AJPH EDITORIALS
reviews. Similarly, organizations empowered by governments to license, relicense, and regulate the behavior of health professionals should examine candidates’ knowledge of quality standards and interpretation of systematic reviews as well as awareness of significant recent reviews. Similarly, organizations that certify and recertify practitioners in particular specialties, including public health, should require candidates to document their awareness of and ability to apply in practice important systematic reviews. Regulators of hospitals, skilled nursing facilities, clinical practice groups, and public health policymakers should require that patients and the public be presented with evidence about alternative interventions, along with evidence of what would likely happen, as a result of natural history, if they chose no intervention. Accrediting bodies might audit practice, or require
evidence of audits, by using a random sample of patients’ records and interviews of randomly selected patients and their caregivers about their experience.
CONCLUSIONS In summary, policy could enhance the production and salience of systematic reviews, building on their significant influence to date. If implemented, our recommendations could result in more effective health services, more efficient allocation of resources, and less waste in both research and practice. Last but not least, they would result in enhanced adherence to international agreements that define access to health services of the highest quality as an essential human right. Iain Chalmers, DSc Daniel M. Fox, PhD
CONTRIBUTORS Both authors contributed equally to this editorial.
ACKNOWLEDGMENTS The authors thank Paul Glasziou and Andy Oxman for helpful comments on an earlier draft of this article. Note. Apart from their longstanding and continuing interests in promoting the principles addressed in this article, the authors declare that they have no material conflicts of interests.
REFERENCES 1. Clarke M, Hopewell S. Many reports of randomized trials still don’t begin or end with a systematic review of the relevant evidence. J Bahrain Med Assoc. 2013;2: 145–148. 2. Page MJ, Shamseer L, Altman DG, Moher D. Epidemiology and reporting characteristics of systematic reviews: 2014 update. Paper presented at: REWARD/EQUATOR Conference; September 28–30, 2015; Edinburgh, UK. 3. Macleod MR, Michie S, Roberts I, et al. Biomedical research: increasing value, reducing waste. Lancet. 2014;383 (9912):101–104.
January 2016, Vol 106, No. 1
AJPH
however, to improve our public health system’s capacity to serve all refugees. With commitment and grit, several communities have increased refugees’ access to quality health services that span the full spectrum from preventive screening to management of complex chronic conditions. These promising practices demonstrate the feasibility of providing efficient, accessible and effective health services for even the most linguistically and economically marginalized members of our communities. As Beth Farmer, the director of International
6. Fox D. Using systematic reviews in health policy. In: Egger M, Smith GD, Altman D, eds. Systematic Reviews in Health Care: Meta-Analysis in Context, 3rd Edition. Oxford and London, UK: Wiley Blackwell; In press. 7. Cochrane Library [website]. Available at: http://www.cochrane.org. Accessed October 13, 2015. 8. Campbell Library [website]. Available at: http://www.campbellcollaboration. org. Accessed October 13, 2015. 9. Glasziou P. The role of open access in reducing waste in medical research. PLoS Med. 2014;11(5):e1001651. 10. Chalmers I, Nylenna M. A new network to promote evidence-based research. Lancet. 2014;384:1903–1904. 11. Jefferson T, Deeks J. The use of systematic reviews for editorial peer reviewing: a population approach. In: Godlee F, Jefferson T, eds. Peer review in Health Sciences. London, UK: BMJ Books; 2003:297–308.
4. Fox D. The Convergence of Science and Governance: Research, Health Policy and American States. Berkeley, CA: University of California Press; 2010. 5. Vogel JP, Oxman AD, Glenton C, et al. Policymakers’ and other
The Health of the Newest Americans: How US Public Health Systems Can Support Syrian Refugees The statistics are stunning: 1.9 million Syrian refugees in Turkey, 1.7 million in Lebanon, 630 000 in Jordan, 506 000 in the European Union, and 1883 in the United States.1–3 The United States will admit an additional 10 000 Syrian refugees during the next fiscal year, at which point Syrians will constitute approximately 18% of the total refugee population admitted in 2016.4 But this is not a public health emergency in the United States. The media attention and national concern about Syrian refugees does provide an opportunity,
stakeholders’ perceptions of key considerations for health system decisions and the presentation of evidence to inform those considerations: an international survey. Health Res Policy Syst. 2013;11:19.
