Health Care of Afghan Refugees: Part 3

December 07, 2021

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Emergency Care and Women's Health, December 6, 2021

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00:00Yeah.
00:07Oh yeah, that's right.
00:07You guys were going to record
00:08it yourselves. You didn't need
00:09me to do it, right?
00:12Correct, Laura Europe. You have that.
00:23So hi everyone, thanks so
00:24much for joining us today.
00:25We're just going to give
00:26people a few minutes to sign
00:28in and we'll get started.
00:29Probably around 12:05.
02:23So welcome to everyone who's joining
02:25us today, I think will give people
02:27just another minute to sign on and
02:28then we'll get started around 12:05.
02:30So thanks so much.
03:29OK, thanks so much for joining us here today.
03:31My name is Tracy Raven.
03:33I'm the director of the Office of
03:34Global Health and the Department
03:36of Internal Medicine here at Yale,
03:37and we are thrilled to be able to
03:39have our our part three in our webinar
03:42series today focusing on the health
03:45care of Afghan refugees and evacuees.
03:47Today will be focusing on
03:49emergency care and Women's Health.
03:53Just a couple of thoughts before we get
03:56started in response to these webinars,
03:59we've been getting a lot of questions
04:01locally about how folks can get
04:03involved in supporting those who
04:05are coming from Afghanistan,
04:06and so Iris is our main refugee
04:09resettlement agency here in New Haven.
04:11And just to say that they have,
04:14they have several mechanisms set up on
04:16their website or through myregistry.com
04:18or Amazon.com for folks to be able
04:22to make donations or to purchase.
04:24Purchase items that are needed
04:25by the families who are coming,
04:27so please feel free to take a
04:29look at that those resources.
04:32As far as additional resources for
04:34those who are interested in learning
04:36more about different aspects of
04:38providing clinical care for refugees,
04:40our colleagues at the University of
04:42Minnesota in their global medicine group
04:44have put together this very helpful website,
04:47which has a whole set of resources.
04:49The QR code that will take you
04:51directly to this website is up
04:53in the top here and I'll show it.
04:55I can show it again at the end.
04:57So as you can see,
04:58they've got some FAQ for providers,
05:01some helpful screening tools and resources.
05:03Information for a Minnesota volunteer
05:05specifically and then some cultural
05:07training tools and resources
05:09that may be useful more broadly,
05:11they also have put together a free
05:13course and so this is a different
05:14QR code that can link you directly
05:16to this free course,
05:17which provides continuing medical education.
05:20It's a four hour course which provides
05:23a little bit more background on
05:25clinical issues related to working
05:27with this population,
05:29so I would encourage people to
05:31take a look at these two resources
05:33and certainly happy to.
05:34To show these again at the end.
05:38As far as our webinar today,
05:39so we're going to ask all of
05:41our attendees to please write
05:42your questions in the chat.
05:44Our speakers are not going to
05:46have time to answer them as we go,
05:47but hopefully will have a few
05:49minutes for question and answer at
05:50the end of each of the sections.
05:52So just put your questions in the chat
05:54and we will get to them as we are able.
05:57The webinar today is being recorded
05:59and will eventually be posted on the
06:01rail Refugee Health Conference website,
06:03which is the link here.
06:05If you have questions or comments.
06:08Or or other thoughts about the webinar,
06:09please feel free to reach out to our
06:11team at refugee health at yale.edu.
06:15So just introducing our panelists today.
06:17I'm very excited to have three
06:19colleagues joining us.
06:20Our first doctor Pooja Agarwal from
06:22the Department of Emergency Medicine
06:24is going to be giving the talk
06:26for the first section on emergency
06:28care and then Dr Shefali Pathy,
06:30who's a medical director of the
06:33Women's Health Center at Sargent Drive
06:35and assistant professor of OB GYN,
06:37will be working together with
06:39Michelle Telfer who's the interim Co.
06:40Director of our nurse would midwifery
06:43specialty and assistant professor
06:44of nursing here.
06:45The old School of Nursing to talk
06:47with us about Women's Health.
06:49Alright, so I'm going to turn it
06:52over to our to our panelists.
06:54Doctor Agarwal looking
06:55forward to hearing your talk.
06:57Thank you. Uh,
07:00we get my slides up.
07:03Alright, well thank you everybody for
07:06joining and I appreciate the time to speak
07:09with with all of you about kind of urgency,
07:12care and Afghan evacuees. And I'm using
07:16that word specifically for residual.
07:19If you haven't heard about it already,
07:20you'll you'll kind of understand
07:21why in just a few moments,
07:22but I am as Doctor Evil mentioned,
07:26an emergency medicine physician.
07:27I'm also on the Board of Directors for IRIS,
07:30which is the local resettlement agency.
07:32Here in in New Haven still have quite
07:34a bit of experience with refugees.
07:37Kind of overtime and locally and and their
07:40transition to life here in the states.
07:43So what I'm going to spend time speaking
07:46about kind of three main topics.
07:48I'm going to introduce the unique
07:50elements of the Afghan evacuee context,
07:52which you may have heard a little
07:54bit about before,
07:54so I'll go through that quickly.
07:55I want you to recognize drivers of acute
07:58care utilization in this population, and.
08:00And understanding and Ed specific
08:02considerations for refugees and
08:04what you need to be thinking about.
08:06And I recognize that this audience
08:07it's not just emergency physicians.
08:09It's probably providers of all types,
08:11but kind of considering how we function
08:13in the Ed and what we're thinking about,
08:16hopefully will help you understand
08:17the greater context of health,
08:19how to care for these individuals.
08:21So the the refugee experience is in
08:24itself an independent risk factor
08:26for poor health outcomes, right?
08:28These are vulnerable populations,
08:29often women, children, the elderly.
08:31They have chronic conditions,
08:32they have physical disabilities,
08:34they have mental health challenges,
08:35their minority populations.
08:37They've often had poor access to care
08:40through the entire process of this.
08:42This experience that they've had
08:44during migration during time waiting
08:46for resettlement.
08:47They've had, physical trauma,
08:48they've had, mental health,
08:49mental trauma, mental health concerns.
08:52Interruptions in their chronic
08:54medications and an ongoing treatment.
08:56New medical conditions that
08:58may not have been addressed.
08:59Exposure to communicable diseases,
09:01vector borne diseases,
09:03poor access to food and education, exercise.
09:06And you know, a lot of barriers.
09:09Accessing care along the way.
09:10Maternal and child health, dialysis, chemo.
09:12If they need it and and so all
09:14of these things play a part in
09:17in their entire experiences.
09:18And then how they how they present us.
09:22So the Afghan experience briefly has
09:24been prolonged. It's been iterative.
09:26It's been nuanced over years,
09:28and it finally came to a head
09:29in August of this year.
09:31We're over 100,000 Afghan nationals,
09:33and actually more than that
09:35were rapidly evacuated.
09:362 transitional points,
09:37military installations,
09:38and then to destinations.
09:40Kind of across the country in the
09:42world through resettlement agencies,
09:44and these are generally people who
09:46have worked with EU S government in
09:48Afghanistan and other vulnerable populations,
09:49so they may have some language capacity.
09:52Within our within our health
09:53care system and they may not.
09:55We call them refugees just 'cause it's
09:57it's a term of all I think familiar with,
09:59but they actually have a little
10:00bit of a different
10:01designation.
10:01They're called humanitarian parolees
10:03and the only reason I bring
10:05this up is that it does there.
10:07There's a nuanced there for our purposes.
10:10It's kind of they are the same as refugees.
10:12They have access to.
