policies, which ma...

Objectives Immigrants are believed to be at high risk of infection with severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019 (COVID-19). A leading suspected risk factor is their role in the essential workforce. We aimed to describe COVID-19–related risk factors among Bhutanese and Burmese refugees in the United States. Methods We administered an anonymous online survey in May 2020 among community leaders of Bhutanese and Burmese refugees. Using a snowball sampling strategy, we invited community leaders to complete the survey and share the link with others who met inclusion criteria (English proficient, aged ≥18, currently living in the United States). We compared respondents with and without recent COVID-19 and identified risk factors for infection. Results Of 218 refugees in 23 states who completed the survey from May 15 through June 1, 2020, fifteen (6.9%) reported infection with COVID-19. Being an essential worker during the pandemic (odds ratio [OR] = 5.25; 95% CI, 1.21-22.78), having an infected family member (OR = 26.92; 95% CI, 5.19-139.75), and being female (OR = 5.63; 95% CI, 1.14-27.82) were risk factors for infection. Among 33 infected family members, 23 (69.7%) were essential workers. Conclusion Although we had a small snowball sample, we found that working in essential industries was associated with an increased risk of COVID-19 infection among Bhutanese and Burmese refugees. We call for larger studies that include Asian immigrant subgroups, as well as immediate attention to protecting immigrant essential workers during the COVID-19 pandemic.

A quality improvement collaborative evaluated Hepatitis B virus (HBV) care for resettled refugees and identified strategies to enhance care. 682 of the 12,934 refugees from five refugee health clinics in Colorado, Minnesota, and Pennsylvania had chronic HBV. Timely care was defined relative to a HBsAg + result: staging (HBV DNA, hepatitis Be antigen, hepatitis Be antibody, alanine transaminase testing) within 14 days, comorbid infection screening (hepatitis C virus and HIV) within 14 days, and linkage to care (HBV specialist referral within 30 days and visit within 6 months). Completed labs included: HBV DNA (93%), hepatitis Be antigen (94%), hepatitis Be antibody (92%), alanine transaminase (92%), hepatitis C screening (86%), HIV screening (97%). 20% had HBV specialist referrals within 30 days; 36% were seen within 6 months. Standardized reflex HBV testing and specialist referral should be prioritized at the initial screening due to the association with timely care.

Objective A growing number of children in the United States are from immigrant families. We conducted a national survey to examine pediatricians’ self-rated preparedness to care for children in immigrant families. Methods A 2017 survey of American Academy of Pediatrics members assessed respondent characteristics, formal training in and experience with global, public, or immigrant health, and preparedness to care for children in immigrant families. Descriptive statistics and a multivariable logistic regression model examined associations between characteristics, formal training, experience, and preparedness. Results The survey response rate was 47% (n = 758/1628). One third of respondents (33.6%) reported being unprepared to care for children in immigrant families. In bivariate analyses, respondents who had graduated from medical school outside of the United States, had previous education on immigrant health care, or had recent international global health experience were most likely to report feeling prepared to care for children in immigrant families. Multivariable regression model results indicated that prior education on immigrant health (adjusted odds ratio [AOR] 4.07; 95% confidence interval [CI] 2.68, 6.32), graduation from medical school outside the United States (AOR 2.35; 95% CI 1.22, 4.67), and proficiency in a language other than English (AOR 1.78; 95% CI 1.14, 2.80) were independently associated with preparedness. Conclusions One in 3 US pediatricians report being unprepared to care for children in immigrant families. Wider implementation of graduate and continuing medical education on immigrant child health is needed to ensure that practicing pediatricians have the appropriate skills and knowledge to care for this patient population.

Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare individuals to recognize and respond to mental health warning signs. This was a non-randomized program evaluation. Using pre- and post-training questionnaires developed for prior evaluations of MHFA, we examined the effectiveness of training offered with and without culturally-appropriate orientation to mental health terminology and concepts (N = 458). Pre- to post-training improvement in ability to recognize schizophrenia, ability to respond to schizophrenia and depression, and the overall mental health literacy was greater for Bhutanese refugees who attended orientation relative to other participants (P

BACKGROUND: Access to written hospital discharge instructions improves caregiver understanding and patient outcomes. However, nearly half of hospitals do not translate discharge instructions, and little is known about why. OBJECTIVES: To identify barriers to and potential strategies for translating children’s hospital discharge instructions. METHODS: We conducted a mixed-methods, multimodal analysis. Data comprised closed- and open-ended responses to an online survey sent to Children’s Hospital Association language services contacts (n = 31), an online environmental scan of Children’s Hospital Association translation policies (n = 22), and county-level census data. We examined quantitative data using descriptive statistics and analyzed open-ended survey responses and written policies using inductive qualitative content analysis. RESULTS: Most survey respondents (81%) reported having a written translation policy at their hospital, and all reported translating a subset of hospital documents, for example, consent forms. Most but not all reported translating discharge instructions (74%). When asked how inpatient staff typically provide translated discharge instructions, most reported use of pretranslated documents (87%) or staff interpreters (81%). Reported barriers included difficulty translating uncommon languages, mismatched discharge and translation time frames, and inconsistent clinical staff use of translation services. Strategies to address barriers included document libraries, pretranslated electronic health record templates, staff-edited machine translations, and sight translation. Institutional policies differed regarding the appropriateness of allowing interpreters to assist with translation. Respondents agreed that machine translation should not be used alone. CONCLUSIONS: Children’s hospitals experience similar operational and organizational barriers in providing language-concordant discharge instructions. Current strategies focus on translating standardized documents; collaboration and innovation may encourage provision of personalized documents.

Objectives To measure COVID-19 pandemic-related discrimination and stress among Bhutanese and Burmese refugees in the USA and to identify characteristics associated with these two measures. Methods From 5/15–6/1/2020, Bhutanese and Burmese refugee community leaders were invited to complete an anonymous, online survey and shared the link with other community members who were English-proficient, ≥18 years old, and currently living in the USA. We identified characteristics associated with pandemic-related discrimination and stress applying ordinal logistic regression models. Results Among 218 refugees from 23 states, nearly one third of participants reported experiencing at least one type of discrimination, and more than two-thirds experienced at least one type of pandemic-related stress. Having had COVID-19, having a family member with COVID-19, and being an essential worker were associated with discrimination. Discrimination, financial crisis, and female gender were associated with stress. Conclusions Reducing pandemic-related discrimination should remain a priority, as should the promotion of social support and coping strategies. Noting that this is a nonrepresentative sample, we recommend that larger national studies tracking experiences with pandemic-related discrimination and stress include Asian American subgroups with limited English proficiency.

A quality improvement collaborative evaluated Hepatitis B virus (HBV) care for resettled refugees and identified strategies to enhance care. 682 of the 12,934 refugees from five refugee health clinics in Colorado, Minnesota, and Pennsylvania had chronic HBV. Timely care was defined relative to a HBsAg + result: staging (HBV DNA, hepatitis Be antigen, hepatitis Be antibody, alanine transaminase testing) within 14 days, comorbid infection screening (hepatitis C virus and HIV) within 14 days, and linkage to care (HBV specialist referral within 30 days and visit within 6 months). Completed labs included: HBV DNA (93%), hepatitis Be antigen (94%), hepatitis Be antibody (92%), alanine transaminase (92%), hepatitis C screening (86%), HIV screening (97%). 20% had HBV specialist referrals within 30 days; 36% were seen within 6 months. Standardized reflex HBV testing and specialist referral should be prioritized at the initial screening due to the association with timely care.

