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Asylum seekers have poor access to health care. Qualitative data portraying their experience is lacking. We conducted focus groups and comprehensive interviews with 35 asylum seekers and 15 expert providers/advocacy organization representatives. Purposive sampling was used to recruit subgroups. Interviews were recorded, coded, and analyzed. 85% male, mostly from African countries. Major barriers: a) Internal, including mental illness, fatalism, mistrust, and perceived discrimination; b) Structural, including affordability, limited services, inadequate interpretation, resettlement challenges such as shelter, food, and employment insecurity; health care for urgent care only; and poor cultural competency; c) Barriers in social assimilation, including difficulty navigating a complex system and inadequate community support. Significant inter-related barriers exist at the individual, provider, and system levels. Strategies to improve access include targeting social programs and mental health services, expanding Medicaid eligibility/enrollment, promoting community-based organizations, enforcing the use of trained medical interpreters, and improving cultural competency.

Background Many patient education materials (PEMs) available on the internet are written at high school or college reading levels, rendering them inaccessible to the average US resident, who reads at or below an 8 th grade level. Currently, electronic health record (EHR) providers partner with companies that produce PEMs, allowing clinicians to access PEMs at the point of care. Objective To assess the readability of PEMs provided by a popular EHR vendor as well as the National Library of Medicine (NLM). Design We included PEMs from Micromedex, EBSCO, and MedlinePlus. Micromedex and EBSCO supply PEMs to Meditech, a popular EHR supplier in the US. MedlinePlus supplies the NLM. These PEM databases have high market penetration and accessibility. Measurements Grade reading level of the PEMs was calculated using three validated indices: Simple Measure of Gobbledygook (SMOG), Gunning Fog (GFI), and Flesch–Kincaid (FKI). The percentage of documents above target readability and average readability scores from each database were calculated. Results We randomly sampled 100 disease-matched PEMs from three databases (n = 300 PEMs). Depending on the readability index used, 30-100% of PEMs were written above the 8 th grade level. The average reading level for MedlinePlus, EBSCO, and Micromedex PEMs was 10.2 (1.9), 9.7 (1.3), and 8.6 (0.9), respectively (p ≤ 0.000) as estimated by the GFI. Estimates of readability using SMOG and FKI were similar. Conclusions The majority of PEMS available through the NLM and a popular EHR were written at reading levels considerably higher than that of the average US adult.

Mrs. Vogul wore the same zip‐up white fleece and leather sandals for thirty‐one days of her husband's hospitalization. She slept in the empty bed in his two‐person room or in a chair. When she couldn't sleep, she stood motionless in the hallway like a gargoyle protecting his room. During each crisis, Mrs. Vogul frowned in the doorway, telling us which tests to order and which interventions we were allowed to try. When we supported his breathing with an oxygen mask, she took it off. “Don't try to put that mask back on him again!” she warned as he gasped for air. Despite this, Mr. Vogul was “full code.” If he were to stop breathing on his own, she wanted us to intubate him. If his heart were to stop, she wanted us to try to restart it. With no advance directive to guide us, we deferred these decisions to Mrs. Vogul, despite what sometimes seemed like contradictions in what she wanted for her husband.

A narrow view of patients' and families' preferences has led to the unjust application of policies meant to accommodate dying patients.A narrow view of patients' and families' preferences has led to the unjust application of policies meant to accommodate dying patients.