The findings of the pilot study suggest that a user-friendly, anonymous, self-administered iPad based touch-screen tool for patients in the waiting room of clinical settings can overcome barriers to psychosocial health-risk assessments in ways that better integrate medical and social services. The studied CaPRA tool positively influenced the intention of recent Afghan refugee patients to visit a psychosocial counselor. Further, the participants agreed with the benefits of the tool and did not necessarily perceive it as a barrier to interact with the clinicians or a barrier to their privacy of information. Notably, the use of tool kept the participants ‘very satisfied’ about the care they received and to the same level as the participants in the usual care. The results are discussed in relation to healthcare practice followed by field challenges and limitations.
The health challenges of the 21st
century needs innovative models of practice [24
]. On one side, chronic and complex conditions are on the rise due to population aging and diversity. On the other, poor coordination across sectors is leading to inappropriate use of services and concerns about quality of care. Integration of services across sectors is one of the key healthcare reforms recommended by the World Health Organization [26
]. This vision is also embraced by the health centers serving migrant populations [27
]. However, these centres face many barriers to integrating care. Recent interactive and user-friendly eHealth tools could be used to meet the integration goal effectively. The eHealth model presented in this study enhanced attention of the medical providers and patients to the services available through psychosocial counselors - a step towards integration of medical and social care. Results suggest that providing patients with an anonymous, instantaneous self-assessment process with tailored recommendation sheet prior to their medical visit can promote self-reflection about psychosocial risks and trigger intention to receive care from a counselor. The CaPRA acceptance scores measured by the CLAS scale are very similar to those reported for English speaking patients who used such a tool in a family medicine clinic [19
]. This enhances confidence in the transferability of this tool including different languages. We anticipate that the studied eHeath tool would contribute in the development of evidence-informed models of effective and integrated primary care provision.
The study findings also demonstrate the need to offer comprehensive care to newcomer refugees from Afghanistan, with attention to mental health issues. The high rates of depressive symptoms, low self-rated health and exposure to violence in the last five years are notable in our study and consistent with other studies with Afghan refugees [28
]. It is also important to acknowledge that compromised mental health and experiences of violence are culturally sensitive issues. Thus, provider capacity in culturally sensitive care is an essential element for effective psychosocial risk assessments in primary care settings whether it is computer-assisted or not. To this end, our collaborative approach facilitated the engagement of multiple providers at the partnering agency in ways that actively reflected on sensitivity and stigma associated with addressing these issues. Provider competency is reflected in high and similar level of patient satisfaction for both the groups. In addition, privacy issues (including the availability of private rooms to use the tool), effective referral process, clarifying provider perspectives about computer literacy among clients, training for providers, medical secretaries and other clinic staff, and ongoing monitoring and evaluation are important considerations for routine use of this eHealth tool.
Limitations and challenges
The study findings should be interpreted in light of the design limitations and the context of place and time. The study was a pilot trial with a select group of refugees visiting a single Community Health Centre. This limits the generalizeability to all refugee groups or newcomers. Yet, participants’ response rate of 78% indicates its likely acceptance across vulnerable communities. The interpretation of results warrant caution due to small sample, differences between two groups and volunteer bias of the participant providers. Although statistically significant difference in the demographics of two groups was found only for the number of years lived-in-Canada, we noted some differences in age, gender and level of education. Future research with a larger sample size is needed to allow control of potential confounders. Further, a follow-up component should be included in future designs to assess the impact on patients’ quality of life overtime once they access the referred or suggested psychosocial services.
It is also important to review some field challenges to inform future work. The study applied narrow eligibility criteria (e.g., exclude new patients) and focused on Afghan refugees due to resource limitations in developing a language specific tool. Consequently, few patients were eligible out of nearly two hundred approached in the waiting room. The focus on one sub-group of patients also inhibited the collaborating site, in compliance with the health information and privacy act, to send any pre-visit information letters to patients about the study to encourage early arrivals. Further, a number of practicing clinicians moved to a different clinic along with their patients during the recruitment phase. Although the clinic hired new providers and accepted new patients within a short time, the study recruitment criteria did not allow inclusion of new patients or those seeing new providers. This lengthened the recruitment time. Future research should consider multiple health centers and broader eligibility criteria to address such field challenges. Future models could explore offsite completion of the computer-assisted health risk assessments. However, assessment of socially sensitive issues might not suit non-synchronized approach because provider’s prompt response might be needed. Finally, additional technological advances should also be incorporated, such as linking the printouts to electronic medical records to reduce the documentation burden on the clinician and the use of voice to facilitate reading by patients and to address literacy issues.