COVID-19 vaccination intention and behavior in a large, diverse, U.S. refugee population.

INTRODUCTION: Refugees often face increased risk of exposure to COVID-19 due to their disproportionate representation in the essential workforce and crowded household conditions. There is a paucity of data about risk factors for under-immunization for COVID-19 among refugees. METHODS: Refugees were surveyed in two phases that corresponded to before and after wide availability of COVID-19 vaccines. Participants were asked about their attitudes, and perceptions about COVID-19, previous acceptance of vaccines, sources utilized to obtain trusted health information, and intent to get vaccinated. The overall participant vulnerability was assessed using the social vulnerability index. In-depth semi-structured interviews were completed with key stakeholders through snowball sampling. RESULTS: Of 247 refugees, 244 agreed to participate in the initial survey. Among those, 140 (57.4%) intended to get vaccinated, 43 (17.6%) were unsure, and 61 (25%) did not intend to get vaccinated. In the follow up survey, all 215 who were reached, agreed to provide information about their vaccination status. Among those respondents, 141 (65.6%) were either vaccinated or expressed intent to do so, and 74 (34.4%) remained hesitant. We did not observe any significant correlation between socio-demographic variables, country of origin, and vaccination status/intent. Among those who initially intended to get vaccinated, nearly 1 in 5 changed their mind and decided to forego vaccination, and among those who initially did not plan getting vaccinated, 1 in 3 changed their mind and got vaccinated. Fears related to the vaccine, concerns that the vaccine is religiously prohibited, "wait and see" how others did with the vaccine, communication and transportation barriers were commonly cited as reason not to get vaccinated. CONCLUSIONS: Over a third of refugees in our study were hesitant to get vaccinated. Refugees desired additional education about the benefits and safety of vaccines along with easier access to vaccination clinics in their communities.

Integrated Care Management to Improve Diabetes Outcomes in Refugee and Immigrant Patients (I-Care).

Purpose: Refugee and immigrant patients face significant barriers to health care and are more likely to have poorly controlled chronic disease than the general U.S. population. I-Care aims to improve health equity for refugees and immigrants who face a disproportionate burden of chronic disease. Methods: Refugees and immigrants with uncontrolled diabetes and associated cardiovascular risk factors were enrolled in a care management program within an academic adult medicine clinic. The program utilized a care manager to coordinate care and services between designated primary care providers, affiliated clinical teams, and community partners. Health literacy, chronic disease parameters, and care utilization were assessed at enrollment and 8-12 months later. Results: A total of 50 refugees and immigrants were followed for 8 to 12 months. Clinical parameters found a reduced mean HbA1c from 9.32 to 8.60 (p=0.05) and reduced low-density lipoprotein mean from 96.22 to 86.60 (p=0.01). The frequency of normal blood pressures was 9 (18%) at enrollment and 16 (32%) at 1 year. The cumulative frequency of emergency room visits decreased from 66% to 36% and hospitalizations from 22% to 8%. Rates of comprehensive care monitoring, including monofilament testing and one-time ophthalmology visits, increased from 60% to 82% and from 32% to 42%, respectively. Cumulative frequency of interdisciplinary support engagement with pharmacy and nutrition visits increased from 58% to 78% and from 26% to 38%, respectively. Conclusion: This program highlights the importance of a multidisciplinary community-engaged care model that has demonstrated improvement in quality metrics and health care costs for refugees and immigrants.