Past 30-day HSD use at follow-up was significantly lower for intervention patients . While the control group reported no change in HSD use over time , the intervention group reported a significant unadjusted mean reduction of 4.4 days from baseline to follow-up . Among the 47 participants who provided urine samples, those in the intervention group were less likely than controls to test positive for their HSD . A logistic regression analysis for testing HSD positive that controlled self-reported baseline HSD use confirmed that intervention group participants were less likely than those in the control group to test HSD positive at follow-up . In the intent-to-treat linear regression model with multiple imputation of missing values , intervention patients reduced their HSD use an average of 4.5 more days in the past month than did controls, controlling for baseline HSD use, high school graduation, number of children under 18 living with them, and having been sexually assaulted before they were 18 years old. The complete sample regression with the same covariates for the 51 patients with follow-up data produced similar results , with intervention patients reducing their HSD use an average of 5.2 more days than controls . Finally, among the 32 patients in the complete sample who reduced their HSD use by a day or more, 28 patients who reported risky alcohol use reduced that use by an average of 0.3 days and 17 patients who disclosed smoking reduced their tobacco use by an average of 2.5 days . Neither change was significant . In this study of mostly Latino primary care patients of an FQHC, the QUIT brief intervention group reported a 40% decline in mean HSD use, corresponding to an adjusted 4.5-day reduction in reported past month HSD use by 3-month follow-up compared to controls ; there was no compensatory increase in use of alcohol or tobacco. This degree of drug use reduction is meaningful clinically according to norms for reductions in marijuana use in clinical trials . The trial has clinical significance as its findings could apply to 12% of our study clinic patients that screen positive for risky drug use ,drying room and represents significant potential public health impact for the 20 million risky drug users in the US if replicated in other clinic populations , 2012; U.S.

Department of Health and Human Services Office of the Surgeon General, 2016. The findings are important given the limited number of randomized trials of screening and brief intervention for risky drug use in primary care, and notable in that the findings affirm the positive findings of the QUIT trial. Some distinctive characteristics of the QUIT intervention that may contribute to its greater success than other brief intervention protocols designed to address risky drug use in primary care include: use of primary care clinicians to deliver brief advice messages about drug use; regular weekly “learning community” meetings among health coaches and the study team; incorporation of quality of life issues patients spontaneously raised as barriers to drug use reduction into telephone coaching sessions; embedding of drug use consent and patient assessment questions within a larger behavioral health paradigm to conceal the study’s drug focus and minimize potential contamination of the control group; and patient self-administered assessment of drug use on tablet computers. The original QUIT study, showed a significant reduction in HSD in 30-day risky drug use , 3.5 day reduction in the completer analysis in intervention compared to control patients . The positive outcomes in all of these different clinics bolstered by positive outcomes from this pilot replication suggest that QUIT may prove effective and implementable in a variety of settings and across a variety of patient demographics. Limitations of the study include: generalizability of the sample to other Latino populations, potential for social desirability bias to influence the primary outcome of self-reported drug use reduction which we tried to minimize by patients’ self-administration of survey items on a tablet computer, loss to follow-up, and small sample size which limits subgroup analysis. Over three million refugees have been resettled in the United States since Congress passed the Refugee Act of 1980.1 In 2015, there were nearly 70,000 new refugee arrivals, representing 69 different countries.1 Refugees undergo predeparture health screening prior to arrival in the U.S., and are typically seen by a physician for an evaluation shortly after arrival.

Refugees are resettled in areas with designated resettlement agencies that assist them with time-limited cash assistance, enrollment in temporary health coverage, and employment options. Refugees are initially granted six to eight months of dedicated Refugee Medical Assistance, which is roughly equivalent to services provided by a state’s Medicaid program.Following this period, refugees are subject to the standard eligibility requirements of Medicaid.3 It is important to highlight the differences between a refugee, an asylum seeker and a migrant, as this study focuses specifically on refugees. A refugee is an individual who has been forced to leave his or her home country due to fear of persecution based on race, religion, nationality, membership in a social group, or policital opinion. Refugees undergo robust background checks and screening prior to receiving designated refugee status. They are relocated only after undergoing this screening process, and have legal protection under the Refugee Act of 1980 given their status as a refugee. An asylum seeker, on the other hand, is an individual who has fled his or her home country for similar reasons but has not received legal recognition prior to arrival in the U.S. and may only be granted legal recognition if the asylum claim is reviewed and granted. As a result, asylum seekers do not have access to services such as Refugee Medical Assistance, time-limited cash assistance, or similar employment opportunities. Migrant is a general term and refers to an individual who has left his or her home country for a variety of reasons.Prior studies have shown differences in utilization of the emergency department by refugees in comparison to native-born individuals.In Australia, refugees from non-English speaking countries are more likely to use ambulance services, have longer lengths of stay in the ED, and are less likely to be admitted to the hospital.A study conducted in the U.S. evaluated refugees one year post-resettlement and demonstrated that language, communication, and acculturation barriers continue to negatively affect their ability to obtain care. These data suggest that there may be unidentified opportunities for improving the acute care process for refugee populations; however, little is known about how refugees interface with acute care facilities. Therefore, the goal of this study was to use in-depth qualitative interviews to understand barriers to access of acute care by newly arrived refugees, and identify potential improvements from refugees and community resettlement agencies. The refugee clinic was located at a tertiary care hospital in a city in the Northeast U.S. The clinic has been in operation for approximately five years and has cared for approximately 200 refugee patients yearly. At the time of the study,vertical farming units the clinic received referrals from one of the three resettlement agencies in the city. Refugee patients were seen within 30 days of arrival. Most refugees were seen for screening evaluations and transitioned to clinics near their homes after twoto three clinic visits. Refugee patients were eligible for this study if they were over 18 years of age, had capacity to consent, and had no hearing difficulties. We excluded refugees if they were deaf, unable to answer questions from an interpreter, or had acute medical or psychiatric illnesses. In the city in which the study was performed, there are three main resettlement agencies and approximately three well-known post-resettlement agencies. Resettlement agencies are responsible for receiving new refugee arrivals and assisting individuals with support for three to six months after arrival.