10:13They've been promised access to Medicaid,
10:15to food stamps, to cash assistance.
10:17They're authorized to work,
10:18and those things all effects, how they
10:20could engage with the health care system.
10:21But the one.
10:22Potential difference is that they may
10:24present to health for health care
10:25without the support of a resettlement
10:27case manager because they've been
10:29kind of brought visits him so quickly
10:31and also prior to enrollment in
10:32kind of fully enrolled in health
10:34insurance before they've actually
10:36seen someone in the health clinic.
10:38And this is local as well as
10:39just kind of national as well.
10:41So keeping that in mind,
10:42you know often when refugees come to see us,
10:44they've already been through
10:45the health care system.
10:46They've had a screening exam,
10:47they know how to manage the system.
10:49This population may be different
10:50and that they may be showing
10:52up without a lot of that.
10:53Already happening,
10:54and so you can imagine with that
10:56level of influx 100,000 and more
10:59coming across into our country
11:01in a very short period of time.
11:04Everybody is taxed by this or
11:06resettlement agencies and their
11:08partners can't possibly keep up.
11:10And that's expected.
11:11And that's OK.
11:12We just need to be prepared for that.
11:14And that's what we've we've had
11:16to be kind of nimble about and so,
11:18of course, that's not all right.
11:21There's these concurrent challenges as well.
11:23There's COVID.
11:23And so if you take away the
11:25refugee context with KOVID,
11:26our health care system was
11:28already taxed with people first,
11:29not showing up in in to get care and
11:32then coming in when it's often late
11:35in their in their clinical history,
11:37neglecting some of their care for awhile.
11:41Kind of taxing the healthcare system.
11:44And on top of that,
11:45now you have this rapid influx of
11:47arrival so our local systems have
11:49been challenged in multiple ways
11:51over the last almost two years now.
11:53And so that the usual process
11:56get an intake exam.
11:57For a refugee you get in and take exam.
12:00You establish care.
12:01You understand the system better.
12:03You know how to navigate the system,
12:05and that usually prevents people
12:06from showing up in the Ed,
12:08but the system has been so taxed
12:09with a lot of that has gone away,
12:11and so now we're seeing people
12:13who have not gotten those things
12:14and they and they arrive with
12:16often little documentation with
12:18little understanding of how what
12:20they need and and and we are.
12:22We are there to care for them.
12:25So in emergency departments,
12:27you know average Americans
12:28visit the Edu one in five.
12:31Visit the Ed every single year.
12:32The Ed is considered a critical point
12:34of entry into the health care system.
12:35A major source of medical care,
12:37and they provide an alternative
12:38when barriers to care exist.
12:40Otherwise you don't know where to go.
12:41Your PCP is not available there,
12:43they're away.
12:43Whatever it is,
12:44people will show up in the D
12:47for emergency things as well As
12:49for non emergency type things.
12:50And what we found a few years
12:52ago in this study that we did is
12:54basically that having that one
12:55piece having a medical evaluation
12:56for refugee within the first 30
12:58days after arrival was associated
13:00with lower likelihood of Ed visit.
13:02And we know that that that exam
13:04is not happening consistently as
13:05consistently as it was before,
13:07which is now leading to more visits.
13:11So let's now focus on the actual
13:13emergency care considerations of and
13:15the experience right there kind of
13:17break it up into three different components.
13:20Their underlying challenges
13:21that we have to be aware of.
13:22I've touched on some of this.
13:23I'm going to go into this with more detail.
13:25Then there are the real time
13:27considerations of when you were
13:28there actually caring for the
13:29patient in the emergency department.
13:31What do you have to consider?
13:31What you have to be thinking about?
13:33And then there is the aftercare
13:36visit logistics that really help
13:38them successfully move beyond
13:39that emergency department.
13:41Visit into something more kind
13:43of with a better understanding
13:46of how the system works.
13:48So the first thing to consider when
13:50people are engaging in kind of in
13:52the healthcare system is what are
13:54their specific barriers to care.
13:56And we often see the output of these
13:59barriers in our in our emergency
14:02department right there often underinsured
14:05or uninsured healthcare equity that is,
14:08you know the the whole that that
14:10is a whole another big concept that
14:12of course our refugee patients are
14:15certainly affected by the the concept of.
14:18Access right?
14:19How do I access the health care provider?
14:21How do I access a specialist if I need it?
14:23How do I navigate the system and
14:25what does what is an emergency
14:27department versus a primary care visit?
14:29How are those things different?
14:30Those are those are those are new
14:32concepts of time system people.
14:34Transportation is hard.
14:35Many of our of our new arrivals don't
14:37have cars or private transportation.
14:39They're relying on buses and
14:42sometimes ubers if possible.
14:44Those are very expensive language,
14:47poor health literacy.
14:49Limited English proficiency and
14:50just language barriers themselves
14:52is a huge component of how they're
14:55of the challenges that they're
14:56having when they access care.
14:59Social,
14:59cultural norms are very different
15:01between what we're used to and
15:03this particular population,
15:04and all kind of refugee populations
15:06will talk about this a bit more later.
15:08Health literacy,
15:09right?
15:09So what are the of the terminology
15:12that we use?
15:13How do I? How do I really understand
15:15the information that I'm getting,
15:17and if I really take that and and?
15:19Actualize that into better care
15:20in the future that sometimes it's
15:22a big challenge and then one
15:23thing we don't think about often.
15:24A barrier to people accessing cares,
15:26competing interests, right?
15:27So these are individuals who have
15:29really left with very little and they
15:31are trying to reestablish their lives,
15:33which include things like getting a job,
15:35holding down a job school for their kids,
15:39food on the table,
15:40and often those things may compete
15:41with their health care and their
15:43health care needs.
15:44And so considering that when you
15:46see somebody in the Ed and and
15:48kind of Wonder Wheel.
15:49Why would they let something go for awhile?
15:50So those are all barriers that people
15:53that people have that that affect
15:55the way that they're engaging with
15:57their health care system and with
15:59the emergency department they're
16:00coming off and with very kind of
16:02end stage challenges that could have
16:04been perhaps affected much earlier.
16:08Moving into some of the contextual
16:10considerations and I've gotten
16:11into a little of this already,
16:13but just think about when you're
16:15presented with the patient in the
16:17Ed or or somewhere in your clinic.
16:18Think about the journey that
16:20each person has really.
16:22It is gone through to get to where
16:24you are to get to seeing you as
16:25a physician or you as a provider
16:27in every state.
16:28Every step of that migration process,
16:29there's been a challenge and because
16:31of the speed of that evacuation,
16:32you know their their medical
16:34screening hasn't happened.
16:34They've offered.
16:35It's possible that they have
16:37been unable to maintain some of
16:40their chronic care needs.
16:41They may have had limited
16:43access to health care,
16:44where you know in their transition point
16:46or even before that vaccinations the
16:48vaccination rate within this population
16:50is actually fairly low they've had.
16:52Undertreated or untreated chronic medical
16:54conditions and new medical issues that
16:56may have come up during this entire
16:58process that have not been addressed yet.
17:00And then, of course,
17:01there's a lot of trauma,
17:03both physical and mental,
17:04that that overlies.
17:06I think almost everything, everything,
17:08everyone that you see they may not.
17:11They may not.
17:13Speak about it,
17:14but it's really important to consider
17:15that as you're treating a patient and
17:17what else they've been through and how
17:19that's affecting their physical health.
17:23Some of the specific clinical considerations
17:25now this is maybe more relevant if
17:27someone has just recently arrived,
17:28although not necessarily so.
