SummaryThe Refugee Women's Health Clinic provides culturally competent, comprehensive care across the reproductive life span to a largely African, Asian, and Middle Eastern refugee community in Maricopa County, Arizona. Clinic services include prenatal care, labor and delivery, family planning, preventive health, gynecological care, and surgical care, including surgery to resolve health issues from female genital cutting. In partnership with a multidisciplinary community coalition, the clinic provides these services in a culturally appropriate and sensitive way, including the use of "cultural health navigators" who guide patients through the health system. Since opening in 2008, the clinic has enhanced access to culturally competent women's health services for more than 3,350 refugee women and generated high levels of patient satisfaction. The clinic's educational classes have increased awareness of breast cancer and mammography (including the likelihood of performing monthly breast examinations) and helped women better plan for childbirth and the care of their newborn infants and children.
See the Description of the Innovative Activity for information about the Refugee Women's Health Clinic's collaboration with VISTA (Volunteers in Service to America) and about new research and community projects. (Updated April 2014.)Suggestive: The evidence consists of post-implementation data on the number of women served by the clinic, surveys and interviews evaluating patient satisfaction among women receiving care at the clinic, a comparison of awareness and knowledge about breast cancer and mammography among refugee women who attended education classes with similar women who did not, and pre- and post-implementation surveys of refugee women who attended a prenatal education class.
Developing OrganizationsMaricopa Integrated Health System
Use By Other OrganizationsThe Boston Center for Refugee Health and Human Rights at Boston Medical Center provides similar services to refugee women; more information is available at http://www.bcrhhr.com/home.html.
Date First Implemented2008
Patient PopulationThe clinic primarily serves refugees from three regions: the Middle East, Southeast Asia, and sub-Saharan Africa. Major ethnic groups include Burmese, Burundian, Congolese, Iraqi, and Somali.Gender > Female; Vulnerable Populations > Immigrants; Non-english speaking/limited english proficiency; Women
Problem AddressedRefugee women from non–English speaking countries face many obstacles to accessing obstetric and gynecologic (OB/GYN) services in the United States, putting them at increased risk of a variety of health problems.
- Many barriers to care: Refugee women face many obstacles to accessing OB/GYN care, as outlined below:
- Fear and anxiety about unfamiliar medical practices: A lack of exposure to Western medical practices, combined with histories of physical and emotional trauma, make many refugee women fearful of physical examinations and anxious about medical screenings and tests that use unfamiliar equipment.1
- Cultural barriers: Coming from different cultural traditions, refugees often have a different understanding of health and when and where to seek care.1 For example, many refugee women do not seek prenatal care until close to the end of their pregnancy, and many come from cultures that oppose use of oral contraceptives.
- Unfamiliarity with U.S. health care system: Many refugees have scant knowledge of the U.S. health care system and Western medicine, and as a result do not understand the services to which they are entitled.1 In Maricopa County, more than 96 percent of refugee patients qualify for coverage through Arizona's Medicaid agency or the Federal Refugee Medical Assistance Program, but many need assistance navigating the required paperwork.
- Language and literacy barriers: Most refugees arrive in the United States with little or no proficiency in English, and in some cases the refugees cannot read or write in their native language. For their part, most local provider organizations do not have clinicians or interpreters who speak the refugee's language. Communication difficulties can lead to missed diagnoses, incomplete followup, and other gaps in care.1
- Limited provider knowledge of culturally diverse populations: Many providers have not had crosscultural training or exposure to individuals from diverse cultures.1 As a result, they are often ill-equipped to address the cultural and emotional needs of refugee women.
- Barriers lead to increased risk of health problems: Refugee women's poor access to prenatal care can lead to various health problems, including low birth weight, premature delivery, and postpartum depression.2 Refugee women frequently do not get screened for breast cancer.3 Some refugee women have experienced female genital cutting (also known as female circumcision) in their native country, putting those who have undergone the most severe forms of the practice at higher risk for long-term health problems, such as difficulty with urination and menstruation, pain during sex, ascending vaginal infections, infertility, and complications during pregnancy and delivery.4 Further, distrust of the health care system, compounded by cultural and language barriers, unfamiliarity with the U.S. health care system, and providers' limited knowledge of this cultural practice, may lead patients to refuse, delay, and avoid necessary and timely medical care, which can adversely affect maternal and child outcomes.