Counseling and Community Services in Washington State put it: “If we fix the healthcare system for refugees—make it understandable and easily accessible—we fix it for everyone” (telephone communication, October 2015).
COMPLEXITY AND CHALLENGES OF US HEALTH CARE SYSTEM Syrians, like refugees before them, arrive with a wide spectrum of issues, including the need to find paid work, transportation, and housing; deferred preventive care; preexisting medical conditions, particularly untreated diabetes and hypertension; and severe mental distress arising from great personal loss and a chaotic and dangerous flight from Syria.5
ABOUT THE AUTHORS Clea A. McNeely is with the Center for the Study of Youth and Political Conflict and the Department of Public Health, University of Tennessee, Knoxville. Lyn Morland is with the Division of Innovation, Policy, and Research, Bank Street College of Education, New York, NY. Correspondence should be sent to Clea A. McNeely, Associate Professor, University of Tennessee, Knoxville, Department of Public Health, 1914 Andy Holt Drive, Suite 390, Knoxville, TN 37996 USA (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This article was accepted October 28, 2015. doi: 10.2105/AJPH.2015.302975
McNeely and Morland
Editorial
13
AJPH EDITORIALS
All this is layered with the bewilderment of encountering a new culture with, in most cases, limited English skills. Public agencies are responsible for finding—and funding—interpretation services.6 Locating certified medical interpreters who speak the right dialect is not easy or affordable, especially when there are fewer established coethnic communities in the United States. Interpretation must include an appreciation for the nuances of culture and ethnicity, because frequently there are fundamental differences in beliefs about health, mental health, and gender roles between providers and their refugee patients. Refugee resettlement is a transnational and public– private enterprise. Health screening, health care, and health promotion for refugees require the coordination of information and funding through an array of multinational organizations (the United Nations High Commissioner for Refugees and the International Organization for Migration), federal agencies (the State Department, the Centers for Disease Control and Prevention, and the Office of Refugee Resettlement), national and state resettlement offices, state and local health and social service agencies, primary care providers, and local resettlement agencies. Given the complexity and the limited support available for the systems involved, problems in information flow and coordination are inevitable. The State Department mandates core resettlement services for 30 to 90 days that include a health assessment, referrals to specialty and mental health care, and, ideally, linking refugees to
14
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a medical home.7 Refugees eligible for Medicaid are enrolled soon after their arrival. For refugees not eligible for Medicaid, the Office of Refugee Resettlement (ORR) provides Refugee Medical Assistance. In most cases, the financial support for medical care provided by ORR ends after eight months, at which point refugees, like the rest of us, must navigate the health care system on their own.
EXAMPLES OF INNOVATIVE STRATEGIES Despite these challenges, communities throughout the United States are assuring refugees access to quality and timely screening and health care by coordinating refugee resettlement, public health, and medical care. We describe two examples.
Philadelphia Refugee Health Collaborative The Philadelphia Refugee Health Collaborative (http:// philarefugeehealth.org) formally brings together three refugee resettlement agencies and eight health care providers to achieve three health equity goals: (1) initial health screenings, (2) a strong relationship with a primary care provider (medical home), and (3) catch-up to preventive care. The source of the Collaborative’s success is cooperation and collaboration where refugee resettlement and health systems overlap. On the medical side, the collaborative set up weekly medical clinics dedicated to refugees, as well as an extensive network of specialty practices that agree to accept refugee patients, provide interpretation services, and are colocated with
the refugee clinics. On the refugee resettlement side, the agencies hired “clinic liaisons” to schedule screenings and follow-up appointments, escort patients to the clinic and pharmacy, and troubleshoot issues. Both the clinic liaisons and the medical providers screen for mental distress and collaborate with the Philadelphia Refugee Mental Health Collaborative (http://www.lcfsinpa.org/thephiladelphia-refugee-mentalhealth-collaborative) to increase access to culturally and linguistically appropriate support for mental health, including clinical services, community-building activities, art therapy, and other strategies. Finally, and very importantly, the medical providers, clinic liaisons, and leadership from both the medical care and refugee resettlement sides meet regularly to evaluate and strengthen the Collaborative. From an original capacity of 250 new refugee patients per year, the Collaborative now provides health screenings, primary care and access to specialty services to up to 800 newly arrived refugees each year. To manage costs, the resettlement agencies contract with volunteers from the Philadelphia HealthCorps program to serve as clinic liaisons and both the resettlement agencies and the medical providers use telephonic and video interpretive services.
