Welcome to CHNET-Works! Fireside Chat #224 April 28 2011 1:00 2:00 PM Eastern Time Evidence-Based Guidelines for Immigrant and Refugee Health Advisor on Tap: Kevin Pottie MD CCFP MClSc FCFP CT Lamont Centre for Primary Health Care Research, EBRI, and the Centre for Global Health, Institute of Population Health University of Ottawa www.chnet-works.ca A project of Population Health Improvement Research Network University of Ottawa 1 Housekeeping - 1 Telephone: (All audio by telephone) (see Fireside Chat Instructions Step #2) If your line is bad hang up and call back in Participant lines muted during presentations Recording notice 2 1
Housekeeping - 2 Visual Presentation: (No audio via internet) (see step # 3 in access instructions) From our computer to yours... Via Bridgit software A few seconds delay in transmission is normal If difficulties per firewalls: slow reception or disconnection use the back up PowerPoint Presentation posted on www.chnet-works.ca (see step # 1 in access instructions) 3 Housekeeping - 3 How to post comments/questions during the Fireside Chat By the Fireside Chat Internet Conference ( Bridgit software) click: participant s icon person/blue shirt Please introduce yourself! Name Organization Location... Group in Attendance? Or By email: Respond to the access instructions email: animateur@chnet-works.ca 4 2
Housekeeping - 4 Or... send your answer via email... 5 What part of Canada are you from? on your province/territory 6 3
What Sector are you from? Put a on your answer Public Health Education/Research Faculty/Staff Provincial /Territorial Government/Ministry Student Health Practitioner Other / 7 Are you working with or caring for new immigrants and refugees? Yes Put a on your answer No 8 4
EVIDENCE BASED GUIDELINES FOR IMMIGRANTS AND REFUGEES Kevin Pottie, MD, CCFP, MClSc. FCFP Associate Professor, Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa on behalf of the Canadian Collaboration for Immigrant and Refugee Health (CCIRH) Although most migrants arrive in good health, subgroups may face health inequities due to differing disease exposures, genetic predispositions, social and cultural K determinants, and lower access to preventive health services. Migrant-specific evidence-based guidelines for clinical prevention are important to support informed decision making and better health outcomes for this population. 9 EVIDENCE BASED GUIDELINES Guidelines for newly arriving immigrants and refugees Through this presentation, you will: Explore the relevance of migration trajectory and language proficiency on health Learn how CCIHR developed evidence-based guidelines to guide practitioners and policy makers and to support immigrant community champions Discover "new CCIRH evidence based recommendations (in press, at the Canadian Medical Association Journal- www.cmaj.ca ) 10 5
CCIRH EVIDENCE BASED GUIDELINES Canadian Collaboration for Immigrant and Refugee Health Team 43 Delphi (primary care) participants from across Canada 23 Interdisciplinary review teams (>120 CCIRH authors) Steering Committee Members: Kevin Pottie (co-chair), Peter Tugwell (co-chair), Chris Greenaway, John Feightner, Vivian Welch, Erin Euffing, Laurence Kirmayer, Helena Swinkels, Meb Rashid, Lavanya Narasiah, Noni MacDonald Photo Credit: Red Cross (Sri Lanka) Collaborating Partners Public Health Agency of Canada, Citizenship and Immigrant Canada, International Organization of Migration (IOM), Calgary Refugee Program, Champlain Local Integrated Health Network, Canadian Institutes for Health Research. Community Partners Edmonton Multicultural Health Brokers Co-operative (Lucenia Ortiz, Yvonne Chiu) 11 Scenario Newly arriving refugee family Mr. Jemi is 35 years old man French/Lingala from the Democratic Republic of Congo who arrived in Canada 6 weeks ago. He is thrilled to have found a family doctor and today he is booked with you for a 15 minute appointment. He arrives with his 32 year old wife who speaks Lingala and Swahili, but not French, and his three children: 15 year old boy, 8 year old girl, 3 year old girl. He arrives in high spirits, although a few minutes late, and he is looking forward for his family to have full check-ups with all the bloods tests that Canada offers. What are some of the challenges facing this family, and facing the health practitioner? 12 6