Description of the Innovative ActivityThe Refugee Women's Health Clinic provides culturally competent, comprehensive care across the reproductive life span to a largely African, Asian, and Middle Eastern refugee community in Maricopa County, AZ. Clinic services include prenatal care, labor and delivery, family planning, preventive health, gynecological care, and surgical care, including surgery to resolve health issues from female genital cutting. In partnership with a multidisciplinary community coalition, the clinic provides these services in a culturally appropriate and sensitive way, including use of "cultural health navigators" who guide patients through the health system. Key program elements are described below:
- Two locations, including one near refugee community: The clinic has two sites, each of which provides a range of care. The main site, open Monday, Wednesday, and Thursday for refugee patients, is located in the Department of Obstetrics and Gynecology at the Maricopa Medical Center in Phoenix (part of the larger Maricopa Integrated Health System). Open on Tuesday mornings, a second satellite clinic resides within a family health center in the Maryvale neighborhood of the city, closer to where many refugees live and thus more accessible to those without transportation. The clinics typically serve 8 to 16 women a day, 3 to 5 of whom are new patients.
- Marketing and outreach: Refugees are referred to the clinic from a variety of sources. Most referrals result from the clinic's collaboration with a network of volunteer refugee resettlement agencies, primary care providers in the local community, and ethnic organizations. In addition, refugee women hear about the clinic via word-of-mouth from friends or family members who have already visited or are otherwise familiar with it. Interested women are introduced to and brought into the clinic through these contacts and related community outreach and educational activities and events.
Figure 1. Jeanne F. Nizigiyimana, Program Manager of the Refugee Women's Health Clinic (left), and Dr. Crista E. Johnson-Agbakwu, Founder and Director of RWHC (right) at the Maricopa Integrated Health System Department of Obstetrics and Gynecology, 2010. Click the image to enlarge.
Image courtesy of Regis Bondrole. Used with permission.
- Culturally competent staff: Core staff includes a medical director (an OB/GYN), a second OB/GYN, two certified nurse midwives, a program manager (a social worker), a medical assistant, and four cultural health navigators (see Figure 1 for an image of the medical director and program manager). All core staff have extensive training and experience working with refugee women in a culturally sensitive manner. The cultural health navigators, as well as the program manager and medical assistant, are multilingual former refugees belonging to their own respective ethnic communities; in aggregate, they speak 13 languages fluently. (A recently hired navigator speaks six Central African languages.) In addition, OB/GYN residents, community volunteers, and students in the fields of medicine, nursing, social work, public health, and the allied health professions help treat or assist patients.
- Cultural health navigators: Many refugees are illiterate both in English and their native language, making it hard for them to participate in their treatment (e.g., filling out forms on their health history, reading home care and medication labels). To overcome such challenges, each patient is assigned a cultural health navigator who speaks her language and hence can address her specific linguistic needs. The navigator accompanies the patient to clinic and other health appointments, serving as an interpreter (using relevant audiovisual aids and patient communication cards as necessary) and explaining cultural issues that may be unfamiliar. Navigators also manage the scheduling of clinic visits, arrange for transportation to them if necessary, and coordinate any other care the patient may need, such as laboratory, imaging, or surgical care and filling of prescriptions. (Some of this work is done in partnership with a local coalition, as described below.) In some cases, navigators may help patients enroll in an English as a second language program or arrange for them to meet with a language tutor.
- Comprehensive, culturally sensitive services: The clinics offer a wide array of culturally sensitive services designed to meet the needs of refugee women across their reproductive life span. More than one-half of patients initiate care because of pregnancy or a reproductive concern, with the rest accessing the clinic for preventive health services (e.g., cervical or breast cancer screening) or to address a gynecologic concern. The staff's training, experience, and background enable them to address a range of unique cultural challenges not ordinarily found at a women's health clinic, such as the following:
- Prenatal- and childbirth-related challenges: Refugees often have culturally based attitudes and concerns about prenatal care and childbirth that may increase the risk of an adverse outcome. For example, many refugees are unaccustomed to having regular prenatal appointments and tests (e.g., blood tests, ultrasound) and may have deep anxiety about the potential need for a cesarean delivery or induction of labor. The navigator and other clinic staff work with the patient to ease her concerns and explain how these interventions benefit the child's health; they also work to build the patient's trust in her health providers.
