1. Development of a Refugee Prenatal Group Model to Improve Health Outcomes Among Somali Refugees: A Community Partnership Tasnim Khalife, MD 10/4/2015

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Tasnim Khalife has indicated that she has no relevant financial relationships to disclose.

3. Objectives How to develop a refugee prenatal group model and curriculum through community partnership Learn about a new approach to refugee education and care for vulnerable refugee populations Discuss approaches to culturally-competent, low-literacy care and education for refugees How to incorporate residency training and education into group visits 3

4. Why prenatal group visits? The maternal child health goals for Healthy People 2020 focus on reducing rates of maternal-infant morbidity and mortality, low birth weight and complications during pregnancy and labor 1 Preconception, prenatal and postnatal health affect health trajectories for women and children. Intervening during critical periods can impact long-term health outcomes 2 4

5. Target population Somali women are the largest pregnant refugee population in our family medicine clinic – currently about 20-25% Vulnerable population: –Experience pregnancy-related health disparities –Disparities in health literacy / understanding of Western healthcare system High fertility rates in the Somali population therefore need to improve pregnancy-related health care. The development of a group prenatal visit model to provide maternal education and supplementary prenatal care may decrease risk factors and help ensure a healthy pregnancy and delivery. 5

6. Community partnership Family medicine is partnering with local players: Southern Arizona Area Health Education Center (SEAHEC) –Public health implementation/research –Plan to develop a sustainable infrastructure through physician and community health worker training to expand this model International Rescue Committee (IRC) refugee resettlement agency –Somali health promoter and in-person interpreter –Recruitment –Somali babysitter –Help with scheduling transportation 6

7. Prenatal care and education Based on the Centering Pregnancy Model of care –Shown to improve pregnancy outcomes, increase patient and provider satisfaction and lower cost of care 3. Curriculum development ongoing based on participant needs and input – 1-year curriculum Group visits supplement routine prenatal care, one morning per month Low-literacy, culturally-sensitive education Average of 3-8 pregnant Somali women and their young children Grant funded transportation, healthy snacks, babysitter 7

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9. Prenatal Topics covered Nutrition and weight gain in pregnancy - Including nutritional advice for Ramadan Prenatal vitamins Contraception options Breastfeeding Prevention: Why do we need vaccines and pap smears? How your baby develops during pregnancy Anemia, gestational diabetes and hypertension GBS infection, preterm labor, postdates Reproductive Life Plan Pain Management Options During Labor 9

10. Team-based approach Key players: Faculty and resident physicians Administrative staff / clinic coordinator IRC Somali interpreter/community health worker OB nurse Refugee agency volunteers Public health graduate interns and research assistant 10

11. Routine 8:00-8:30 am physician chart review and presentation set up 8:30-9:00 am patient check in – vitals and by OB nurse; healthy snacks 9:00-10:30 am educational topic for the day 10:30 am to 12:00 pm individual OB visits and surveys 11

12. Residency education FM residents have the opportunity to participate in the education and prenatal care of group visits as part of their Maternal Child Health rotation. Meets ACGME competencies, mostly notably Interpersonal and Communication Skills to “communicate effectively with patients, families, and the public across a broad range of socioeconomic and cultural backgrounds.” Development of this unique and innovative community learning experience allows residents to: –Improve cultural competency –Use low-literacy tools for teaching –Learn how to run a group visit 12

13. Funding and research Funding through Arizona Area Health Education Centers (AHEC) grant Aim 1: To develop culturally-tailored instruments to measure knowledge, attitudes and behaviors around prenatal care among pregnant Somali refugee women. Aim 2: To conduct a pilot study to collect data on: Birth outcomes: birth weight, gestational age, complications Maternal outcomes: labor and delivery complications, knowledge of factors affecting pregnancy, newborn care, attitudes regarding western maternity care Changes in knowledge, attitudes and behaviors regarding prenatal care among participating community health workers and physicians 13

14. Next steps Using assessment and evaluation tools, we will continue to educate resident and faculty physicians, patients, community health workers and Somali Health Promoters on pregnancy-related issues. Partnering with SEAHEC and IRC, we plan to develop a network of providers and community health workers within Arizona and create a long-term plan to disseminate the group visit model and curriculum to these networks. We anticipate this model of care will positively impact maternal- child morbidity in Arizona and possibly nationally. 14

15. Challenges Transportation Recruitment Attendance, consistency, time Childcare Incentives Misconceptions about goals of prenatal education Sustainability 15

16. References 1.HealthyPeople.gov.2020 Topics and Objectives: Maternal, Infant and Child Health. Washington, DC; 2014 [updated September 4, 2014; cited September 4, 2014]; Retrieved from: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx ? topicId=26 2.Kotch, JB. Maternal and Child Health: Programs, Problems and Policy in Public Health. 3rd ed. Burlington (MA): Jones and Bartlett Learning; 2013. p. 65-66. 3.Centering Healthcare Institute Inc. Model Overview. Boston, MA: Centering Healthcare Institute; 2014. Retrieved from: http://centeringhealthcare.org 16

17. Contact information Tasnim Khalife, MD tkhalife@email.arizona.edu 17