By Mahima Ginjupalli and Salma Yazji

Establishing a Chronic Disease Self-Management Program at San Antonio Refugee Clinic

By Mahima Ginjupalli and Salma Yazji

Aden Tadese, Ojasvie Agnihotri, Zachary Harbin, Natalya Ponomareva, Sehwa Nick Kang, Ariana Maleki, Zuha Alam, Serena Luke, Reem Farra RD, Rosalynda Rodea RD, Carolina Gutierrez Garcia, MD, Esther Shin MD,Etny Candelario, MD, Khorshid Amirkhosravi, MD, Tara Taloui, MD, Fehima Dawy, MD, Lizzette Lugo, MD, Armando Flores, MD, Carolina Sanchez, MD, Sabeen Abdullah, Zainab Essaji, Munawar Iqbal, Fozia Ali, MD – The University of Texas Health Science Center at San Antonio

Statement of the Problem The San Antonio Refugee Health Clinic (SARHC) is a student-run free primary care clinic for refugees from over 20 countries. A partnership between UT Health San Antonio and Center for Refugee Services, the clinic promotes the wellness and self-sufficiency of resettled refugee families. During the COVID-19 pandemic, telehealth efforts determined that chronically ill patients were disproportionately affected by clinic closure. Subsequently, outreach was done to assess patients’ efficacy in diabetes and hypertension self-management to develop a six-month intervention.

Materials and Methods • Initial patient outreach and survey administration took place from October - December 2020. Responses lead to the development of a sixmonth program that began in June 2021 with three in-person seminars and remote monthly surveys. During each seminar, distribution & training with blood pressure cuffs and glucose monitors was done, along with nutritional counseling and recording of initial body composition data. Returning participants received gift cards and had medications refilled • Monthly phone call check-ins with MS2s and FM residents were conducted to gauge at home monitoring. • After the final seminar in January 2022, we analyzed data from the pre-and post- program surveys and patient longitudinal quantitative data using a paired t-test. Results • Of over 100 individuals contacted, 14 new participants from five language groups (Arabic, Burmese, Nepali, Rohingya, Spanish) attended the initial seminar on 6/30/21. Nine new participants and five returning participants attended the second seminar on 10/27/21. • 65% of participants have hypertension. 56.5% have type 2 diabetes. • The average initial A1C levels for our diabetic participants are above the recommended 7% or less, demonstrating an overall shared problem with glucose control. • The average initial BMIs for all groups are either overweight or obese. Our goal is to help lower these values through the healthy interventions we are implementing. • The initial pre-survey identified that regular self-monitoring is an area for improvement. • The monthly follow-up calls showed that half of the participants reported checking their levels regularly; however, only 30 - 37.5% recorded and shared this information.

Figure 1. Flyer distributed to recruit community members.

• At monthly follow-ups, the most common response for ongoing barriers to tracking glucose/blood pressure included limited time and work. The most common response for ongoing barriers to healthy diet and physical activity included limited food access, chronic pain, neighborhood safety and limited transportation. • In total, of the initial 14 participants, only 2 individuals attended all three seminars. As such, the data is not significant enough to merit quantitative analysis. Plans are currently being made for another six month follow through with changes to the current organization of the program.

Conclusions and Recommendations ● This is an ongoing project to assess effectiveness of culturally and linguistically accessible community education, and follow-up for promoting self-management of chronic conditions among refugee populations. ● While the final turnout was much less than anticipated, this project serves as a lesson of cultural competency and applied research education. Plans are under way to address the needs identified during our first iteration. ● Plans for the upcoming cycle include modifications such as a multilingual WhatsApp group to share transport needs and increase engagement, one-on-one monthly in-person dietician and provider check-ins rather than phone calls, and collaboration with SA Food Bank delivery service.

Acknowledgements Margaret Costantino, Director of Center for Refugee Services UTHSCSA Community Service Learning Grant

References 1. Adel, Fadi W., et al. “San Antonio Refugees: Their Demographics, Healthcare Profiles, and How to Better Serve Them.” PLOS ONE, vol. 14, no. 2, 2019, doi:10.1371/journal.pone .0211930. 2. Harbin, Z., Yazji, S., Ginjupalli, M., et al. (2021, March). San Antonio Refugee Health Clinic COVID-19 Telehealth Response and Cross-Sectional Study of Refugee Population Needs During the Pandemic. Poster presented at 2021 Society of Student Run Free Clinics Conference.