- Corrective genital surgery: Some refugees have experienced female genital cutting in their native countries, which can lead to complications in those who have experienced the most severe form of this practice. The clinic's medical director—one of only two OB/GYNs in the United States whose practice has a significant number of circumcised women—can perform surgery to revise the scar, addressing their medical concerns while also producing the cosmetic results the patient desires. A small percentage of these women view their circumcision with pride and honor and seek to achieve partial reapproximation of their original circumcision scar to uphold their own ideals of beauty and restore their own cultural sense of normalcy to their genital appearance.
- Sexually transmitted infections: Some refugees come from polygamous cultures in which men often have simultaneous relationships with multiple partners. In these situations, clinic staff counsel women on how to protect themselves from sexually transmitted infections, being careful to do so in a way that does not drive them away from the health care system.
- Contraception: Refugee women may resist using contraceptives because of religious or cultural beliefs. In such cases, clinic staff educate them about natural family planning methods and birth spacing.
- Cultural education for hospital personnel: During daily encounters and through periodic seminars, clinic staff educate hospital personnel (physicians, nurses, registration staff, and others) about the cultural backgrounds and health preferences of refugee women. For example, they teach staff about the variety of preferred childbirth methods across cultures, with some women being accustomed to giving birth while stooping or squatting, and they stress the importance of allowing women to walk around during labor as long as it is safe for the mother and fetus.
- Referrals to outside services: Clinic staff regularly refer refugee women to a range of additional services available at the hospital and in the community, such as the following:
- Family care: The clinic has partnered with the health system to provide continuity of care for newborn babies and children. The health system provides primary and specialty care and serves as the patient-centered medical home for refugee women and their families.
- Mental health care: Women who have experienced posttraumatic stress disorder, depression, trauma, torture, or gender-based violence receive referrals to local behavioral health programs.
- HIV/AIDS care: Refugee women who are HIV positive receive treatment through the health system's HIV program, funded by the Federal Ryan White Care Act—Part A.
- Community engagement through coalition: The clinic keeps close ties to the community through the Refugee Women's Health Community Advisory Coalition, a multidisciplinary organization that includes roughly 70 representatives from State and local public health and social services agencies, refugee resettlement agencies, ethnic organizations, and the business community. The coalition has subcommittees that work on six areas: public relations, program promotion, education, resource development, research, and strategic planning. Key coalition activities include the following:
- Patient education: The coalition sponsors education classes at the medical center, in community centers, and in apartment complexes where refugees live.
- Care coordination and transportation: Clinic staff work closely with apartment managers, resettlement agencies, and local providers, who are also part of the coalition, to coordinate care and transportation for refugees to their medical appointments.
- Cultural competency workshops: The coalition sponsors ongoing cultural competency workshops on refugee women's health for community members and local health care and social service providers.
- Donations of supplies: Through the partnership of local organizations and foundations that are part of the coalition, the clinic accepts donations of supplies, including diapers, infant formula, clothing, strollers, and car seats.
- VISTA collaboration: According to information provided in April 2014, the Arizona Refugee Resettlement Program (RRP) is partnering with the Corporation for National and Community Service to develop the Arizona Refugee Resettlement VISTA Project. This 5-year project provides opportunities for nonprofit agencies in central and southern Arizona to develop sustainable VISTA assignments that can enhance refugee resettlement and integration. The Refugee Women’s Health Clinic was selected as an RRP site for VISTA.
- Resource development: VISTA developed a sustainable child restraint project through grants, allowing the clinic to provide a yearly donation of 300 child restraints to 15 women every month; developed and sustained a relationship with an Arizona-based Storage Solutions, allowing the clinic to continue to store donated items for the mothers and families; and enhanced the relationship with Second Look, a consignment store based in Arizona that ensures continued donations of clothing for the families.