17:29And back in August in September
17:31when we were hearing about this
17:33population for starting to arrive,
17:34we were hearing more about this from CDC.
17:38The the kind of the the notices that
17:41the CDC was putting out specifically,
17:43and as I mentioned before,
17:44the vaccination rate the vaccination coverage
17:46in Afghanistan is actually quite low,
17:48only about 60%,
17:49and so we were seeing we didn't see an
17:52outbreak of measles and that did cause
17:54a kind of a halt in the whole process of
17:56moving people forward through this system.
17:58While they did contact tracing,
18:00vaccinations, quarantine,
18:02kind of mandatory quarantine periods,
18:04now they didn't.
18:05You know, my my guess is that.
18:08There probably are more individuals
18:09out there who are unvaccinated,
18:10who are now kind of amongst us,
18:12and so something to consider.
18:14You probably have never or very
18:15rarely seen a measles rash,
18:17so something to think about when you're
18:19seeing a new rash and in a new arrival.
18:21The mumps obviously.
18:22Also part of that same vaccine
18:24series Lashman I assist.
18:25Also something that we see within the
18:28population kind of transferred by sandflies.
18:31We don't see that here,
18:32but it's something that it's mainly cutaneous
18:34features and this is just one example.
18:36Looks like there's very.
18:38There are lots of different
18:39presentations of that,
18:40so if you see somebody in the Ed and
18:42there's someone that someone has recently
18:44arrived or there's actually latent
18:45period for a lot of these things too,
18:47you may.
18:48You may consider these particular things.
18:49Other considerations that don't have
18:52the cutaneous manifestations malaria.
18:54There's a long incubation period for Vivax,
18:57and so you could see people you know months
19:00out even later than that with malaria,
19:02tuberculosis, and polio.
19:04Again, because of the low vaccination
19:07coverage and then there is.
19:09You know,
19:10quite a bit of GI infections that
19:11that you may see.
19:12Yeah, shigella Giardia.
19:13Cryptosporidium is hepatitis rotavirus.
19:15Those kinds of things have been seen also,
19:18so you want to make sure you're asking
19:20about and trying to get some information
19:22about vaccination status patients,
19:23even if they're coming into
19:25the ET and then beyond this,
19:27you know there are the things
19:28that everybody gets right.
19:30The diabetes and hypertension
19:31and all the other things that
19:33that that we all get as well,
19:36that you want to make sure you're
19:38thinking about that may not have
19:40been diagnosed in this population.
19:41And then the you know the next kind
19:44of the final consideration here is
19:46the the specific cultural and care
19:48considerations for this population, right?
19:50So you know the the individuals
19:53from Afghanistan, that's they.
19:55They have their promise.
19:58Very, very patriarchal culture, right?
20:00So the men will often speak for and make
20:02decisions for the members of the household,
20:04and rather whether you
20:05agree with that or not.
20:07It doesn't matter.
20:08You have to be sensitive to that
20:09in order to really deliver the best
20:11care to your patient in front of you.
20:13Uhm, there are kind of very unique family
20:15and gender roles that you have to be aware
20:17of and and it's a very modest culture,
20:18so you may find that your patients
20:20may not shake hands which we
20:22probably don't do anyway.
20:23'cause of COVID anymore,
20:24but shaking hands,
20:25making physical contact eye contact might
20:27be a little bit different and just being
20:30aware of that translation is is a huge
20:35part of the way we can engage with this.
20:39With this population, you know we do.
20:41You know, Yale, we're lucky to have.
20:43The Marty carts where we have video
20:46translation and pasta is actually a very.
20:48It's accessible and usable diary as well.
20:50Those are the two main languages that
20:53that we've been seeing here anyway,
20:55and so that is available.
20:56You might other something you may
20:58not have considered is that actually
20:59the video part of the translation
21:01may not be comfortable for everybody,
21:02and so I've had several patients
21:04who have actually asked to turn the
21:06actually the screen away while they'll
21:07speak verbally with the person they
21:09actually don't want to see the they
21:10don't want to be seen on the video,
21:12and that's something to be aware of.
21:13Just kind of culturally.
21:16The other thing to consider is who
21:19is doing the translation, right?
21:20So as much as you can trying to
21:22get someone who is not a family
21:24member is is appropriate.
21:25People may not be comfortable speaking
21:28in front of somebody that they know
21:31and also thinking back to just the
21:34family dynamics and and who who may be
21:36comfortable speaking in front of other
21:38members of their family and how that can be.
21:40You can get the information that you need.
21:42Communication challenges kind of
21:44apart from language and you know,
21:46people may not feel as empowered or
21:48just comfortable asking questions
21:50you may not get as much pushback.
21:52You might just kind of get a,
21:53you know.
21:53OK,
21:54I'll do what you say or just kind of
21:55a nod and a lot of difference and so
21:57really making sure that your patient
21:59understands what you're saying and
22:00understands what's happening is important.
22:03You know how they engage
22:05with medical professionals?
22:06May not be the same way this year
22:08used to and and so that's something
22:10to really consider when you're
22:12doing discharge instructions.
22:13For example,
22:14and making sure they understand
22:16what their next steps are.
22:18And then of course, like I mentioned,
22:20mental health and trauma.
22:21You know,
22:21there could certainly be some
22:23stigmatization of of their complaints
22:26that that relate back to some of the
22:28other deeper things that are happening.
22:30And you know,
22:30here you know,
22:31you know we're lucky enough to have
22:33the Refugee health clinic with with
22:34a very strong psychiatric component
22:36to it that that could look into
22:38some of these things.
22:39And so considering that also what?
22:42What other services they may need.
22:45And then finally, you know.
22:46So you you kind of thought about the context
22:48you cared for the patient in the Ed.
22:50Now let's think about how you transition
22:52them safely and appropriately back
22:54to outside of the hospital system
22:56where you can actually make sure
22:57that they maintain their care right.
22:59And so the actual decision making
23:01component of it while you want to have that
23:05conversation with your with your patient,
23:07in case there is a challenge with
23:09understanding or with language
23:10collaborating with relevant staff and
23:12with outpatient clinics if possible,
23:14can certainly be.
23:16Be important as well as referrals
23:18and other specialty services.
23:20The care delivery itself so are you.
23:23Are you assuring good quality of care
23:25with your trend interpretation available
23:27throughout the entire encounter?
23:29A stallion understanding whether
23:30their hot water is serially helps
23:33is matched to where they can
23:35understand what you're telling them.
23:36Is their trauma informed care,
23:38considering what they have been
23:40through and the care transition,
23:42have you been able to kind of explain
23:44things like how do your prescription?
23:47Here is a copy of your record.
23:48How did this?
23:49How you get follow up work with
23:50clinics and and staff to get the
23:52transition models for timely?
23:54Follow up with clear communication and
23:56then finally you know care outcomes.
23:58Are we doing the best we can
24:00for our patients including this
24:02challenging population?
24:03And that's really kind of in our
24:05own personal metrics and how in
24:07terms of you know,
24:07people returning to the Ed versus
24:09going to other other places for
24:11care that may be more appropriate.
24:13Looking at their outcomes.
24:14Making sure things like they're
24:15you know they're insuring statuses.
24:17Or create those kinds of things
24:18that we can help check for them.
24:20So those are kind of my main
24:22thoughts about emergency care with
24:25come with our Afghan population.
24:27I'm happy to take questions
24:29either now or later.
24:30Whatever is that we have time for.
24:33Great, thank you so much.
24:34Uh Puja that was wonderful.