In the past decade, an estimated 274,000 children and adolescents have come to the United States as refugees. Their exposure to health-related risk and protective factors varies by nationality, socioeconomic status, and time period. This chapter will focus on refugee groups who have arrived in the United States in the prior decade, from arrival to the transition to ongoing primary care. After arriving in the United States, growth and nutrition, communicable conditions, vaccine catchup, potentially toxic exposures, and entry into primary and specialty care are the focus of healthcare. Over time, psychosocial needs and chronic disease management, including development and dental health, may predominate. Lastly, the structure of the initial and ongoing visits, including cultural considerations, effective triadic communication, and collaboration with community services, is formative in the care experience for both children and their families. The intent of this chapter is to review core information and guidelines, bearing in mind that children’s specific health needs, exposures, and experiences are heterogeneous.

Efforts to address child trafficking require intensive collaboration among professionals of varied disciplines. Healthcare professionals have a major role in this multidisciplinary approach. Training is essential for all professionals, and policies and protocols may assist in fostering an effective, comprehensive response to victimization.

Purpose We explored attitudes and beliefs pertaining to sexual and reproductive health (SRH) among unmarried, female, resettled Bhutanese refugees 16–20 years. Methods Fourteen interviews were analyzed using the constant comparison method, and major themes were identified. Results SRH was stigmatized for unmarried youth, making seeking information about SRH or accessing family planning difficult. There were many misconceptions about access to SRH. Conclusions Universal, culturally, and linguistically appropriate comprehensive SRH education is recommended for female Bhutanese refugee youth. Terminology used should take into account differences in conceptualization of concepts like dating. Educators and health care providers should clearly describe consent and confidentiality laws regarding adolescent SRH services.

Our objective was to examine refugees' acute care use early in resettlement. We conducted a retrospective cohort study of acute care use, emergency room and hospital visits, by adult refugees arriving in Southern Connecticut between 2/1/2013 and 2/1/2015. We examined associations between any acute care use and collected demographic as well as health characteristics. Of the 248 refugees in our sample, 57% had a medical evaluation within 30 days of arrival. 102 (41%) had at least one acute care visit within 8 months of arrival. Male sex (OR 1.90, 95% CI 1.09-3.30) and prior history of hypertension (OR 2.87, 95% CI 1.06-7.33) were associated with greater likelihood of an acute care visit within 8 months of arrival, while having a medical evaluation within 30 days of arrival was associated with lower likelihood (OR 0.56, 95% CI 0.32-0.98). Designing systems to ensure timely evaluations of newly arrived refugees may reduce frequent acute care utilization.

BACKGROUND: Interest and participation in global health (GH) experiences have increased over the past 30 years in both medical schools and residencies, but little is known at the level of practicing pediatricians. METHODS: Data were compared from the American Academy of Pediatrics Periodic Surveys conducted in 1989 and 2017. The surveys had a response rate of 70.8% in 1989 and 46.7% in 2017. There were 638 and 668 postresidency pediatricians in the 1989 and 2017 surveys, respectively. Descriptive analyses were performed to look at changes in experience and interest in GH. A multivariable logistic regression was conducted specifically looking at characteristics associated with interest in participating in GH experiences in the next 3 years. RESULTS: Pediatrician participation in GH experiences increased from 2.2% in 1989 to 5.1% in 2017, with statistically significant increases in pediatricians ≥50 years of age. Interest in participating in future GH experiences increased from 25.2% in 1989 to 31.7% in 2017, with a particular preference for short-term clinical opportunities. In the multivariable logistic regression model, the year 2017 was associated with an increased interest in future GH experience, especially in medical school, hospital or clinic practice settings, as well as among subspecialists. CONCLUSIONS: Over the past 28 years, practicing pediatricians have increased their involvement in GH, and they are more interested in future GH experiences. The focus is on short-term opportunities. Our study reveals that practicing pediatricians mirror medical trainees in their growing interest and participation in GH.

