"Please don’t tell my parents.” These were the words spoken by
20-year-old "Gwenivere” upon learning that her routine pregnancy test to
determine which post-resettlement vaccinations she could receive was positive.
Gwenivere had just resettled to Knoxville, TN, after fleeing the war and
violence of Burundi, an East African country that borders Rwanda, Tanzania, and
the Democratic Republic of Congo. She and her family, including her parents and
younger sister, lived in a Tanzanian refugee camp for 12 years after fleeing
Burundi; eight of these years were spent undergoing the UN Refugee Agency’s
formal resettlement process.
Two weeks after arriving to Knoxville, and after being
oriented to their new home by the local resettlement agency, Gwenivere and her
family made their first visit to Cherokee Health Systems (CHS) where they
received routine vitals and had labs that were specific to their country of
origin or country of refuge performed.
At their second visit, which occurs 10
days after these initial labs are drawn, Gwenivere and her family met with a
medical provider who performed a medical screen designed by the CDC and Office
of Refugee Resettlement. She and her family also met with a behavioral health
consultant (BHC) who assessed Gwenivere and her family’s adjustment to
resettlement and screened for psychological symptoms including posttraumatic
stress disorder and depression. The results of Gwenivere’s labs 10 days prior
revealed a positive pregnancy test.
"Please don’t tell my parents,” Gwenivere said via an
in-person Kirundi interpreter. "If they find out that I’m pregnant and I’m not
married, they will kick me out of their home.” Because CHS has a
well-established model of integrated care and because continuity of care is key
as refugees settle into their new lives in the US, the care team collaborated
with Gwenivere to quickly implement a plan to accommodate her new healthcare
The BHC provided an overview of the available services at CHS including
but not limited to blended primary
care and BH services; obstetrical and gynecological care; care coordination
from community health coordinators; and specialty services including
psychiatry, cardiology, and nephrology, and worked to develop a culturally
appropriate and sensitive treatment plan that best suited Gwenivere’s needs. The
care team honored Gwenivere’s wishes to not disclose her health status to her
parents and utilized that opportunity to teach an important lesson regarding
protected health information and privacy, something with which Gwenivere was
The care team
coordinated an initial prenatal care visit on a day when Gwenivere was already
scheduled to return to the clinic to receive another vaccination. As such, this
additional medical visit did not appear unusual to her parents. She met with
the OB/GYN provider and a BHC who worked with Gwenivere to explore pros and
cons of informing her parents of her pregnancy. The BHC coordinated with a community
health coordinator who met with Gwenivere to discuss alternate housing
arrangements in the event that her parents did ask her to leave their home after
learning of her pregnancy.
The CHC also provided resources for obtaining
necessary supplies for the baby upon its birth. With coaching and support from
the care team, Gwenivere made a plan to tell her parents of her pregnancy,
which went surprisingly well. Her parents expressed disappointment but did not
ask her to leave the home. Gwenivere continues to receive behaviorally-enhanced
prenatal care at CHS, which emphasizes wellness promotion during pregnancy as
well as ongoing monitoring for the development of trauma-related symptoms
secondary to her exposure to war in Burundi.
When CHS began
the integrated refugee resettlement program in October 2015, members of the
care team quickly learned that offering care via our health care home helped
eliminate barriers such as access to care, language difficulties, and a sense
of displacement that may linger after being uprooted from one’s home of origin.
We also learned that routine BH monitoring was essential for prevention, early
detection, and intervention of trauma-related symptoms, which may not appear
until several months after refugees have resettled in their new home countries.
Not only are BH providers able to implement interventions at the point of care
but they are also able to reduce stigma associated with receiving BH care by
being present at every clinical encounter refugees have during their initial
year following resettlement. Sharing an EHR allows for enhanced communication
of previous traumatic experiences to various care team members, which improves
the overall delivery of trauma-informed and culturally sensitive care. Accordingly,
whether Gwenivere would have had a positive pregnancy test or not, she and her
family would have been invited to make CHS their health care home where
they would then gain access to the range of services presented to Gwenivere.
refugee resettlement program is still in its infancy, but since its inception
one year ago, we have provided services to individuals from Iraq, Burundi,
Ukraine, Sudan, Colombia, Tanzania, Cuba, South Africa, and Burma. As we
continue to evaluate and improve the care we provide, we seek to do so in a
manner that is culturally sensitive and responsive to the needs of this unique
population while also remaining true to the spirit of integrated care. We are
honored to serve these families and to work as a bridge as they start their new
Eboni Winford, Ph.D.
is a Behavioral Health Consultant and licensed psychologist at Cherokee Health
Systems in Knoxville, TN. Dr. Winford is involved in workforce development and
is a member of the training committee of CHS’s APA-accredited clinical
psychology internship and the APPIC-approved postdoctoral fellowship program.
She supervises trainees at multiple levels including postdoctoral fellows,
clinical psychology interns, and graduate-level psychology practicum students.
Additionally, she consults with other primary care organizations as they seek
to integrate their practices. She is currently involved in multiple integrated
care initiatives including the refugee medical screening process and the
National Institute of Medicine’s All of Us: Precision Medicine Initiative. She
is the incoming Co-Chair and previous co-secretary to the Primary Care
Behavioral Health Special Interest Group, a member of the Early Career
Professionals Task Force, and the recipient of CFHA’s 2016 Founders’ Early
Career Professionals Award. Dr. Winford earned her degree in Clinical Health
Psychology from the University of North Carolina at Charlotte.