Assessing Medical Student Readiness to Navigate Language Barriers in Telehealth: A Cross-Sectional Survey Study (Preprint)

BACKGROUND The COVID-19 pandemic has massively increased telehealth usage in the U.S. Patients with limited English proficiency (LEP) face barriers to healthcare, which may be mitigated when providers work with professional interpreters. However, telemedicine may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers. OBJECTIVE To investigate advanced medical students’ confidence in caring for patients with LEP during telehealth encounters. METHODS We administered a written survey to medical students on clinical clerkships in one U.S.-based institution between August to September 2020. We assessed students’ overall confidence in working with interpreters; confidence in performing eight clinical tasks in in-person versus telehealth encounters; and frequency of performing five different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed rank tests and chi-squared tests were used to compare confidence and task performance frequency respectively for patients with LEP vs. English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free response was qualitatively analyzed using open coding to categorize barriers (key themes). RESULTS Of 300 medical students surveyed, 121 responded. 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (p<0.001), developing trust (p<0.001), identifying agenda (p=0.005), eliciting preferences for diabetes management (p=0.012), and empowering patient in lifestyle modifications (p=0.044) during telehealth encounters. During both in-person and telehealth encounters, nearly half of students (40-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building. CONCLUSIONS Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the U.S. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure in order to ensure high quality care for linguistically diverse patients. CLINICALTRIAL N/A

Effects of spousal migration on access to healthcare for women left behind: A cross-sectional follow-up study

Background Women left behind by migration represent a unique and growing population yet remain understudied as key players in the context of migration and development. Using a unique longitudinal survey of life in Bangladesh, the Matlab Health and Socioeconomic Surveys, we examined the role of spousal migration in healthcare utilization for women. The objective of this study was to assess realized access to care (do women actually get healthcare when it is needed) and consider specific macrostructural, predisposing, and resource barriers to care that are related to migration. Methods and findings In a sample of 3,187 currently married women, we estimated multivariate logistic and multinomial regression models controlling for a wide range of baseline sociodemographic factors measured as far back as 1982. Our analyses also controlled for selection effects and explored two mechanisms through which spousal migration can affect healthcare utilization for women, remittances and frequent contact with spouses. We found that women with migrant spouses were approximately half as likely to lack needed healthcare compared to women whose spouses remained in Bangladesh (predicted probability of not getting needed healthcare 11.7% vs. 21.8%, p<0.001). The improvements in access (logistic regression coefficient for lacking care for left-behind women -0.761 p<0.01) primarily occurred through a reduction in financial barriers to care for women whose spouses were abroad. Conclusions Wives of international migrants showed significantly better access to healthcare even when accounting for selection into a migrant family. While the overall story is one of positive migration effects on healthcare access due to reductions in financial barriers to care, results also showed an increase in family-related barriers such as not being permitted to get care by a family member or travel alone to a facility, indicating that some of the benefits of migration for women left behind may be diluted by gendered family structures.

“COVID affected us all:” the birth and postnatal health experiences of resettled Syrian refugee women during COVID-19 in Canada

Background Prior to COVID-19, postnatal resettled refugee women in Canada reported barriers to healthcare and low levels of social support, contributing to maternal health morbidities. The COVID-19 pandemic appears to be further exacerbating health inequities for marginalized populations. The experiences of resettled refugee women are not fully known. Aim To understand Syrian refugee women’s experiences accessing postnatal healthcare services and supports during the COVID-19 pandemic. Methods Semi-structured, virtual interviews were conducted with eight resettled Syrian refugee women living in Nova Scotia (Canada) who were postnatal between March and August 2020. Data analysis was informed by constructivist grounded theory. Findings Three themes emerged: “the impacts of COVID-19 on postnatal healthcare;” “loss of informal support;” and “grief and anxiety.” Women experienced difficult healthcare interactions, including socially and physically isolated deliveries, challenges accessing in-person interpreters, and cancelled or unavailable in-home services (e.g., public health nurse and doula visits). Increased childcare responsibilities and limited informal supports due to pandemic restrictions left women feeling overwhelmed and exhausted. Stay-at-home orders resulted in some women reporting feelings of isolation and loss, as they were unable to share in person postnatal moments with friends and family, ultimately impacting their mental wellness. Conclusions COVID-19 and associated public health restrictions had significant impacts on postnatal Syrian refugee women. Data presented in this study demonstrated the ways in which the pandemic environment and related restrictions amplified pre-existing barriers to care and postnatal health inequalities for resettled refugee women—particularly a lack of postnatal informal supports and systemic barriers to care.