24:36We we do have a couple of questions
24:38that have come up in the chat,
24:39so the first question was,
24:42you know when you say that folks
24:44have a lower vaccination rate?
24:46Does this mean that they're
24:47not going through routine
24:48pre screening before arrival?
24:50And so Camille Brown had just weighed
24:52in to say that evacuees have no pre
24:55screening done until they arrive in
24:57EU S most are coming to military
24:59bases and are getting their first
25:00of the series of age appropriate
25:02and available vaccines there.
25:04And that for children,
25:05they'll need several of the series
25:07to be up to date for full protection,
25:09so they're still considered under vaccinated.
25:11So puja what?
25:11What other comments would you want to add
25:13to that? Yeah, no.
25:13I mean, that's exactly right.
25:15Is that, you know we the you know when
25:17someone is goes through the process of
25:19the traditional refugee process, right?
25:21That takes sometimes 18 months, two years.
25:23And that's the time that that
25:25usually part of that is taken up in
25:27making sure that the entire vaccine
25:29series and everything is could have
25:30done checked kind of taken care of
25:32with the rapid evacuation of this.
25:34Population that hasn't happened
25:35and so Camille is absolutely right.
25:37You know, as much as they're
25:39able to start that process,
25:40they are still considered under
25:42vaccinated and so you know what in
25:45the Ed we need to be considering.
25:47What is the implication of being under
25:49vaccinated from some of these things
25:50that we often may not have seen,
25:52and so that's absolutely I
25:53agree with that completely
25:55and then actually skipping
25:56ahead to a related question.
25:58So just put in the chat.
25:59Do we need to check check
26:00titers for vaccines?
26:01Or do you just typically
26:03assume that everybody is not?
26:04Vaccinated. Uhm,
26:07so that would be actually a question for,
26:09but I would probably defer that
26:10to my primary care colleagues.
26:12We don't obviously check
26:13titers in the D at all.
26:15We kind of assume that they are unvaccinated.
26:19Unless we have proof otherwise and in
26:21terms of our evaluation of the patient,
26:23and so we kind of consider all of it
26:25until we know that that's not the case.
26:27Instead, I would defer the tighter
26:29question to to another colleague of mine
26:31gotcha and I see it. So Camille,
26:33who's director of our pediatric clinic,
26:35says we don't tend to check titers.
26:38For kids, as most have had one vaccine,
26:40although they do check have a titers,
26:42I see that any animal I who is also
26:44who's the director of our adult Refugee
26:47Clinic has just joined the line,
26:48so I don't know if you're able to turn
26:51your video on and address this question,
26:53or if you want to just put
26:54an answer in the chat.
26:56Yeah sorry, I was trying to type fast so we
26:59do for the adults. We if
27:02we do actually have proof of documented
27:04proof that they have had the vaccines.
27:06We don't check titers,
27:07but that's not always a given so we
27:09sort of have it as part of the protocol
27:11to just check the titles because we
27:13never know ahead of time whether
27:14we're going to have them or not.
27:16But but basically, yeah,
27:17if we if we are pretty sure
27:19that and they can show us the
27:21documentation then we don't.
27:23Great, OK, so if there's no documentation
27:26then your practice is to check titers.
27:28OK, and then the other question in the chat,
27:30which I think will will definitely
27:32carry over to our next talk.
27:34This was a question about so
27:36regarding situations where you
27:38will have a male decision maker
27:41for a family or for for a spouse.
27:44How do you navigate?
27:46Getting consent from the patient
27:49herself prior to procedures when
27:51you also have a from a male
27:52decision maker who's in the room.
27:54So Puja and Camille you you put
27:55us some thoughts in the chat puja
27:57I'm going to ask you just to.
27:58Respond to that as well.
28:01Yeah, you know it's challenging when,
28:03UM, in the D it's often.
28:05There's often implied consent
28:06for a lot of things when we do.
28:08When there is a procedure that needs to
28:09be done that needs an actual that we can,
28:11we can take the time to get a consent.
28:13We kind of have to just do our best,
28:16explain to if it's a I assume that's
28:18the question is if it is a a female
28:20patient and we asked the you know
28:22the female patient to you know
28:24whether she has any questions and
28:26you know we just do the best that we
28:29can write if she defers to a male.
28:32Member of her family then,
28:33and we just kind of have to go with it.
28:36It's not ideal,
28:37but that's just saying that's
28:38kind of what we do.
28:42I just I want to add sorry I'm gonna
28:45add an echo that I think it can
28:47be very challenging and for these
28:50situations where it is our Patriarch,
28:52patriarchal culture.
28:53But I think that we have to
28:56document we do suggest that,
28:57especially in areas of consent and
28:59Michelle you can talk about if
29:01there's anything else but in areas
29:03of consent we actually do have a
29:05translator and we don't just use a
29:07family member and I'm happy to have a
29:09family member in the room with us or.
29:11As part of that conversation,
29:13but I think that that's where we do
29:15have to give some autonomy to that
29:18family or to that woman that she's
29:21going to hear the conversation.
29:26Thank you and that I mean that
29:27basically is is just in line with
29:29what Camille had typed in as well.
29:30Saying you know,
29:31being sensitive to cultural norms,
29:33a husband or male family member may be
29:35present during the content discussion,
29:37and an interpreter should be present
29:38even if the husband speaks English.
29:40So so great. Thank you so much.
29:44OK, so we are right on time,
29:46so let me turn it over to
29:47Shefali and Michelle for the
29:49next half of our presentation.
29:54Can you guys see my screen?
29:56Looks good? OK, I think that there's
29:58another part of it. I don't know.
30:00Michelle's name didn't come in this,
30:01so I want to make sure it's the right slides.
30:04So I'm Shefali pathy and thank you
30:07for inviting us to come and speak
30:10on this very important topic and
30:12very relevant to our practice here.
30:14And Michelle Telfer is one of the midwives
30:17who's really been involved in caring
30:19for the New Haven population as well.
30:21So I look forward to working with.
30:24Speaking with her and sharing some of our
30:27pearls, and hopefully if you have questions,
30:29please add them to chat or ask them at
30:32the end. We'd be happy to answer them.
30:35So just what we want to get out of, UM,
30:38get you to know about this and the key
30:40objectives that we hope to get through today.
30:44One is really identifying the key Women's
30:47Health needs for this population and also
30:51highlight some available resources or
30:53opportunities where we can really serve
30:55these women and these patients better.
30:58And so we're going to focus on the
31:01Women's Health aspect of this,
31:03but I think we work very collaboratively.
31:05With our other primary care colleagues
31:08in this realm,
31:09both in adult medicine but also
31:12in Pediatrics,
31:13because there is that continuum of care
31:16with women who will deliver a newborn child.
31:19And really having that continuity,
31:21continuity of care and having the
31:23pediatricians when they're seeing
31:24the newborns work closely with
31:26the moms and with us.
31:27If there's anything that we can work
31:29together with and it's going to build
31:31upon what Pooja had also talked about?
31:33Because I think that there's
31:34some key tenants of.
31:35Uhm,
31:36what are the challenges and
31:37what are the needs for this?
31:38These women and these patients.
31:40And so the first part of it,
31:42we'll just talk a little bit about more
31:44the global and broader perspective,
31:45and then Michelle will take you through
31:48some really focused on information and
31:51thoughts specific to maternity care.
31:54So this is who we are and I
31:55didn't put our emails there.
31:57But I think maybe I speak
31:58from Michelle as well.
32:00We are happy to get investment
32:02messages or emails,
32:03just asking questions and I will say
32:05I just want to highlight that we've
32:07had so many people like I've had
32:09people in the clinic reach out to me
32:11asking questions and which I think is
32:13really helpful because it's really
32:15timely and that's what's needed.