- Education and outreach programs: VISTA joined a team that implemented a community health advisers program in the Bhutanese and Burmese communities that addressed the Affordable Care Act. This train-the-trainer initiative enabled community health advisers to focus on the health needs in their respective communities.
- Collaboration development: VISTA helped organize and establish future partners for the Refugee Women's Health Clinic 4th Annual Holiday Drive. VISTA also helped establish the University Subcommittee for the Refugee Women's Health Clinic Advisory Coalition. This faction increases awareness and volunteers of the Refugee Women's Health Clinic by reaching out to young professionals. (Updated April 2014.)
- Research projects and community projects (added April 2014)
- Health demonstration project: Aku Anyi Swastha, or Help for Health, is an initiative among several agencies and the Bhutanese and Burmese communities to address the issue of low health literacy among refugee populations. It helps community members enroll in health insurance programs offered through the Affordable Care Act. To date, the Aku Anyi Swastha program has achieved more than 70 percent of its first cycle enrollment benchmark.
- Culturally specific physical activity intervention for refugee women: A community-based participatory approach postdoctoral fellow, Dr. Jenelle Walker, has developed and implemented an optimal health program focusing on physical activity, health education, and behavior change. It is hoped that this research model and program can be used to serve other refugee populations.
Context of the InnovationMaricopa Integrated Health System provides comprehensive health care services to predominantly low-income residents in Maricopa County, AZ, including inpatient and outpatient services through Maricopa Medical Center. In the past decade, the county—like the rest of Arizona—has seen a steady increase in the number of refugees arriving from other countries, particularly African, Asian, and Middle Eastern nations. The State ranks fifth in the United States for refugee resettlement, with an average of 3,400 arrivals annually between 2008 and 2012.
The impetus for this program dates back to the mid-2000s, when health system leaders became increasingly concerned that refugee women were having difficulties accessing care because of the various barriers outlined earlier, including unfamiliarity with and distrust of the health care system, poor language skills, and low health literacy. To address this issue, the chair of the Department of Obstetrics and Gynecology recruited an OB/GYN with extensive knowledge of health disparities among refugee women to establish and run the region's first clinic providing culturally competent and sensitive care to this population.
ResultsSince opening in 2008, the clinic has enhanced access to culturally competent services for more than 3,350 refugee women and generated high levels of patient satisfaction. The clinic's educational classes have increased awareness about breast cancer and mammography (including the likelihood of performing monthly breast examinations) and helped women better plan for childbirth and the care of their newborn infants and children.
Suggestive: The evidence consists of post-implementation data on the number of women served by the clinic, surveys and interviews evaluating patient satisfaction among women receiving care at the clinic, a comparison of awareness and knowledge about breast cancer and mammography among refugee women who attended education classes with similar women who did not, and pre- and post-implementation surveys of refugee women who attended a prenatal education class.
Figure 2. Third anniversary of the Refugee Women’s Health Clinic (RWHC): Patients from Burma, Burundi, Congo, Ethiopia, Iraq, Ivory Coast, Rwanda, Somalia, and Sudan were proud to share their stories and positive experiences with the RWHC. Each story was unique and highlighted the various services the patients had received, including attentive care by the providers, educational classes, interpretation, car seats, baby clothing and other supplies, home visits, and transportation. Their stories were featured at the third anniversary of the RWHC that took place on December 2, 2011, at the Maricopa Integrated Health System. Click the image to enlarge. Image courtesy of Regis Bondrole. Used with permission.
- Enhanced access to culturally competent services: Between October 2008 and October 2012, the clinic treated more than 3,350 refugee women from 41 countries, speaking 36 languages, including 350 who received prenatal care and delivered babies through the clinic or the medical center's OB/GYN department and nearly 600 women who accessed gynecological services including contraceptive care and counseling (see Figure 2 for an image of patients and staff who attended the third anniversary of the clinic). Approximately 25 women have undergone corrective surgery for obstetric or gynecologic complications related to female genital cutting. In the absence of this program, it is unlikely that these women would have had access to this type of culturally competent care.