In one well planned visit you will be able look after the preventive health needs of this family? Put a on your answer Yes No Don t know 13 Migrating Populations, 1990-2000 2000: 175 million; >4x increase from 1975 2050: 230 million Sources: Population Action International 1994, International Organization for Migration, 2003 14 2 7
Healthy immigrant effect 15 RISK OF REPORTING POOR HEALTH refugees (2.1 OR; CI 1.5-2.9) limited English or French language proficiency (2.0 OR; CI 1.5-2.7), those with cost-related problems that impair access to health care (2.8 OR; CI 1.7-4.5) Longitudinal Survey of Immigrants to Canada Pottie, Ng, Spitzer et al et al. Canadian Journal of Public Health 2007 16 8
DECLINE IN HEALTH STATUS: LONGITUDINAL SURVEY OF IMMIGRANTS TO CANADA (STATS CANADA) Prolonged limited proficiency in English or French associated with a transition to poor health (OR 2) significant for both sexes, but associated risk factors differed by sex: Men: refugee status, self-reported discrimination, and living in Vancouver Women: age, health care access problems, and limited friendliness of neighbours Ng, Pottie, Spitzer, Health Reports (in press) 17 DECLINE IN HEALTH GREATER FOR FEMALES % in poor health Female Overall Male Years since immigration Source: LSIC cycle 3 data Ng et al, Health Reports,in press 18 9
Socially disadvantaged individuals experience impaired accessibility to health care services 19 CCIRH PROJECT OBJECTIVE To develop evidence-based clinical preventive guidelines for immigrants and refugees new to Canada (focus on first 5 years) for primary care practitioners. 20 10
What are the health problems? Why does it occur (risk factors)? How do immigrants and refugees differ from the Canadian population? What actions might be most feasible for primary care practitioners? Does doing this cost more than that? Will immigrants accept it? 21 PRIORITY SETTING: DELPHI SELECTION PROCESS Importance Usefulness Disparity Photo Credit L. Narasiah Swinkels H, Pottie K, Tugwell P, Rashid M, Narasiah L. Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions. CMAJ 2010 DOI: 10.1503/cmaj.090290) 22 11
PROFESSOR ARCHIBALD LEMAN COCHRANE, (1909-1988) because resources will always be limited, they should be used to provide equitably those forms of health care which had been shown in properly designed evaluations to be effective. 23 DEVELOPING A LOGIC MODEL Tugwell P, Pottie K, Welch V, Ueffing E, Chambers A, Feightner J. Evaluation of evidence-based literature and formation of recommendations for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada. CMAJ 2010 DOI:10.1503/cmaj.090289 24 12
GRADE APPROACH Balancing Desirable and Undesirable Effects Quality of the Evidence Values and Patient Preferences Cost (Resource Allocation) GRADE: The Grades of Recommendation, Assessment, Development, and Evaluation 25 CCIRH EVIDENCE BASED GUIDELINES 26 13
Scenario Jemi Family arrives from Kenya Mr. Jemi is 35 years old man French/Lingala from the Democratic Republic of Congo who arrived in Canada 6 weeks ago as a convention refugee. Ms Jemi is a 32 year old wife who speaks Lingala and Swahili but not French. (convention refugee) Their three children: 15 year old boy, 8 year old girl, 3 year old girl. (convention refugees) 27 VACCINATION Do MMR and TDP-P serology on Jemi family on arrival? Do Hepatitis B serology on Jemi family on arrival? Do varicella serology on Mr and Ms Jemi on arrival? 28 14
VACCINATION CCIRH guideline publications in press at the Canadian Medical Association Journal and slated to release in June 2011 (http://www.cmaj.ca/misc/service/guidelines.dtl) 29 INFECTIOUS DISEASES Screen the Jemi family for malaria? Screen Mr. Jemi for HIV? Screen the Jemi family for intestinal parasites with stool for ova and parasites? 30 15