Objectives We developed and piloted a process for sharing guideline-based clinical decision support (CDS) across institutions, using health screening of newly arrived refugees as a case example. Materials and Methods We developed CDS to support care of newly arrived refugees through a systematic process including a needs assessment, a 2-phase cognitive task analysis, structured preimplementation testing, local implementation, and staged dissemination. We sought consensus from prospective users on CDS scope, applicable content, basic supported workflows, and final structure. We documented processes and developed sharable artifacts from each phase of development. We publically shared CDS artifacts through online dissemination platforms. We collected feedback and implementation data from implementation sites. Results Responses from 19 organizations demonstrated a need for improved CDS for newly arrived refugee patients. A guided multicenter workflow analysis identified 2 main workflows used by organizations that would need to be supported by shared CDS. We developed CDS through an iterative design process, which was successfully disseminated to other sites using online dissemination repositories. Implementation sites had a small-to-modest analyst time commitment but reported a good match between CDS and workflow. Conclusion Sharing of CDS requires overcoming technical and workflow barriers. We used a guided multicenter workflow analysis and online dissemination repositories to create flexible CDS that has been adapted at 3 sites. Organizations looking to develop sharable CDS should consider evaluating the workflows of multiple institutions and collecting feedback on scope, design, and content in order to make a more generalizable product.

Over the last decade, approximately 200,000 refugee children have resettled across the United States. This population is dispersed, resulting in limited data. Collaborative research networks, where clinicians across distinct practice sites work together to answer research questions, can improve the evidence base regarding clinical care. We distributed a web-based survey to pediatric refugee providers around North America to assess priorities, perceived barriers and benefits to collaborative research. We recruited 57 participants. Of respondents, 89 % were interested in collaborative research, prioritizing: (1) access to health care (33 %), (2) mental health (24 %) and (3) nutrition/growth (24 %). Perceived benefits were "improving clinical practice" (98 %) and "raising awareness about the needs of pediatric refugees" (94 %). Perceived barriers were "too many other priorities" (89 %) and "lack of funding for data entry" (78 %). There is widespread interest in collaborative networks around pediatric refugee healthcare. A successful network will address barriers and emphasize priorities.

INTRODUCTION Few eligible children participate in early intervention (EI) programs. The objective of this study was to determine feasibility and outcomes of a novel patient navigation program on EI referrals among a diverse group of at-risk children. METHODS During a 6-month period, a patient navigator was assigned to an urban pediatric clinic to engage families, provide education on early child development and EI, and assist families with completing multidisciplinary evaluations. Families were eligible to participate if they spoke English, had a child

Children in immigrant families are less likely to screen positive with the Children with Special Health Care Needs Screener (CSHCN-S). This may indicate that children in immigrant families are healthier or require fewer health services than non-immigrant peers. Alternatively, the screener may under-identify special healthcare needs in this population. Using the 2011-2012 National Survey of Children's Health, we examined the prevalence of a positive CSHCN-S among children from first, second, and third generation households with an equivalent number of currently diagnosed chronic conditions (0, 1, 2+). Multivariate analyses controlled for sociodemographic factors. Among children with an equivalent number of chronic conditions, fewer children from first and second generation households screened positive with the CSHCN-S relative to children from third generation households. This association remained after adjusting for covariates. The CSHCN Screener may under-identify children from immigrant households, allowing for missed opportunities to allocate health resources.

Objective. We examined whether or not high maternal smoking rates at the neighborhood level increase the likelihood of individual smoking by Latina women in the three months prior to and during pregnancy, independent of other individual and neighborhood factors. Methods. This study was observational in nature, using linked vital statistics records for 24,443 Latina women in Pennsylvania (2009–2010) and U.S. Census data for 2,398 census tracts. We used multilevel logistic regression models to determine the individual odds of self-reported maternal smoking given different census tract-level rates of maternal smoking in the previous three years (2006–2008), adjusting for maternal and census-tract characteristics, including ethnic density, population density, and poverty. Results. Higher levels of maternal smoking at the census-tract level were associated with increased individual odds of smoking among Latina mothers. In the fully adjusted model, a 10% increase in the neighborhood smoking rate was associated with a 1.28 (95% confidence interval 1.22, 1.34) increase in the individual odds of smoking. Conclusion. Latina women living in census tracts where more women have smoked during or immediately prior to pregnancy are themselves at higher risk of smoking during this period.