- High patient satisfaction: In surveys and interviews, women who visit the clinic report high levels of satisfaction with their treatment. For example, a Burmese refugee who received prenatal care and delivered a child at the clinic stated, "With the assistance of a cultural health navigator and interpreter from my own country, I was able to communicate with my providers and felt that my medical services went smoothly. The clinic made me feel at home." Other comments from refugee women include the following: "I like to go the clinic because they understand my problems and they speak my language" and, "I have received many services for my entire family just by being a patient of the clinic."
- Greater awareness of breast cancer and mammography: The clinic provided breast cancer education to more than 320 women in 28 sessions in 2010 and 2011, and more than 50 of these women came in for a mammogram. A survey of refugee women (16 of whom attended a session and 35 who did not) found that attendees were more likely to plan to do monthly breast self-examinations; more comfortable getting a mammogram; and more knowledgeable about basic facts related to breast cancer, including that mammograms can detect cancer that a self-examination may miss, that breast cancer can be cured if found early, and that breast cancer is a common cause of death among women in the United States.
- Improved ability to plan for childbirth: Surveys (conducted before and after the class) of six pregnant women who attended a prenatal education class found that the session significantly enhanced their ability to plan the birth of their child. For example, before taking the class, most women did not know how to recognize the signs of labor or call for transportation after labor begins. Afterward, most said they would adjust their plans for delivery, and all indicated they were comfortable using a cell phone to arrange for transportation to the hospital.
Planning and Development ProcessKey steps included the following:
- Hiring initial staff: After being appointed clinic director in August 2008, the OB/GYN hired a program manager (a social worker who was formerly a refugee) and medical assistant, and opened the clinic in October 2008.
- Creating community coalition: In January 2009, clinic staff established the Community Advisory Coalition with support from hospital administration. The coalition initially comprised 20 members but has since expanded to 70. The coalition facilitated the clinic's gradual expansion, with coalition members playing important roles in recruiting and training additional staff, enlisting volunteers, arranging for local transportation companies to provide rides to refugees (which is paid for by the State's Medicaid agency), conducting educational classes for refugees, and increasing the clinic's profile and visibility in the refugee community.
- Hiring and training cultural health navigators: In 2009, the clinic hired its first two navigators (one originally from Burma and the other originally from Somalia), enabling it to provide enhanced language services to its growing patient base. Additional navigators were added in 2010 and 2012. Newly hired navigators receive extensive training that covers medical and administrative issues and includes time shadowing senior staff as they guide patients through their care.
- Opening satellite clinic: In January 2012, the clinic opened a site within the Maryvale Family Health Center to better serve the needs of refugees who find it difficult to get to the main medical campus. This clinical site is located closer to refugee communities and provides enhanced access to those with transportation challenges.
Resources Used and Skills Needed
- Staff: As noted earlier, the clinic's full-time staff consists of the medical director (an OB/GYN), another OB/GYN, two certified nurse midwives, a program manager, a medical assistant, and four navigators.
- Costs: The clinic's annual budget totals approximately $467,000, with the major expense being staff salaries and benefits. Most patient services are eligible for reimbursement by State or Federal programs, as described below.
Funding SourcesThe health system covers most of the clinic's operating expenses, with occasional grants and contracts through State agencies and local foundations supporting some of the cost. The Arizona Health Care Cost Containment System (the State's Medicaid agency) and the Refugee Medical Assistance Program (a Federal program that covers medical expenses during the first 8 months after a refugee arrives in the United States) provide reimbursement for most clinic services provided to patients enrolled in these programs. Uninsured patients pay the health system for clinic services according to a sliding-scale, income-based fee schedule.
Tools and Other ResourcesAdditional information about the Refugee Women's Health Clinic is available on the clinic's Web site at: http://www.refugeewomensclinic.org/.
Getting Started with This Innovation
- Form community advisory board: An active, multidisciplinary advisory board can assist with many functions and tasks, including hiring and training staff and building awareness and trust among refugees.
- Hire culturally competent navigators: Refugee patients will feel more comfortable accessing care if they can work with staff who have had similar experiences and who speak their language.