New Arrivals Working Group, King County, Washington The New Arrivals Working Group meets bimonthly to identify and solve many of the challenges involved in providing health care for refugees. Members include medical providers and staff from refugee
resettlement agencies, mental health agencies, local transportation agencies, county and state health departments, the state Office of Refugee and Immigrant Assistance, and representatives of ethnic-based community organizations. The New Arrivals Working Group has improved refugees’ access to care by working with state agencies to facilitate the Medicaid enrollment process for newly arrived refugees, thereby shortening the time between arrival in the United States and access to medical coverage. Another success was working with local service providers to improve transportation options for refugees for health care visits, including medical screenings. In 2014, the New Arrivals Working Group hosted a conference for medical providers serving refugee populations. More than 200 medical and mental health professionals participated in the conference, and evaluations demonstrated increased knowledge among attendees on the care for newly arrived refugees.
CONCLUSIONS These two examples highlight the feasibility of improving health care access for refugees by focusing on the points of intersection between refugee resettlement and health care systems. In-depth interviews with stakeholders at federal, state, and local levels revealed three common elements of successful strategies. First, it is imperative to bring together representatives of multiple state and local agencies that interact with refugees to identify barriers to physical and mental health care and devise solutions. Include frontline staff in these meetings, as they know the real problems in accessing quality and timely health services.
AJPH
January 2016, Vol 106, No. 1
AJPH EDITORIALS
Second, when refugees arrive and for several months thereafter, they need cultural brokers who can help them access medical services, locate a pharmacy, understand dosages, and reconnect to medical care as needed. Although not expensive, these strategies are not free either. They require, as do all successful programs, a modicum of funding and deeply dedicated leadership. There also needs to be applied research funding for improving health services for refugees and asylum seekers. Rigorous evaluations that measure efficacy,
January 2016, Vol 106, No. 1
AJPH
cost-effectiveness, and scalability will help refine best practice and, ultimately, improve health at a lower cost. Clea A. McNeely, DrPH, MA Lyn Morland, MSW, MA CONTRIBUTORS Both authors contributed equally to the conceptualization of this editorial. C. A. McNeely wrote the first draft of the editorial. L. Morland contributed to the writing and editing.
REFERENCES 1. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Syrian Arab Republic: Crisis Overview. Available at: http://www.
unocha.org/syria. Accessed October 10, 2015.
syrian-refugees.html. Accessed October 6, 2015.
2. United Nations High Commissioner for Refugees (UNHCR). Europe: Syrian Asylum Applications from Apr 2011 to Sep 2015. Available at: http://data.unhcr. org/syrianrefugees/asylum.php. Accessed October 15, 2015.
5. Cultural Orientation Resource Center. Refugees from Syria. Available at: http://coresourceexchange.org/ wp-content/uploads/2015/06/SyriansBackgrounder.pdf. Accessed October 10, 2015.
3. Refugee Processing Center (RPC). Refugee Admissions Report 2015_09_30. Available at: http://www. wrapsnet.org/Reports/AdmissionsArrivals/ tabid/211/language/en-US/Default.aspx. Accessed October 10, 2015.
6. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med. 2007;22(suppl 2): 362–367.
4. Harris G, Sanger DE, Herszenhorn DM. Obama increases number of Syrian refugees for US resettlement to 10,000. New York Times. September 10, 2015. Available at: http://www.nytimes.com/ 2015/09/11/world/middleeast/obamadirects-administration-to-accept-10000-
7. US Department of State. Bureau of Population, Refugees, and Migration (PRM), Reception and Placement Cooperative Agreement. Available at: http://www.state.gov/j/prm/releases/ sample/181172.htm. Accessed October 15, 2015.
