Gynecologic care utilization in asylum-seeking women in New York City.

Introduction: Over 25,000 individuals are granted asylum status in the United States annually. Gender-based violence (GBV) has historically been supported as a claim for persecution to apply for asylum. In women, GBV is a known risk factor for sexually transmitted infections, poor mental health, and worse perinatal outcomes. Less is known about the links between GBV, asylum seekers, and gynecologic outcomes or care utilization. Reported rates of gynecologic care-seeking are low in asylum-seeking women and women with histories of GBV often experience barriers to care. We hypothesized that asylum-seeking women with a history of GBV at the Libertas Center, a comprehensive center for survivors of torture in New York City, would receive low rates of recommended gynecologic screening and infrequent gynecologic care. Materials and methods: This retrospective cross-sectional study included adult self-identified female patients who had completed intake at the Libertas Center from 2005-2020. In order to examine the relationship between GBV and gynecologic care use, patients were included if they had an electronic medical record (EMR) at Elmhurst Hospital, were female, 18 years of age and older, and had ever experienced GBV in their lifetime. EMRs were reviewed for medical and psychiatric diagnoses as well as routine components of gynecologic care and were linked to intake data from the Libertas Center characterizing patients' torture history. The primary outcome of this study was whether or not patients attended a gynecology visit. Demographic characteristics, medical histories, adequacy of gynecologic care, and gynecologic care-seeking behavior were compared between the gynecologic care group and the no gynecologic care group. Results: A total of 249 female patients were seen at the Libertas Center from December 2005 until January 2020 at the time of data collection. The prevalence of GBV in this population was 48%. Among women who suffered GBV, 81 received medical care at Elmhurst Hospital and 44 (54%) received gynecologic care. Nearly 50% of those patients who sought care at Elmhurst carried a diagnosis of post-traumatic stress disorder or depression. Women who received gynecologic care were significantly more likely than those who did not receive gynecologic care to have had an Emergency Room visit (68% vs. 41%), an obstetric visit (32% vs 3%), and/or have been seen by a social worker (46% vs 24%; all p < 0.05). Women who saw a gynecologist were significantly more likely to have completed four basic gynecologic care measures (Pap smear, gonorrhea/chlamydia screen, pelvic exam, and mammogram if applicable) compared to women who did not (77% vs 8%, p < 0.05). Conclusion: This study characterizes the gynecologic care utilization of female patients within a comprehensive care center for survivors of torture. We found a high lifetime rate of gender-based violence of 48% in this population. Adequate gynecologic care was uncommon among those who experienced GBV. However, gynecologic care was significantly more likely in patients receiving gynecologic specialty care, which frequently occurred after initial interaction with another provider (i.e. Emergency Department providers). These findings highlight the importance of trauma-informed care and establishing pathways to help asylum seeking and refugee women receive adequate gynecologic care. Further research is needed to explore specific barriers to gynecologic care in this population, how programs for asylum-seekers can integrate gynecologic care into existing structures for medical and mental healthcare, and how to increase awareness amongst providers on the prevalence of GBV and the gynecologic needs of these patients.

Impact of a focused trauma course on retention of provider skills, knowledge and confidence at a regional hospital in the Dominican Republic.

INTRODUCTION: Road traffic accidents are a public health epidemic, causing significant morbidity and mortality in low- and middle-income countries. The Dominican Republic (DR) ranks among the highest road traffic fatality rates in the world. There is no formalized trauma curriculum in the DR. A short trauma course was implemented at a San Pedro de Macoris, DR hospital with pre-, post- and retention evaluation of the knowledge, skills and confidence of the providers. METHODS: A 4-day trauma course was developed for medical students and residents. On days 1 and 4, providers completed pre- and post-training assessments consisting of a 40-question written exam, 1 simulation case and a trauma confidence questionnaire. Simulation cases were evaluated using a critical actions checklist and a non-technical skills scale (TNOTECHS). Assessments were repeated in 2 months to evaluate for knowledge, skill and confidence retention. A repeated measures ANOVA model was used to evaluate pre-, post- and retention training differences in the written exam, non-technical skills and critical actions scores. Confidence scores were assessed using a cumulative logistic regression model. RESULTS: A total of 65 people participated (36 medical students, 22 EM and 7 family medicine residents). Of the 65 participants, 39, 22 and 21 participants had complete scores for pre-post, pre-retention and post-retention comparisons respectively. Mean test scores for the written exam were 37.2, 63.5 and 52.2 for pre, post and retention results respectively. Comparisons between pre and post as well as pre and retention showed statistically significant differences (p=0.0001). Mean TNOTECHS total scores were 15.8, 21.3 and 20.8 for pre-, post- and retention results respectively with a significant difference found between pre- and post- training and pre- and retention training (p <0.05). Simulation mean checklist scores were 57.7%, 67.8% and 74.1% for pre-, post- and retention training respectively with a significant difference established between pre- and retention scores (p<0.05). Provider opinion that their ED patients received best care possible and patients' needs were identified and addressed showed statistically significant increases. CONCLUSION: A short trauma course can improve trauma specific knowledge, skills and confidence with significant retention at two months. A longitudinal trauma curriculum may bolster retention.

PTSD in asylum-seekers: Manifestations and relevance to the asylum process.

Post-Traumatic Stress Disorder (PTSD) is common among asylum-seekers and manifests with symptoms uniquely problematic to the United States asylum-seeking process. Chiefly, hyper-vigilance, avoidance behavior, dissociative amnesia and a tendency towards non-linear narratives hinder the articulation of an effective asylum claim. Moreover, the format and environmental circumstances of the asylum-seeking process further heighten these difficulties.