INFECTIOUS DISEASES CCIRH guideline publications in press at the Canadian Medical Association Journal and slated to release in June 2011 (http://www.cmaj.ca/misc/service/guidelines.dtl) 31 MENTAL HEALTH AND MALTREATMENT Screen Mr. and Ms. Jemi for depression? Screen Ms. Jemi for PTSD? Screen the Jemi children for child maltreatment? 32 16
MENTAL HEALTH AND MALTREATMENT CCIRH guideline publications in press at the Canadian Medical Association Journal and slated to release in June 2011 (http://www.cmaj.ca/misc/service/guidelines.dtl) 33 CHRONIC NON-COMMUNICABLE DISEASES Screen Mr. and Ms. Jemi for type 2 diabetes? Screen the Jemi family for tropical eye diseases? Screen the Jemi family for dental pain and treat with antibiotics? 34 17
CHRONIC NON-COMMUNICABLE DISEASES CCIRH guideline publications in press at the Canadian Medical Association Journal and slated to release in June 2011 (http://www.cmaj.ca/misc/service/guidelines.dtl) 35 WOMEN S HEALTH Screen Ms. Jemi for iron deficiency anemia? Screen Ms. Jemi for cervical cancer (pap test) on first visit? Screen Ms. Jemi for intimate partner violence? 36 18
WOMEN S HEALTH CCIRH guideline publications in press at the Canadian Medical Association Journal and slated to release in June 2011 (http://www.cmaj.ca/misc/service/guidelines.dtl) 37 PUBLIC HEALTH IMPLICATIONS Burden of chronic disease and mental health issues overtaking infectious disease Importance of access to health; access to social, education, and employment services Importance of Language and Health literacy Need to address social determinants of health Role for effective social interventions, i.e. multicultural health broker, interpreters, etc. 38 19
GUIDELINE DISSEMINATION CMAJ CCIRH publications (www.cmaj.ca) CCIRH Podcasts CCIRH Decision Aids Global and Refugee Health e-learning Program 39 GLOBAL AND REFUGEE HEALTH- E-LEARNING - coming soon to http://www.ccirh.uottawa.ca/ In Breaking Bad experience how communication can impact the quality of health care ideo Photo credit: David Ponka, MSF In The X-Factor learn unique health needs and health care access barriers of newly arriving refugees In Being Human wander in the field of social justice with health advocates ( In Off the Map find out how working in the field can turn your professional identify upside down In Modern Family appreciate the role of interdisciplinary collaboration, community engagement, and provider networks In Against All Odds discover the importance of good manager skills in resource limited settings In The Fringe uncover the role of science and scholarly work in global health 40 20
KEY POINTS Clinical preventive care for should be informed by region of origin and migration history. Forced migration, low income, and limited English/French language proficiency increase the risk for decline in health. Vaccination (MMR, TDPP, varicella, and Human papillomavirus) and screening for Tuberculosis, HIV, hepatitis B/C, intestinal parasites, cervical cancer, iron deficiency, dental pain and vision loss should be. routinely provided to at-risk immigrants. Detecting and addressing depression, PTSD, malaria, diabetes, child and intimate partner maltreatment, and unmet contraceptive needs should be individualized to improve detection, adherence and treatment outcomes. 41 CCIRH GUIDELINES Thank You! CCIRH Website http://www.ccirh.uottawa.ca/ Complete CCIRH guideline paper series to be released at: www.cmaj.ca in June 2011. 42 21
CCIRH GUIDELINES Thank You! CCIRH Website http://www.ccirh.uottawa.ca/ Complete CCIRH guideline paper series to be released at www.cmaj.ca in June 2011. Questions? 43 Thanks for joining in! www.chnet-works.ca Contact animateur@chnet-works.ca for information about partnering with CHNET-Works! A project of Population Health Improvement Research Network University of Ottawa 44 22