McNeely and Morland
Editorial
15
reviews. Similarly, organizations empowered by governments to license, relicense, and regulate the behavior of health professionals should examine candidates’ knowledge of quality standards and interpretation of systematic reviews as well as awareness of significant recent reviews. Similarly, organizations that certify and recertify practitioners in particular specialties, including public health, should require candidates to document their awareness of and ability to apply in practice important systematic reviews. Regulators of hospitals, skilled nursing facilities, clinical practice groups, and public health policymakers should require that patients and the public be presented with evidence about alternative interventions, along with evidence of what would likely happen, as a result of natural history, if they chose no intervention. Accrediting bodies might audit practice, or require
evidence of audits, by using a random sample of patients’ records and interviews of randomly selected patients and their caregivers about their experience.
CONCLUSIONS In summary, policy could enhance the production and salience of systematic reviews, building on their significant influence to date. If implemented, our recommendations could result in more effective health services, more efficient allocation of resources, and less waste in both research and practice. Last but not least, they would result in enhanced adherence to international agreements that define access to health services of the highest quality as an essential human right. Iain Chalmers, DSc Daniel M. Fox, PhD
CONTRIBUTORS Both authors contributed equally to this editorial.
ACKNOWLEDGMENTS The authors thank Paul Glasziou and Andy Oxman for helpful comments on an earlier draft of this article. Note. Apart from their longstanding and continuing interests in promoting the principles addressed in this article, the authors declare that they have no material conflicts of interests.
REFERENCES 1. Clarke M, Hopewell S. Many reports of randomized trials still don’t begin or end with a systematic review of the relevant evidence. J Bahrain Med Assoc. 2013;2: 145–148. 2. Page MJ, Shamseer L, Altman DG, Moher D. Epidemiology and reporting characteristics of systematic reviews: 2014 update. Paper presented at: REWARD/EQUATOR Conference; September 28–30, 2015; Edinburgh, UK. 3. Macleod MR, Michie S, Roberts I, et al. Biomedical research: increasing value, reducing waste. Lancet. 2014;383 (9912):101–104.
January 2016, Vol 106, No. 1
AJPH
however, to improve our public health system’s capacity to serve all refugees. With commitment and grit, several communities have increased refugees’ access to quality health services that span the full spectrum from preventive screening to management of complex chronic conditions. These promising practices demonstrate the feasibility of providing efficient, accessible and effective health services for even the most linguistically and economically marginalized members of our communities. As Beth Farmer, the director of International
6. Fox D. Using systematic reviews in health policy. In: Egger M, Smith GD, Altman D, eds. Systematic Reviews in Health Care: Meta-Analysis in Context, 3rd Edition. Oxford and London, UK: Wiley Blackwell; In press. 7. Cochrane Library [website]. Available at: http://www.cochrane.org. Accessed October 13, 2015. 8. Campbell Library [website]. Available at: http://www.campbellcollaboration. org. Accessed October 13, 2015. 9. Glasziou P. The role of open access in reducing waste in medical research. PLoS Med. 2014;11(5):e1001651. 10. Chalmers I, Nylenna M. A new network to promote evidence-based research. Lancet. 2014;384:1903–1904. 11. Jefferson T, Deeks J. The use of systematic reviews for editorial peer reviewing: a population approach. In: Godlee F, Jefferson T, eds. Peer review in Health Sciences. London, UK: BMJ Books; 2003:297–308.
4. Fox D. The Convergence of Science and Governance: Research, Health Policy and American States. Berkeley, CA: University of California Press; 2010. 5. Vogel JP, Oxman AD, Glenton C, et al. Policymakers’ and other
The Health of the Newest Americans: How US Public Health Systems Can Support Syrian Refugees The statistics are stunning: 1.9 million Syrian refugees in Turkey, 1.7 million in Lebanon, 630 000 in Jordan, 506 000 in the European Union, and 1883 in the United States.1–3 The United States will admit an additional 10 000 Syrian refugees during the next fiscal year, at which point Syrians will constitute approximately 18% of the total refugee population admitted in 2016.4 But this is not a public health emergency in the United States. The media attention and national concern about Syrian refugees does provide an opportunity,
stakeholders’ perceptions of key considerations for health system decisions and the presentation of evidence to inform those considerations: an international survey. Health Res Policy Syst. 2013;11:19.