32:17If you have a patient in the office
32:19there or in the emergency room there
32:20because of some of the barriers that
32:22were discussed already, you know it is.
32:24Helpful to have a contact there,
32:25so feel free to reach out to us.
32:29So who are the patients?
32:30And I I won't belabor this
32:31because I think even in reviewing
32:33the prior talks about this,
32:34I think that we're getting to
32:36realize that the Afghan refugee
32:38population that's happening in
32:40Connecticut is been increasing.
32:41We are fortunate to have
32:43organizations and communities
32:45that are really welcoming.
32:48However, you know, I think that we
32:51have to recognize that there are some
32:54challenges and that are just phased
32:56by these people as they have been.
32:59Required to leave or forced
33:00to leave their own homeland,
33:01which often comes with leaving family
33:03members there and other things that
33:05are there but also on top of it.
33:07Some of the psychosocial and
33:10emotional changes that happened.
33:12And so I think that over the next few
33:14years it's probably going to increase.
33:16And how can we serve our patients better?
33:20So looking specifically at the
33:22reproductive health care needs,
33:23what are the needs that they have?
33:25So I think some of the concerns
33:28that are include and have already
33:30been discussed by some of the
33:33other folks in this webinar series.
33:36One is really the big,
33:37bigger barriers to care.
33:38You know, we see barriers for care.
33:40In general urban populations.
33:42We think about it,
33:43but specific to this group,
33:45I think as Puja has spoken about,
33:48you know language and cultural barriers.
33:50And I think that with the language
33:54specifically besides just finding maybe a
33:57posture interpreter or a Dari interpreter,
34:00we think about there.
34:01Even within those there may be dialects
34:04that are specific to these groups.
34:06And then we also have found similar
34:09to where some of the questions,
34:10if they have a male versus
34:12a female interpreter,
34:13and many of these women really feel more
34:16comfortable with having female interpreters.
34:18So there is a challenge in even the language.
34:21Component of it.
34:22Just because there is this
34:24embedded cultural piece of it,
34:26transportation can be very challenging.
34:28As has already been discussed,
34:30because many of the women that we see
34:33are dependent on their spouses or their
34:36family members to bring them to visits.
34:38They are reliant on potentially
34:41on public transportation means,
34:42but they may not have the funding
34:44to pay for all of those things.
34:46So really,
34:47thinking about when they're
34:48scheduling the appointments?
34:49How can we be supportive of that?
34:51We try to think about when will they
34:53be able to get a ride and finally is
34:56the child care needs and you know we
34:58had a situation and I think last year
35:02before we moved to Sargent Drive.
35:04That really made me think about this
35:07that just looking at the barriers of
35:10care the patient was coming for her OB
35:13visit and she realized that she had.
35:15She wanted to make the visit she was
35:17afraid not to make the visit but she
35:19left her children right at the waiting area.
35:21As you enter into the what
35:23was the old primary care?
35:24Because she didn't really want
35:25to miss her appointments.
35:26She knew how important they were,
35:27but she had her children there with her,
35:29and fortunately the person she left
35:31him with was of the same culture
35:34who came into the waiting area,
35:36just to mention to us.
35:37And this is in the height of the
35:39pandemic where we weren't allowing
35:40visitors and we had them sit right
35:42outside of the entrance and and and
35:44so to make sure that they were OK.
35:46But I think that we just have to
35:48remember there are all these things that
35:50are embedded in why and when they come from.
35:52Here the mental health
35:54needs we've spoken about.
35:55There's a lot of post traumatic
35:57stress from some of the trauma
35:59that they've experienced.
36:00Their high levels of potentially depression,
36:03not only from trauma related,
36:05but also from leaving their
36:07families feeling isolated and being
36:09trying to assemble,
36:10assimilate to these to the new culture
36:13and the new norm that they have.
36:16Underlying some of their, UM, some.
36:19Some of the hesitancy is really
36:21the they're dependent on their
36:23partners and their family members,
36:25but they may be experiencing intimate
36:27and victims of intimate partner
36:28violence and sexual violence,
36:30and in their countries they may have
36:32not necessarily been the victim,
36:33but may have witnessed this.
36:34So thinking about sort of sexual
36:37violence and how it might play into
36:39when you're seeing these women,
36:41they may lack social supports,
36:43an especially since they've left.
36:46Any family members or friends
36:48and other networks over there,
36:50and we are fortunate, I think,
36:52to have some community organizations
36:55and groups such as IRIS that
36:57really do support these women.
37:00And I think that there are even
37:01prior to the pandemic there were
37:03opportunities to go there to really
37:05reach out at virus headquarter and
37:06talk to some of the patients about
37:08their health needs and questions.
37:12So how can we address some
37:14of these specific needs?
37:15And I think, UM, really,
37:17the overarching message I would say is
37:19is that we have to really be sensitive
37:22and come to their to what they're asking,
37:25or maybe potentially ask the questions of.
37:27Well, how can we help you?
37:28Because sometimes we make
37:30assumptions of what we want to do.
37:32You know, a patient who's coming for
37:33prenatal care or misses some appointments?
37:35Well, you have to come to prenatal care.
37:37Really going back to the Y and
37:39asking well what is it that why
37:40is it that you're missing it?
37:42What is it that we can do to help
37:43and there might be opportunities
37:45that we can really uncover when
37:46we build some of this rapport
37:48and relationships with them?
37:50We talked a little bit about barriers
37:53to care with regards to some of
37:56the interpreter services and some
37:58of the cultural accommodations,
38:00though the cultural needs and really
38:02thinking about in Ark specific in Women's
38:05Health is really identifying that many
38:07of these women really want female providers.
38:10And, you know,
38:11in such a complex.
38:15Practice. Sometimes it's
38:16challenging to do that,
38:17but how can we try to accommodate that?
38:19We sometimes will make sure that
38:21they have continuity with one of
38:23the advanced practice providers
38:25who's routinely there as opposed to
38:27potentially with one of the MD's or
38:29physicians was only there once a week.
38:30So I think that we're trying to navigate.
38:33How can we best accommodate some of
38:35those services were also trying to
38:37schedule some of the interpreter
38:39services ahead of time so that we can
38:41make sure that it is a visit that is.
38:45Efficient and effective,
38:46and potentially we used to
38:48use patient navigators.
38:49We have a nurse care coordinator who
38:51really can help with this when we
38:53have two that can help with some of
38:55this so that we make sure patients
38:57aren't showing up that there someone
38:59reaches out to them now within our
39:01move to our to 150 Sargent we have
39:05embedded behavioral health teams
39:07which really has been a blessing and
39:09the opportunity even in real time
39:11to make a connection with someone
39:13from behavioral health is really.
39:15Been a great asset to us,
39:16so I think trying to understand how
39:18can we connect them with services even
39:21if in other organizations they may be
39:23doing that with the health care teams.
39:25If we can do that,
39:26I think it also builds a better
39:27relationship with their patient to see
39:29that we're doing what we can to think
39:31about the global need their global needs,
39:34and really understanding trauma
39:36informed care when we have patients
39:40who potentially or risk for.
39:42A sexual trauma or intimate partner.
39:45Violence really being thoughtful and
39:47how we ask questions where we ask
39:49questions and when we're doing exams
39:51really being thoughtful about that.
39:53And then looking at the social supports,
39:55what's there.
39:56And even though we're in OB GYN practice,
39:58really thinking about more probably.