Objectives. To determine whether the addition of hepatitis B virus (HBV) vaccine to national immunization programs improved vaccination rates among refugee children, a marginalized population with limited access to care. Methods. The sample included 2291 refugees younger than 19 years who completed HBV screening after arrival in the United States. Children were categorized by having been born before or after the addition of the 3-dose HBV vaccine to their birth country’s national immunization program. The outcome was serological evidence of immunization. Results. The odds of serological evidence of HBV immunization were higher for children born after the addition of HBV vaccine to their birth country’s national immunization program (adjusted odds ratio = 2.54; 95% confidence interval = 2.04, 3.15). Conclusions. National HBV vaccination programs have contributed to the increase in HBV vaccination coverage observed among US-bound refugee children. Public Health Implications. Ongoing public health surveillance is needed to ensure that vaccine rates are sustained among diverse, conflict-affected, displaced populations.

Objectives. We examined the impact of a maternal–child home visitation program on birth spacing for first-time Latina mothers, focusing on adolescents and women who identified as Mexican or Puerto Rican. Methods. This was a retrospective cohort study. One thousand Latina women enrolled in the Pennsylvania Nurse–Family Partnership between January 1, 2003, and December 31, 2007, were matched to nonenrolled Latina women using propensity scores. The primary outcome was the time to second pregnancy that resulted in a live birth (interpregnancy interval). Proportional hazards models and bootstrap methods compared the time to event. Results. Home visitation was associated with a small decrease in the risk of a short interpregnancy interval (≤ 18 months) among Latina women (hazards ratio [HR] = 0.86; 95% confidence interval [CI] = 0.75, 0.99). This effect was driven by outcomes among younger adolescent women (HR = 0.80; 95% CI = 0.65, 0.96). There was also a trend toward significance for women of Mexican heritage (HR = 0.74; 95% CI = 0.49, 1.07), although this effect might be attributed to individual agency performance. Conclusions. Home visitation using the Nurse–Family Partnership model had measurable effects on birth spacing in Latina women.

BACKGROUND AND OBJECTIVES: Limited data examine longitudinal nutrition outcomes of refugee children after United States resettlement. Among refugee children, our aims were to (1) assess the changes in weight-based nutritional status between baseline (0–3 months) and 10-24 months after arrival and (2) compare the BMI (BMIz) or weight-for-length z score (WFLz) trajectories to nonrefugee children for up to 36 months after arrival. METHODS: We conducted a retrospective study of refugees aged 0-16 years from Washington and Pennsylvania and compared them with an age and sex-matched nonrefugee low-income sample from Washington. Data included anthropometric measurements from the initial screening medical visit and subsequent primary care visits. Multilevel linear mixed-effects regression models evaluated the change in BMIz or WFLz trajectory. RESULTS: The study included 512 refugee and 1175 nonrefugee children. The unadjusted prevalence of overweight/obesity increased from 8.9% to 20% (P < .001) for 2- to 16-year-old refugees from baseline to 10-24 months. Refugees (2–16 years old) had a steeper increase in their BMIz per 12 months compared with nonrefugees (coefficient 0.18 vs 0.03; P < .001). Refugees CONCLUSIONS: Older refugee children exhibited a higher risk of obesity than nonrefugees, whereas refugees

Undocumented immigrants treated with isoniazid (INH) for latent tuberculosis infection should be covered for transplant for INH-related liver failure.