Counseling and Community Services in Washington State put it: “If we fix the healthcare system for refugees—make it understandable and easily accessible—we fix it for everyone” (telephone communication, October 2015).
COMPLEXITY AND CHALLENGES OF US HEALTH CARE SYSTEM Syrians, like refugees before them, arrive with a wide spectrum of issues, including the need to find paid work, transportation, and housing; deferred preventive care; preexisting medical conditions, particularly untreated diabetes and hypertension; and severe mental distress arising from great personal loss and a chaotic and dangerous flight from Syria.5
ABOUT THE AUTHORS Clea A. McNeely is with the Center for the Study of Youth and Political Conflict and the Department of Public Health, University of Tennessee, Knoxville. Lyn Morland is with the Division of Innovation, Policy, and Research, Bank Street College of Education, New York, NY. Correspondence should be sent to Clea A. McNeely, Associate Professor, University of Tennessee, Knoxville, Department of Public Health, 1914 Andy Holt Drive, Suite 390, Knoxville, TN 37996 USA (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This article was accepted October 28, 2015. doi: 10.2105/AJPH.2015.302975
McNeely and Morland
Editorial
13
AJPH EDITORIALS
All this is layered with the bewilderment of encountering a new culture with, in most cases, limited English skills. Public agencies are responsible for finding—and funding—interpretation services.6 Locating certified medical interpreters who speak the right dialect is not easy or affordable, especially when there are fewer established coethnic communities in the United States. Interpretation must include an appreciation for the nuances of culture and ethnicity, because frequently there are fundamental differences in beliefs about health, mental health, and gender roles between providers and their refugee patients. Refugee resettlement is a transnational and public– private enterprise. Health screening, health care, and health promotion for refugees require the coordination of information and funding through an array of multinational organizations (the United Nations High Commissioner for Refugees and the International Organization for Migration), federal agencies (the State Department, the Centers for Disease Control and Prevention, and the Office of Refugee Resettlement), national and state resettlement offices, state and local health and social service agencies, primary care providers, and local resettlement agencies. Given the complexity and the limited support available for the systems involved, problems in information flow and coordination are inevitable. The State Department mandates core resettlement services for 30 to 90 days that include a health assessment, referrals to specialty and mental health care, and, ideally, linking refugees to
14
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a medical home.7 Refugees eligible for Medicaid are enrolled soon after their arrival. For refugees not eligible for Medicaid, the Office of Refugee Resettlement (ORR) provides Refugee Medical Assistance. In most cases, the financial support for medical care provided by ORR ends after eight months, at which point refugees, like the rest of us, must navigate the health care system on their own.
EXAMPLES OF INNOVATIVE STRATEGIES Despite these challenges, communities throughout the United States are assuring refugees access to quality and timely screening and health care by coordinating refugee resettlement, public health, and medical care. We describe two examples.
Philadelphia Refugee Health Collaborative The Philadelphia Refugee Health Collaborative (http:// philarefugeehealth.org) formally brings together three refugee resettlement agencies and eight health care providers to achieve three health equity goals: (1) initial health screenings, (2) a strong relationship with a primary care provider (medical home), and (3) catch-up to preventive care. The source of the Collaborative’s success is cooperation and collaboration where refugee resettlement and health systems overlap. On the medical side, the collaborative set up weekly medical clinics dedicated to refugees, as well as an extensive network of specialty practices that agree to accept refugee patients, provide interpretation services, and are colocated with
the refugee clinics. On the refugee resettlement side, the agencies hired “clinic liaisons” to schedule screenings and follow-up appointments, escort patients to the clinic and pharmacy, and troubleshoot issues. Both the clinic liaisons and the medical providers screen for mental distress and collaborate with the Philadelphia Refugee Mental Health Collaborative (http://www.lcfsinpa.org/thephiladelphia-refugee-mentalhealth-collaborative) to increase access to culturally and linguistically appropriate support for mental health, including clinical services, community-building activities, art therapy, and other strategies. Finally, and very importantly, the medical providers, clinic liaisons, and leadership from both the medical care and refugee resettlement sides meet regularly to evaluate and strengthen the Collaborative. From an original capacity of 250 new refugee patients per year, the Collaborative now provides health screenings, primary care and access to specialty services to up to 800 newly arrived refugees each year. To manage costs, the resettlement agencies contract with volunteers from the Philadelphia HealthCorps program to serve as clinic liaisons and both the resettlement agencies and the medical providers use telephonic and video interpretive services.