40:00What are the other social services that
40:02might be helpful and reaching out to our,
40:04our social worker or our case managers?
40:08And finally, some of the specific
40:11Women's Health care needs.
40:12So.
40:14You know,
40:15look at that and here are just some
40:17of the Women's Health reproductive
40:19health things that we face and are
40:21trying to address with our patients.
40:23Maybe not in all of them in one visit,
40:25but over the course of visits
40:27and try to get to target those,
40:29you know we start to look at.
40:32Just move this a little bit.
40:34Some of the key things where we may
40:36not be able to address everything.
40:38But really focusing on one
40:39or two things you know,
40:41the preventative help piece.
40:42For example,
40:43they come in with a lot of health.
40:45Some health screenings thinking about
40:46what project said and some of the other
40:48talks when they're in their primary care.
40:50However,
40:51we also want to make sure some of the
40:53other main health screenings that we do.
40:55Pap smears, mammograms,
40:57colorectal screening.
40:58We talk about because in
40:59their own culture there might
41:00be differences in what they do.
41:02They might not even know
41:03what that those things are.
41:05I'm going towards some of the
41:07misconceptions and other health basic needs.
41:10I think health,
41:12education and understanding what their
41:14understanding of their own health is.
41:16Is really important?
41:17For example,
41:18some people don't even understand
41:20sort of the basic anatomy and sort of
41:23Physiology of the menstrual cycle,
41:24making sure they understand why is it that
41:27they're getting periods or what is normal.
41:28What is not normal and really
41:30putting it on a level of health
41:32literacy that they understand.
41:34And so I think it's really,
41:36really important.
41:37I think the other piece that's really
41:39important is when we talk about
41:41pregnancy prevention or contraception,
41:43for example, or STI prevention.
41:45It's talking really in
41:46a culturally sensitive.
41:47Manner thinking about asking
41:48the question first,
41:50what is your family planning or what
41:52are your family planning goals or
41:53your sort of goals in in reproduction?
41:56Because I think for there is a stigma
41:59in using contraception or altering
42:02the opportunity to get pregnant,
42:04we have a lot of women who fear that
42:05using contraception they won't allow
42:07be able to get pregnant in the future.
42:09So really asking the question
42:10as to what you're going to,
42:12what are your goals and how
42:14can we best help you?
42:16And the last piece I'll add
42:17about that is is finding.
42:19That's where the balance of
42:20having a family member in the
42:22room or not might be important.
42:24You know,
42:24using a translator and allowing the
42:26patient to speak without having her
42:28husband or a male family member in the room,
42:30or any family member in the
42:31room might allow her to,
42:33as she opens up,
42:35maybe in over subsequent visits,
42:37really share well.
42:38I don't want to get pregnant or I
42:40really do want to get pregnant because
42:41my family views me not being able to
42:44get pregnant as a as some kind of.
42:46Camp anomaly or some that
42:48she scrutinized for it.
42:49So I think gaining trust and then
42:52having these conversations are really
42:54really important so that we can
42:56build a relationship and let these
42:58women know that we're here to help them.
43:03See, so I'm going to transition over
43:05to Michelle who will talk a little
43:07bit more about the maternal needs,
43:09and Michelle just move this lights for you.
43:11Great thanks so much to finally.
43:17Yeah, perfect, so I'm going to talk
43:19a little bit about prenatal and
43:21intrapartum and postpartum care for.
43:24For this population and a lot of it
43:26is the same care and same things.
43:27I would emphasize probably for every
43:29pregnant person that we care for.
43:30But really, the importance of a
43:32continuity model it care especially
43:34in the outpatient setting,
43:35I think is even more important
43:38for this population.
43:39I think, you know,
43:40we have the evidence that this really
43:42is the best model for everybody,
43:43but to really focus on making sure
43:45they're seeing the same provider,
43:47there is a study from 2010 where
43:49patients had said stuff you know can
43:52do good follow up when you know.
43:54You know you can really get to know
43:55the patient, know where they are.
43:57They're not having to re tell
43:59their story every every time,
44:00and especially if you're
44:03using an interpreter,
44:04it can take a lot more time to sort of
44:07get to know your patient each visit,
44:09which you can avoid if
44:11you have that continuity.
44:13And again,
44:13using a lot of trauma informed care.
44:15Again, this should be for everybody.
44:18I'm really working on consent for everything,
44:20especially the cervical exams.
44:23Any anything that is invasive that we would
44:27always do for for all of our patients.
44:29But and really try.
44:30And especially on the labor floor,
44:32to protect patients.
44:33Modesty.
44:33I know for a lot of us for a lot of
44:37providers we get very used to sort of just.
44:41Kind of letting people be out in the open,
44:43but it really is dumb.
44:47Something to take care with,
44:49and there are ways of sort of draping,
44:51you know,
44:51as sheets and sort of tempting it,
44:53so that the patient is not exposed
44:55to the whole room.
44:56Really trying to limit learners and
44:59have continuity of providers while
45:01they're in the inpatient setting can
45:04really help reduce anxiety and stress,
45:07and there is a preference
45:08for female providers.
45:10That's not always possible,
45:12but and most patients will come.
45:16We'll agree to this if if
45:17there is nobody else,
45:19but we really try to make an effort,
45:21so we tend to get a lot of patients
45:24on our practice 'cause we are.
45:27As the midwifery practice,
45:28we don't have any milk providers
45:30outside of our attending obstetricians,
45:32but so a lot of the patients will come to us.
45:37And I just want to make another
45:38comment on the use of interpreters.
45:40Sometimes even you know it is
45:41has been a struggle to get female
45:43interpreters which can can be a problem,
45:45especially talking about very sensitive
45:47things that we talked about during
45:50labor and birth and as well as not
45:52having somebody that's too young.
45:53There have been some things in the
45:56literature about patients not even
45:58having a hard time talking and sharing
46:00information with very young interpreter
46:02who doesn't maybe understand a lot
46:04of things around birth and and.
46:08Uhm?
46:08And so it,
46:09you know.
46:10But you have to do the best that you can.
46:14One thing with interpreters that point
46:16out like at the beginning they had
46:19talked about the different languages
46:21and diary and cash to and making
46:23and some of even the dialects there
46:25can be difficult and challenging.
46:27We had a patient who all day had been used,
46:29had had an interpreter when
46:31I came on in the evening.
46:33We found out she really
46:34wasn't understanding anything,
46:35and it was the wrong language completely.
46:38But I think sort of her modesty and not.
46:40Went into to say much really hadn't
46:42been understanding what had been
46:43going on most of the day and so
46:46sometimes doing reflective discussion,
46:49especially around consent and
46:50shared decision making.
46:51Sort of saying back to the patient.
46:53This is what I hear you saying.
46:55I'm trying to say it in another
46:57way because sometimes the the
46:58translation is not always accurate.
47:00I was struggling once with a patient
47:02who seemed very uncomfortable and
47:04trying to talk about pain medication,
47:06but she kept saying I want a
47:08natural birth which to me meant.
47:10No medication,
47:10but in fact she just was really worried
47:12about taking any medication 'cause she
47:14was afraid of having a caesarean birth,
47:16which to her was not a natural birth.
47:18So so even like the interpretation of
47:21words can sometimes. Be a challenge.
47:24Go ahead and next slides Shefali thank you.
47:30One thing to think about Antenatally, UM,
47:32is that we still have family restrictions
47:35on labor and birth right now due to COVID,
47:39and so there's only there are
47:41only allowed two support people.
47:44And it. Can be really helpful.
47:47Often families don't have close friends
47:49or other family members like they would
47:51normally come with their mother or sister,
47:54and so it may be their husband.