Objectives. We conducted a large-scale study of newly arrived refugee children in the United States with data from 2006 to 2012 domestic medical examinations in 4 sites: Colorado; Minnesota; Philadelphia, Pennsylvania; and Washington State. Methods. Blood lead level, anemia, hepatitis B virus (HBV) infection, tuberculosis infection or disease, and Strongyloides seropositivity data were available for 8148 refugee children (aged Results. We identified distinct health profiles for each country of origin, as well as for Burmese children who arrived in the United States from Thailand compared with Burmese children who arrived from Malaysia. Hepatitis B was more prevalent among male children than female children and among children aged 5 years and older. The odds of HBV, tuberculosis, and Strongyloides decreased over the study period. Conclusions. Medical screening remains an important part of health care for newly arrived refugee children in the United States, and disease risk varies by population.

Objectives This article reviews the available evidence regarding the efficacy, effectiveness, ethics, and sustainability of approaches to strengthen systems to care for and protect children living outside family care in low- and middle-income countries. Method For trafficked children, children of and on the street, children of conflict/disaster, and institutionalized children, a systems framework approach was used to organize the topic of sustainable approaches in low- and middle-income countries and addresses the following: legislation, policies, and regulations; system structures and functions (formal and informal); and continuum of care and services. The article draws on the findings of a focal group convened by the U.S. Government Evidence Summit: Protecting Children Outside of Family Care (December 12–13, 2011, Washington, DC), tasked with reviewing the literature on systems, strategies, and interventions for sustainable long-term care and protection of children with a history of living outside of family care in low- and middle-income country contexts. The specific methodology for the review is described in the commentary paper ( Higgs, Zlidar, & Balster, 2012 ) that accompanies these papers. Results For the most part, the evidence base in support of sustainable long-term care for the populations of interest is relatively weak, with some stronger but unreplicated studies. Some populations have been studied more thoroughly than others, and there are many gaps. Most of the existing studies identify population characteristics, needs, and consequences of a lack of systemic services to promote family-like care. There is some evidence of the effectiveness of laws and policies, as well as some evidence of service effectiveness, in improving outcomes for children outside of family care. Conclusions Despite the weaknesses and gaps of the existing research, there is a foundation of research for going forward, which should focus on developing and implementing systems for these most vulnerable children. The evidence reviewed indicates that child protection systems should aim for appropriate, permanent family care (including reunification, adoption, kinship care, or kafalah ) for children in order to secure the best environment for a child's developmental prospects. Evidence also suggests that the quality and duration of care, including both permanent family care and alternative care, are important regardless of setting. The diversity of political, socioeconomic, historical, regional, community, and cultural contexts in which child protection systems operate need to be taken into account during programming and research design.

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

Trained counselors interviewed 192 women who had been trafficked and sexually exploited about abuse and evaluated their physical and mental health status within 14 days of entry into posttrafficking services. Most reported physical or sexual violence while trafficked (95%), pre-trafficking abuse (59%), and multiple posttrafficking physical and psychological problems. Newly identified trafficked women require immediate attention to address posttrauma symptoms and adequate recovery time before making decisions about participating in prosecutorial or immigration proceedings or returning home.

The objective of this study was to document barriers to care, help-seeking behaviors, and the impact of a community-based patient navigation intervention on patient activation levels among Bhutanese refugees in the U.S. Data sources comprised 35 intake and 34 post-intervention interviews with program participants, 14 intake and 14 post-intervention interviews with patient navigators, and 164 case notes. Textual data were analyzed using the constant comparison method. Patient activation level was assessed at both time points. Participants had limited English proficiency (97 %), limited literacy (69 %), and the lowest level of patient activation (69 %). Participants routinely experienced complex insurance access, coverage, and payment problems and had limited healthcare-related life skills. Help-seeking began within social networks, with high reliance on bilingual, literate family members perceived to have experience with “the system.” Help-seeking was not stigmatized and was instead consistent with societal norms valuing mutual assistance. Participants preferred helpers to act as proxies and required repeated social modeling by peers to gain confidence applying healthcare-related life skills. Following the intervention, only one-third reported the lowest level of patient activation (35 %) and one-third were highly activated (32 %). Bhutanese refugees overcome healthcare access barriers by seeking help from a network of support that begins within the community. Community health workers serving as patient navigators are readily sought out, and this approach is concordant with cultural expectations for mutual assistance. Community health workers serving immigrant groups should model healthcare-related life skills in addition to providing direct assistance.