New Arrivals Working Group, King County, Washington The New Arrivals Working Group meets bimonthly to identify and solve many of the challenges involved in providing health care for refugees. Members include medical providers and staff from refugee
resettlement agencies, mental health agencies, local transportation agencies, county and state health departments, the state Office of Refugee and Immigrant Assistance, and representatives of ethnic-based community organizations. The New Arrivals Working Group has improved refugees’ access to care by working with state agencies to facilitate the Medicaid enrollment process for newly arrived refugees, thereby shortening the time between arrival in the United States and access to medical coverage. Another success was working with local service providers to improve transportation options for refugees for health care visits, including medical screenings. In 2014, the New Arrivals Working Group hosted a conference for medical providers serving refugee populations. More than 200 medical and mental health professionals participated in the conference, and evaluations demonstrated increased knowledge among attendees on the care for newly arrived refugees.
CONCLUSIONS These two examples highlight the feasibility of improving health care access for refugees by focusing on the points of intersection between refugee resettlement and health care systems. In-depth interviews with stakeholders at federal, state, and local levels revealed three common elements of successful strategies. First, it is imperative to bring together representatives of multiple state and local agencies that interact with refugees to identify barriers to physical and mental health care and devise solutions. Include frontline staff in these meetings, as they know the real problems in accessing quality and timely health services.
AJPH
January 2016, Vol 106, No. 1
AJPH EDITORIALS
Second, when refugees arrive and for several months thereafter, they need cultural brokers who can help them access medical services, locate a pharmacy, understand dosages, and reconnect to medical care as needed. Although not expensive, these strategies are not free either. They require, as do all successful programs, a modicum of funding and deeply dedicated leadership. There also needs to be applied research funding for improving health services for refugees and asylum seekers. Rigorous evaluations that measure efficacy,
January 2016, Vol 106, No. 1
AJPH
cost-effectiveness, and scalability will help refine best practice and, ultimately, improve health at a lower cost. Clea A. McNeely, DrPH, MA Lyn Morland, MSW, MA CONTRIBUTORS Both authors contributed equally to the conceptualization of this editorial. C. A. McNeely wrote the first draft of the editorial. L. Morland contributed to the writing and editing.
REFERENCES 1. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Syrian Arab Republic: Crisis Overview. Available at: http://www.
unocha.org/syria. Accessed October 10, 2015.
syrian-refugees.html. Accessed October 6, 2015.
2. United Nations High Commissioner for Refugees (UNHCR). Europe: Syrian Asylum Applications from Apr 2011 to Sep 2015. Available at: http://data.unhcr. org/syrianrefugees/asylum.php. Accessed October 15, 2015.
5. Cultural Orientation Resource Center. Refugees from Syria. Available at: http://coresourceexchange.org/ wp-content/uploads/2015/06/SyriansBackgrounder.pdf. Accessed October 10, 2015.
3. Refugee Processing Center (RPC). Refugee Admissions Report 2015_09_30. Available at: http://www. wrapsnet.org/Reports/AdmissionsArrivals/ tabid/211/language/en-US/Default.aspx. Accessed October 10, 2015.
6. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med. 2007;22(suppl 2): 362–367.
4. Harris G, Sanger DE, Herszenhorn DM. Obama increases number of Syrian refugees for US resettlement to 10,000. New York Times. September 10, 2015. Available at: http://www.nytimes.com/ 2015/09/11/world/middleeast/obamadirects-administration-to-accept-10000-
7. US Department of State. Bureau of Population, Refugees, and Migration (PRM), Reception and Placement Cooperative Agreement. Available at: http://www.state.gov/j/prm/releases/ sample/181172.htm. Accessed October 15, 2015.
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