Resettlement employees assist refugees with establishing housing, employment, transportation, primary care, and language services. After three to six months, refugees are able to seek additional assistance at post-resettlement agencies. Post-resettlement agencies provide additional support in terms of support groups, language services, cultural activities, and case management. Employees were eligible for this study if they worked at a resettlement or post-resettlement agency, were over 18 years of age, and had no hearing difficulties. This was an in-depth interview study using semi-structured, open-ended interviews. Separate interview guides for refugees and resettlement agency employers were developed by all members of the study team. Study team members included the following: an emergency physician and investigator with expertise in qualitative methodology ; an internal medicine physician with many years of experience working at the refugee clinic ; a third-year emergency medicine resident with three years of experience working bimonthly at the refugee clinic ; a second-year EM resident with no experience at the refugee clinic , an MD/PhD student with three years of experience working at the refugee clinic and content expert on refugee studies ; and an undergraduate student with two years of experience working at the refugee clinic . The study team composition allowed for a range of expertise with individuals who had experience working with refugees and those who did not. Questions were vetted among the all members of the study team and revised to ensure that content reflected the goals of the study. Prior to interviewing resettlement and post-resettlement employees, a resettlement/post-resettlement employee interview guide was developed using the same process. Refugee interviews were conducted in person at a refugee clinic, and refugees were recruited during the study period when an interviewer was present during clinic hours. Refugees were asked to participate if a room and interpreter were available. If the aforementioned conditions were met, all refugees awaiting clinic appointments or available after their appointment were asked to participate. All of the refugees who were asked agreed to consent and participated. Interviews with refugees were conducted by two members of the study team using the Refugee Interview Guide and lasted approximately 30 minutes. A phone interpreter was used for verbal consent prior to participation and for the interview. Demographic information was collected about each participant . After interviews were completed for refugee patients, a second phase of semi-structured, open-ended, interviews were conducted in person at local resettlement and post-resettlement agencies in the region. We obtained a list of employees involved in case management, health coordination, and program development for refugees/immigrants from resettlement healthcare teams. These employees were contacted via email with information regarding the study and consent form. Of 13 employees contacted, 12 participated. Employee interviews were conducted at their respective agencies, and verbal consent was obtained prior to participation. Interviews with resettlement employees were conducted by two members of the study team using the Resettlement/Post-resettlement Employee Interview Guide and lasted approximately 20 minutes. This study was approved by the institutional review board at the University of Pennsylvania.A total of 16 interviews were completed with refugees. Participants had a mean age of 34 and 50% had completed high school. Countries of origin were Syria , Bhutan , Democratic Republic of the Congo , Burma , Sudan , Iraq , Iran and the Central African Republic . Most refugees seen at this refugee clinic undergo medical screening within one to two months of arrival. A few of the patients remained at the clinic for long-term follow-up. All refugees required an interpreter and all interpretation was done with phone interpreters. A total of 12 interviews were completed for resettlement and post-resettlement agencies. Resettlement employees interviewed represented two resettlement agencies and two post-resettlement agencies. We identified several barriers to access of acute care facilities by newly arrived refugees . The process by which refugees seek care and barriers at each step can be visualized in Figure 1.Our principal findings identify barriers throughout the process of accessing acute care for newly arrived refugees. Overall, refugees face uncertainty when accessing acute care services because of prior experiences in their home countries and limited understanding of the complex U.S. healthcare system. The unfamiliarity with the U.S. healthcare system drives refugees to rely heavily on resettlement employees as an initial point of triage or, if they are very sick, to call 911. At the resettlement agency, employees express concern about identifying the appropriate level of care to which to send a refugee client.