Importance Human trafficking and exploitation of children have profound health consequences. To our knowledge, this study represents the largest survey on the health of child and adolescent survivors of human trafficking. Objective To describe experiences of abuse and exploitation, mental health outcomes, and suicidal behavior among children and adolescents in posttrafficking services. We also examine how exposures to violence, exploitation, and abuse affect the mental health and suicidal behavior of trafficked children. Design, Setting, and Participants A survey was conducted with 387 children and adolescents aged 10 to 17 years in posttrafficking services in Cambodia, Thailand, or Vietnam, which along with Laos, Myanmar, and Yunnan Province, China, compose the Greater Mekong Subregion. Participants were interviewed within 2 weeks of entering services from October 2011 through May 2013. Main Outcomes and Measures Depression, posttraumatic stress disorder, anxiety, suicidal ideation, self-injury, and suicide attempts. Results Among the 387 children and adolescent study participants, most (82%) were female. Twelve percent had tried to harm or kill themselves in the month before the interview. Fifty-six percent screened positive for depression, 33% for an anxiety disorder, and 26% for posttraumatic stress disorder. Abuse at home was reported by 20%. Physical violence while trafficked was reported by 41% of boys and 19% of girls. Twenty-three percent of girls and 1 boy reported sexual violence. Mental health symptoms were strongly associated with recent self-harm and suicide attempts. Severe physical violence was associated with depression (adjusted odds ratio [AOR], 3.55; 95% CI, 1.64-7.71), anxiety (AOR, 2.13; 95% CI, 1.12-4.05), and suicidal ideation (AOR, 3.68; 95% CI, 1.77-7.67). Sexual violence while trafficked was associated with depression (AOR, 2.27; 95% CI, 1.22-4.23) and suicidal ideation (AOR, 3.43; 95% CI, 1.80-6.54). Conclusions and Relevance Children and adolescents in posttrafficking care showed high symptom levels of depression, anxiety, and posttraumatic stress disorder, which are strongly associated with self-harm or suicidal behaviors. Mental health screening and reintegration risk assessments are critical components of posttrafficking services, especially in planning for family reunification and other social integration options.

Globally, more than two billion persons have been infected at some time with the hepatitis B virus (HBV), and approximately 3.5 million refugees have chronic HBV infection. The endemicity of HBV varies by region. Because chronic hepatitis B is infectious and persons with chronic infection benefit from treatment, CDC recommends screening for HBV among all refugees who originate in countries where the prevalence of hepatitis B surface antigen (HBsAg; a marker for acute or chronic infection) is ≥2% or who are at risk for HBV because of personal characteristics such as injection drug use or household contact with an individual with HBV infection. Currently, almost all refugees are routinely screened for hepatitis B. However, prevalence rates of HBV infection in refugee populations recently resettled in the United States have not been determined. A multisite, retrospective study was performed to evaluate the prevalence of past HBV infection, current infection, and immunity among refugees resettled in the United States; to better characterize the burden of hepatitis B in this population; and to inform screening recommendations. The study incorporated surveillance data from a large state refugee health program and chart reviews from three U.S. sites that conduct medical screenings of refugees. The prevalence of HBV infection (current or past as determined by available titer levels) varied among refugees originating in different countries and was higher among Burmese refugees than among refugees from Bhutan or Iraq. Current or past HBV infection was also higher among adults (aged18 years) and male refugees. These data might help inform planning by states and resettlement agencies, as well as screening decisions by health care providers.