47:56But if they have other children
47:58at home this the laboring woman
48:00may come in a completely alone,
48:02which can be really scary.
48:04So really talking about this
48:05ahead of time trying to connect
48:07them with community support.
48:08I think one of the things that would be
48:11great is to work with hours to try to
48:13train some of the refugees to be doulas.
48:16For the community to be this labor
48:18support person who could come in if
48:20the husband needs to stay home with
48:22family with this other children and
48:24can come in and be support for her and
48:27and to help because it can be really
48:30terrifying to come in and not have that.
48:33And often there used to be
48:34unable to bring their children.
48:36We when we were at Saint refills
48:37pre COVID we were able to have other
48:39children come and even stay as long as
48:41there is an adult responsible for them
48:43and we just the restrictions with COVID.
48:46Right now is such that we can't do that.
48:48Another thing to think about is patients
48:50coming from a low resource setting.
48:52Maybe really,
48:52uhm,
48:53it can be very anxiety provoking
48:55with a lot of the technology and
48:57sort of the things that we use.
49:00Here is so the fetal heart rate monitoring
49:02may be very distressing for some patients,
49:05so really kind of preparing patients
49:06for sort of some of the things they
49:08may anticipate during labor and birth.
49:10Here in our setting can be helpful
49:13and also thinking about is this a
49:15patient that we can do intermittent
49:16auscultation and have them with.
49:18Fewer interventions and again,
49:20you know,
49:21using trying to provide as much continuity
49:24and limiting the number of learners.
49:27Not to say that you can't have
49:29learners we work with residents and
49:31midwifery students all the time,
49:33and as long as patients consent they're
49:35usually fine with that next slide,
49:38please.
49:39Uhm,
49:40and so just kind of thinking about
49:42some of the things that we can.
49:44As you know,
49:45providers and clinicians,
49:46and if there's hospital administration
49:48on this,
49:48I would really encourage to think about
49:51in the outpatient setting the timing of
49:53patients when they need interpreter services.
49:56Everybody knows where our panels
49:57are getting very full.
49:59We're having to push people through,
50:00but.
50:01If you look at your schedule and you
50:02know you've got to use interpreters
50:04for your next five patients,
50:06and they're all scheduled for
50:07the same 15 or 20 minutes lots,
50:10it can create provider bias
50:12against patients that speak other
50:14languages and that can come out
50:17and unintentional ways people
50:19providers get more stressed.
50:20They're more likely to miss things.
50:22They're less likely to probe and ask further
50:24questions if they don't have the time,
50:25and we all know having to use an interpreter.
50:28Services adds time to your visit,
50:30so I think it's something that we can.
50:32Think about and try to push forward to give
50:34more time and clinics for longer visits.
50:37I know it'll be a hard push because
50:38a lot of it comes down to money,
50:39but it is something that as from an
50:42equity point of perspective can really.
50:45Create a friction in the setting and
50:48then you're not giving you know.
50:51Being able to address all the issues
50:53that you might be able to if you had
50:55a longer visit thinking about things
50:56like hospital and nutrition services,
50:58seeing about getting some
51:00culturally appropriate foods.
51:02I know Sanctuary Kitchen is a kitchen here
51:04in New Haven and restaurant that's run by
51:07refugees and that might be something to
51:09encourage the hospital to think about.
51:12You know what kinds of foods might we
51:13be able to offer patients to help them?
51:16Feel more at home here and then again,
51:20talking about hospital doula services.
51:22Healthy start has been working with
51:26training black doulas in the community
51:30to support and help to support patients
51:33that have a higher mortality rate,
51:36often because of institutional
51:38and structural racism,
51:39and this might be something that we could
51:42try to get some Afghani journalist to
51:44help support the patient population.
51:46And looking at resources here locally,
51:49there's a family home visiting program
51:51here in New Haven that used to be
51:54nurturing families that's open to
51:56patients on Medicaid using the patient
51:58navigators through iris can be very helpful,
52:00especially if a pregnant patient
52:03develops a lot of high risk.
52:05Pathologies during prenatal care,
52:07they end up having to have multiple
52:09appointments in different settings
52:10that can just be the transportation
52:12and and just navigating that whole
52:14system can be really challenging
52:16and then thinking about postpartum
52:19support and perinatal mental health.
52:22Really trained to look at we.
52:24We use the Edinburgh postpartum depression
52:27scale and most of our settings now,
52:29but.
52:30You can use it with an interpreter,
52:32but even those those same questions just
52:35may not be culturally have an equivalent,
52:38and to really work with the Afghani
52:40community to see what might be more
52:43appropriate questions for us to ask
52:45to really get to to whether or not
52:47they're having symptoms of depression.
52:51And uh,
52:52with programs that can help with
52:55support with breastfeeding with
52:57nutrition often there can be,
53:00you know,
53:01some malnourishment and to really
53:02work and making sure people are
53:04getting foods that are appropriate
53:06and helpful and to consider postpartum
53:09home visits patients on Medicaid do
53:12qualify for getting a home visit.
53:14We don't have.
53:14There aren't a lot of home maternal
53:17home nurses in the area,
53:19but I think the more that we use them and.
53:21Ask for them.
53:22They may start to get more of
53:23them, so then we can increase
53:25those visits 'cause we know from
53:26the data are postpartum care.
53:28Here in the US is pretty abysmal and in
53:30the past we only saw patients at six weeks.
53:33We're now starting to see them
53:34with it for a two week check in,
53:36but even that compared to most other.
53:39Advance high income countries
53:41or even low income countries.
53:43They are seeing patients in
53:44the first few days.
53:45They're seeing them in their
53:46homes and doing and doing visits,
53:48and I think this would be really
53:50helpful to support breastfeeding and
53:53especially for patients that may not be
53:55able to have their own transportation
53:57to get out of the House with other kids.
54:00And I want to leave time for questions,
54:02so I think that's it.
54:03I just left this one picture just to
54:05kind of give an image of sort of the
54:07things most of us will be kind of
54:09working around the the microhouse.
54:10Here is providers,
54:11but to really think about all
54:13these things that are surrounding.
54:16Surrounding our patients and
54:17impacting them and can lead to
54:20reasons why they're not making
54:22their appointments or why they're
54:24not sharing information with us.
54:26OK, thank you.
54:26I want to leave time for questions.
54:29Great, thanks so much.
54:31Both Michelle and Shefali.
54:32Uhm, there's been a lot of sort of
54:34great activity in the chat and I know
54:35we just have a couple of minutes.
54:37So let me try to just boil these
54:39down to a few that haven't been
54:41sort of answered comprehensively.
54:43So the first question had to do with
54:46supporting supporting lack tating women.
54:49Sort of thinking about a question
54:51from a lactation consultant asking if
54:53there's any any nuances or anything.
54:54Any pearls that you might have to share
54:56around supporting women in the sort
54:58of postpartum period around lactation?
55:02I mean, I think you know,
55:03working with lactation
55:04consultants such as yourself,
55:05I don't have any specific.
55:09Things outside of that,
55:11but I don't know if other other
55:13folks might have something different.
55:23I think I just went out for a minute.
55:25What was the question
55:26that you had asked Tracy?
55:29No, the question just had to
55:31do with some pearls around
55:33supporting frustrating women. Yeah,
55:35and I think I'm, I'm assuming
55:37that Michelle had talked to now.
55:38I mean, we have a great lactation
55:40team even in our at Sargent
55:42Drive that is really great.
55:44So I think it's really important to
55:46reach out to some of these resources,
55:48and especially while they're in the office.
