Date of Award

January 2022

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Emily R. Christison-Lagay


Ongoing international conflicts have displaced 80 million people, with over 500,000 resettling in the United States (US). Approximately half (53%) of these are children. Reports from Middle Eastern conflict areas and surveys of refugees arriving in Europe have highlighted increased pediatric surgical burden in refugees. However, surgical conditions and barriers to access in refugee children after resettlement in the US remain largely understudied. This mixed-methods study aimed to quantify the pediatric surgical needs of refugee children resettled in Southern Connecticut, and to explore the factors, facilitators, and barriers that impact Middle Eastern refugee families’ experiences with pediatric surgical care.

A two-phase explanatory mixed-methods design featured a quantitative retrospective cohort study within a hospital-network covering Southern Connecticut between 09/01/2009-09/27/2019 of all refugee children younger than 18 years old, followed by a qualitative investigation informed by and designed to explain the trends in the first phase. The quantitative component compared demographics, surgical referrals, incidence of surgical diseases, and pre-operative and post-operative encounters between refugee children and all pediatric patients within the network. The qualitative phase included semi-structured video or phone interviews conducted in English, Pashto, or Arabic with parents of children who underwent surgery, women who sought prenatal surgery consultation, and refugee providers. Interviews were analyzed for core themes and coded using an integrated approach.

In the quantitative phase, 1211 refugee children were identified. The need for some operative intervention in refugee children (21.2%) was nearly twice that of children (11.6%) within the network (p<0.0001). Almost half (45.0%) of refugees required postoperative admissions, compared to 32.2% of the general population (p<0.0001). Dental procedures were the most common. Compared to the general population, refugees also carried a higher incidence of circumcision (Incidence Ratio [IR] of 4.73, 95% Confidence Interval [95%CI]: 3.202-6.953, p<0.0001), spinal fusion (IR: 136.4, 95%CI: 58.86-315.6, p<0.0001), inguinal hernia repairs (IR: 2.05, 95%CI: 1.114-3.764, p=0.0350), myringotomy (IR: 7.24, 95%CI: 3.296-15.84, p=0.0002), liver transplants (IR:51.08, 95%CI: 24.81-104.9, p<0.0001), and congenital diaphragmatic hernia repairs (IR:30.86, 95%CI: 8.083-117.5, p=0.0023). Refugee families cancelled 17.7% appointments before and 31.3% within the year after surgery (p<0.0001), and never arrived at 7.2% before and 11.1% within the year after surgery (p<0.0001).

The quantitative phase of the study identified four major themes impacting refugee families’ experiences with pediatric surgery: (1) medical navigation and illness experiences, (2) personal support systems, (3) structural determinants of health, and (4) the COVID-19 pandemic. Each theme included multiple barriers and facilitators for refugee families while accessing surgery. Notable subthemes were language and immigration experiences as structural determinants of health; the support of faith, family, friends, and community, balanced with privacy concerns among personal support systems; and communication between the care team and the family as it relates to cultural humility.

This work demonstrates that while refugee children were more likely to require operative procedures and post-operative hospital admissions than the general population, they were less likely to comply with suggested post-operative follow-up. As such, our qualitative findings highlight important barriers and facilitators that may lead to these epidemiologic trends and elucidate actionable steps for improving surgical care access for refugee families resettled in the US.


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