SETTING Philadelphia, PA, USA. OBJECTIVES To compare the evaluation and treatment of latent tuberculous infection (LTBI) in refugees seen at member clinics of the Philadelphia Refugee Health Collaborative (PRHC) vs. non-PRHC clinics. DESIGN Refugees with Class B (non-communicable) tuberculosis (TB) admitted to the United States from 2010 to 2012 who were being treated at PRHC clinics were compared to those treated at non-PRHC clinics. Odds ratios (ORs) for attending a follow-up appointment, completing treatment, and time from arrival to the United States to the first TB screening test were calculated. RESULTS Of the 2094 refugees who arrived in Philadelphia in 2010-2012, the Philadelphia Department of Public Health was notified of 149 who required additional evaluation for TB. Among these, 57 (38.3%) were confirmed to have LTBI, and none were diagnosed with active TB. All LTBI cases were recommended for anti-tuberculosis prophylaxis and 43 (75.4%) completed treatment. Refugees receiving care from PRHC clinics were more likely to be screened within 30 days of arrival (OR 4.70, 95%CI 2.12-10.44), attend a follow-up appointment (OR 4.53, 95%CI 1.36-16.27), and complete treatment (OR 9.44, 95%CI 2.39-37.3). CONCLUSION Refugees who attended PRHC clinics were more likely to be evaluated promptly and to complete LTBI treatment. The PRHC clinics serve as a model for communities seeking to improve refugee health care.

Our goal was to describe the forms of persecution reported by adult refugees in the U.S. and the relationships between persecution and health status among this population. Data were derived from the 2003 New Immigrant Survey, a representative sample of new U.S. lawful permanent residents. Major depression, impairment in daily activities due to pain, poor self-reported health, and declining health were described for refugees who had and had not reported persecution prior to arrival in the U.S. Health status was also examined for refugees who reported different forms of persecution. Half of refugees (46.7 %) in this sample reported that they or an immediate family member had been persecuted. One in three persecuted refugees (31.8 %) reported both incarceration and physical punishment. Major depression, pain-related impairment, poor health, and declining health were twice as common among persecuted refugees than among non persecuted refugees. Notably, despite these adverse experiences, the majority of persecuted refugees did not report poor health outcomes.

Objectives. To evaluate publicly available data sets to determine their utility for studying refugee health. Methods. We searched for keywords describing refugees in data sets within the Society of General Internal Medicine Dataset Compendium and the Inter-University Consortium for Political and Social Research database. We included in our analysis US-based data sets with publicly available documentation and a self-defined, health-related focus that allowed for an examination of patient-level factors. Results. Of the 68 data sets that met the study criteria, 37 (54%) registered keyword matches related to refugees, but only 2 uniquely identified refugees. Conclusions. Few health data sets identify refugee status among participants, presenting barriers to understanding refugees’ health and health care needs. Public Health Implications. Information about refugee status in national health surveys should include expanded demographic questions and focus on mental health and chronic disease.

Background: The time-limited nature of health and public health research fellowships poses a challenge to trainees' and community partners' efforts to sustain effective, collaborative, community-based participatory research (CBPR) relation- ships. Objectives: This paper presents CBPR case studies of part- nerships between health services research trainees and com- munity organization leaders in a medium-sized city to describe how participation in the partnership altered com- munity partners' understanding and willingness to conduct research and to engage with research-derived data. Methods: Trainees and faculty used participatory methods with community leaders to identify research questions, and conduct and disseminate research. Throughout the process, trainees and faculty included research capacity building of community partners as a targeted outcome. Community partners were asked to reflect retrospectively on community research capacity building in the context of CBPR projects. Reflections were discussed and categorized by the authorship team, who grouped observations into topics that may serve as a foundation for development of future prospective analyses. Results: Important ideas shared include that trainee partici- pation in CBPR may have an enduring impact on the com- munity by increasing the capacity of community partners and agencies to engage in research beyond that which they are conducting with the current trainee. Conclusion: We posit that CBPR with research trainees may have an additive effect on community research capacity when it is conducted in collaboration with community leaders and focuses on a single region. More research is needed to char- acterize this potential outcome.