Sustaining This Innovation
- Educate hospital staff: Doctors, nurses, and other health care staff will provide better care to refugees if they understand their cultures, including health issues specific to their backgrounds.
- Adapt to changes in refugee population: The composition of the local refugee population often shifts with world events, such as wars and changes in national leadership. Whenever an influx of refugees from a different region or country occurs, make sure that staff become familiar with their culture and language and hire additional staff as necessary and feasible.
- Look for partners to expand range of care: Some refugee health needs, such as dental, eye, and HIV care, cannot be handled at a women's health clinic; in addition, such clinics generally cannot provide care to spouses. To address these gaps in care, work with local hospital and government officials and representatives of community organizations to establish partnerships that can provide such services.
Use By Other OrganizationsThe Boston Center for Refugee Health and Human Rights at Boston Medical Center provides similar services to refugee women; more information is available at http://www.bcrhhr.com/home.html.
Contact the InnovatorCrista E. Johnson-Agbakwu, MD, MSc, FACOG
Assistant Research Professor
School of Social Work
Southwest Interdisciplinary Research Center
College of Public Programs
Arizona State University
Refugee Women's Health Clinic
Women's Care Center, 2nd Floor
2525 East Roosevelt Street
Phoenix, AZ 85008
Jeanne F. Nizigiyimana, MA, MSW
Co-Founder and Program Manager
Refugee Women's Health Clinic
Women's Care Center, 2nd Floor
2525 East Roosevelt Street
Phoenix, AZ 85008
Innovator DisclosuresDr. Johnson-Agbakwu reported receiving grant funding from the March of Dimes; payment for lectures from the International Society for the Study of Women's Sexual Health, the Association of Women's Health, and the Obstetric and Neonatal Nursing Annual Meeting; travel expenses from the International Society of Sexual Medicine; payment for manuscript preparation from The Female Patient; and payment for development of educational presentations for JSI Research and Training Institute, all in relationship to her work as described in this profile.
Ms. Nizigiyimana reported receiving financial support from the University of Arizona's Southwest Interdisciplinary Research Center to cover ground transportation and meal costs at a conference on community-campus partnerships in December 2012. She also reports that she is a member of the research center's community advisory board and an active volunteer in the Burundi-Arizona Heritage Organization, an organization that helps Burundian refugees with social integration issues.
References/Related ArticlesIbe C, Johnson-Agbakwu CE. Female genital cutting: addressing the issues of culture and ethics. The Female Patient. 2011;36(8):28-31. Available at: http://www.femalepatient.com/Article.aspx?ArticleId=pRvK1AX/+7I=&FullText=1.
Johnson CE, Ali SA, Shipp MP. Building community-based participatory research partnerships with a Somali refugee community. Am J Prev Med. 2009;37(6S1):S230-6. [PubMed]
Johnson C, Nour NM. Surgical techniques: defibulation of type III female genital cutting. J Sex Med. 2007;4(6):1544-7. [PubMed]
Public Policy Advisory Network on Female Genital Surgeries in Africa. Seven things to know about female genital surgeries in Africa. Hastings Center Report. 2012;42(6):19-27. Available at: http://onlinelibrary.wiley.com/doi/10.1002/hast.81/full.
Refugee Health Technical Assistance Center. Women's health section. Available at: http://www.refugeehealthta.org/physical-mental-health/health-conditions/womens-health/.
Ye Hee Lee M. Phoenix health clinic volunteers guide, connect with refugee women. The Arizona Republic. September 5, 2010. Available at: http://www.azcentral.com/arizonarepublic/local/articles/2010/09/05
Eckstein B. Primary care for refugees. Am Fam Physician. 2011;83(4):429-36. [PubMed]
Lalchandani S, MacQuillan K, Sheil O. Obstetric profiles and pregnancy outcomes of immigrant women with refugee status. Ir Med J. 2001;94(3):79-80. [PubMed]
Percac-Lima S, Milosavljevic B, Oo SA, et al. Patient navigation to improve breast cancer screening in Bosnian refugees and immigrants. J Immigr Minor Health. 2012;14(4):727-30. [PubMed]
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Original publication: April 10, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 10, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.