55:49It's there's an opportunity to do that.
55:55Great thank you. There was also there
55:56was a great question about sort of
55:58thinking about mental health and how
56:00do you begin these conversations.
56:02I will say that are the second webinar in
56:04this series that we did just last month.
56:06Was focused exclusively on mental health
56:10supports for both adults and children,
56:12and so hopefully that video will be
56:14able to be posted shortly and I'll
56:16be sharing the website for that.
56:18I know that Camila nanny had both put
56:20a couple of pearls regarding mental
56:22health supports in the chat and.
56:24And I believe everyone could see those,
56:26but Camilla.
56:26Is there anything that you would
56:28want to say just in response to
56:29that question to the group?
56:35No, it's just just wanna add stuff
56:37to what I wrote in the chat.
56:39That yes, it is a sort of sensitive issue
56:42and people can take offense sometimes
56:44if you offer mental health treatment,
56:46but that's not to say it's across the board
56:48and I think when you sort of frame it as
56:51you're responding to some distress there,
56:53you know responding to the distress
56:54therein or responding to like some
56:56symptoms they may have, like poor sleep.
56:58I mean if you reframe it that way,
57:00it goes over much better.
57:01And also I think it's almost never.
57:05Something they know about.
57:06If you just say Oh well,
57:07send you for therapy.
57:08They really don't know what therapy is about.
57:09Typically so really sort of have
57:11to explain what that means,
57:12and they may be OK with it if
57:14you say this is what happens.
57:15You talk to somebody.
57:16They help you work through your feelings
57:17rather than say it's mental health therapy.
57:19So I think it's really all
57:21a matter of framing.
57:22I guess that's what I would say.
57:26And I would agree, and I think
57:29it helps to have a. It helps to
57:32be seeing these families and building a
57:36trusting relationship before entering.
57:38I think sometimes it's providers
57:39we're ready for the family to
57:40receive mental health services,
57:42but we sometimes have to wait
57:43until the family is able to
57:45receive mental health services.
57:46And as Annie says,
57:47I think approaching the different
57:49symptoms rather than you know,
57:50kind of saying, you know,
57:52kind of global therapy.
57:54So they understand how it can help them,
57:58but I think it it takes time and it's
57:59kind of a journey well on with our
58:01families to bring them the supports.
58:02And part of that is is the
58:04mental and behavioral health.
58:05We do need more support
58:07though for the families.
58:08I think having access to
58:10interpreters and having mental and
58:12behavioral health services out in
58:14the community for these families.
58:17UM is is a great need right now.
58:22Great, thank you.
58:22There's one sort of quick question
58:24that followed on something.
58:25I believe Michelle said.
58:27So question about whether sort of
58:29culturally it's considered a failure
58:31to deliver by C-section is that
58:34something that has come up? I don't
58:36think it's necessarily closely,
58:38but I think it may be more tide
58:40to sort of having you know value,
58:42infertility and wanting to have maybe
58:45a larger family that having multiple
58:47C sections can can impact that.
58:49So I think certainly in our preference to
58:51us to have a vaginal birth if possible,
58:54but I haven't encountered that it's been
58:56a barrier when it's been indicated.
59:02And I think that for many women
59:03you know they also have to.
59:04They want to go home.
59:05They don't want to be in the
59:06hospital for a long time.
59:07They don't want to be able to unable
59:09to care for their families here
59:11because there are less supports.
59:13So I think for some women they just
59:14want to make sure that they're
59:16able to do all of those things.
59:20Great, thank you.
59:21I know that there's been some great
59:23questions and and activity in the
59:25chat around screening for intimate
59:27partner violence that has come up.
59:29And so the question being raised
59:31about whether there's anything one
59:33might do differently to support
59:34individuals who who may be suffering
59:37from ongoing intimate partner violence.
59:39Especially if the potential
59:40perpetrator is actually at the
59:42clinic visits or in the health
59:44care setting with the individuals.
59:46So just in our last will go a minute
59:47over in our last minute or so.
59:49Is anybody have any?
59:50Pros to share with respect to that.
59:52Yeah, I think I just want to suggest I think
59:54it's a really difficult topic and you know,
59:57it's easy to set a training where we're at.
59:59We've taught where taunts
01:00:00and standard questions,
01:00:01but as we've talked about,
01:00:03even with mental health,
01:00:04you know it's it's the context
01:00:06of how you ask the question.
01:00:07And you don't always get the response
01:00:09because there's not as much try.
01:00:11So I think the biggest
01:00:12thing is building trust.
01:00:13I think continuity of care with
01:00:16having similar having content,
01:00:17the same provider team.
01:00:19I think that then how we phrase
01:00:21the question and saying we want to
01:00:24help you feel safe in all aspects
01:00:26and I sometimes do it that way as
01:00:29opposed to in with their provider.
01:00:30How can we do that?
01:00:31And you know,
01:00:32I think after like two or three visits
01:00:34people start to potentially open up
01:00:36about that that but I think some of
01:00:39it is also recognizing the nonverbal
01:00:41cues of of that where I always try
01:00:44and speak to patients by themselves,
01:00:47whether it's at the beginning or during
01:00:48the exam and during the exams I usually.
01:00:50Have that partner step out and
01:00:52trying to ask the questions.
01:00:54I don't want to take up too much
01:00:55time because I'm sure other
01:00:56people have other pieces to add.
01:00:58I think that's great and I was
01:01:00just going to add to like also
01:01:01just letting patients be aware
01:01:03that there are resources and that
01:01:05we can help them because they may
01:01:06just not realize there is anywhere
01:01:08from them to go if they don't have
01:01:09family and friends here and we did
01:01:11have somebody a couple year or two
01:01:13ago when we were at the old woman
01:01:16center that did come forward and we
01:01:18were able to get her to a safe house.
01:01:21With her children,
01:01:22they were able to pick up the children.
01:01:23I remember this patient.
01:01:26Great, thanks so much to both of you and to
01:01:29all of you for offering your perspectives.
01:01:31I'm just going to share a last
01:01:35closing slide here. Here we go,
01:01:37maybe maybe two closing slides, so uhm.
01:01:41So thanks to everyone for attending again,
01:01:43this webinar was recorded and so if
01:01:45there are pieces that you would like
01:01:47to sort of rewind in here again,
01:01:49or if you have colleagues that
01:01:51you think might have benefited
01:01:52from hearing this conversation,
01:01:53we anticipate that this recording
01:01:55as well as the other the second one
01:01:58will be soon posted on our website
01:02:00for the refugee health conferences.
01:02:03We do anticipate hosting our annual
01:02:05our 6th annual Refugee refugee Health
01:02:07Education Conference on Thursday,
01:02:09March 17th.
01:02:10It's usually an evening conference
01:02:12that happens in.
01:02:13More details will be coming out about that.
01:02:16If you registered for these webinars
01:02:17then we will be pushing out information
01:02:19about that conference to you.
01:02:20And if you have any questions or
01:02:22want to connect to the speakers,
01:02:23please feel free to reach out to
01:02:25the team at the refugee health
01:02:27at yale.edu email and then just
01:02:29again for those who are interested
01:02:30in some additional resources,
01:02:32the folks at University of Minnesota
01:02:34have correlated at just a tremendous
01:02:37number of helpful resources for
01:02:39variety of folks working with.
01:02:41Afghan evacuees and so the QR code for
01:02:44this website is up here in the top corner.
01:02:47And with that we will stop our
01:02:50recording and thanks everybody.
01:02:52Hope that you have a wonderful
01:02:54rest of your day.