“It was surprisingly equivalent to the appointment I had in person”: Advantages and disadvantages of synchronous telehealth for delivering primary care for autistic adults

Autistic adults experience barriers to primary care, including distant/inaccessible clinics, sensory stressors, and communication barriers with providers. Synchronous telehealth visits, termed “virtual visits,” may be a way to minimize these barriers. We investigated the advantages and disadvantages of primary care virtual visits using a phenomenological approach. We interviewed autistic adults ( n = 7) and caregivers of autistic adults ( n = 12) from one primary care clinic. Using thematic analysis, we identified three advantages to virtual visits: (1) increased patient comfort from avoiding travel to the clinic, crowded waiting rooms, and other sensory stressors; (2) increased safety by avoiding physical contact with others who may be sick; and (3) similar or better patient–provider communication than in-person visits. Disadvantages included the following: (1) Internet instability and other technological issues, (2) the inability to receive hands-on care from the provider, and (3) reduced patient engagement due to environmental distractions. Virtual visits may minimize barriers to care for autistic adults by reducing travel time, exposure to sensory stressors, and barriers to communication with the provider. While we recognize that virtual visits may not be appropriate for all patients or in all situations, they may be a promising model of health care delivery for autistic adults. Lay abstract Autistic adults face many barriers to receiving quality primary health care like clinics that are far away and sensory sensitivities. Real-time telehealth visits, called “virtual visits,” are live video chats between the patient and provider. Virtual visits may minimize barriers to care for autistic adults. We wanted to describe advantages and disadvantages of using virtual visits for delivering primary health care for autistic adults. We interviewed 7 autistic adults and 12 caregivers of autistic adults who receive primary care through one clinic. Autistic adults and caregivers said advantages to virtual visits were that (1) patients were more comfortable at home, (2) patients could get health care while avoiding physical contact with other people during the pandemic, and (3) virtual visits were similar to or better than in-person visits. The disadvantages included that (1) there could be technology problems like grainy video, (2) the doctor could not physically examine the patient (e.g. look in ears), and (3) patients sometimes participated less in the virtual visit than they would in person. Virtual visits may be beneficial for autistic adults by eliminating travel to the clinic and avoiding stressful sensory stimuli. We recognize that virtual visits may not work for all patients or in all situations. However, our study shows that primary care virtual visits may be beneficial for autistic adults during and beyond the pandemic.

Patient experience with healthcare: Feedback for a Post COVID-19 clinic at a tertiary care center in rural area

Purpose: Post-acute sequelae of SARS-CoV-2 infection(PASC) is a complex condition with multi-system involvement. We assessed patients perspectives and experience with a PASC clinic established at University of Iowa in June 2020. Methods: We conducted a mixed-method survey in June 2021 to ask PASC clinic patients about 1) PASC symptoms and their impact on physical and mental health, and cognition using the PROMIS Global Health and Cognitive Function abilities items, and 2) satisfaction with clinic services and referrals, barriers to care, and recommended support resources. Findings: Ninety-seven patients (97/277, 35% response rate) completed the survey. Most were women(67%, n=65/97), Caucasian(93%, n=90/97) and received outpatient care during acute COVID-19 illness (79%). Fifty percent reported wait time of 1-3 months and 40% traveled >1 hour for the appointment at PASC clinic. The most common symptoms >3 months from initial infection were fatigue (77%), brain fog (73%), exercise intolerance (73%), anxiety (63%), sleep difficulties (56%) and depression (44%). A minority of patients reported significantly reduced functioning (≥1.5 SD below mean) of their physical health (22.5%), mental health (15.9%) and cognitive abilities (17.6%). Qualitative analysis of open-ended answers added valuable context to quantitative results. Satisfaction with clinical services was high though participants identified barriers to care including scheduling delays and financial concerns. Respondents suggested potential strategies for optimizing recovery including continuity of care, a co-located multispecialty clinic and being provided with timely information from emerging research. Conclusion: Our study reports high PASC symptom burden, its impact on health and patient experience with healthcare. It is important that primary healthcare professionals listen to patients with empathy and support them during recovery. Healthcare systems and policymakers should focus on accessible, comprehensive, and patient-centered integrated care.