Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.[1]
BRYCS’ Spotlight this month provides an overview of health issues for refugee families and lists practical resources for those who serve them. Like the World Health Organization’s definition above, we take a holistic approach to health that incorporates physical, mental, and social well-being – an approach likely to resonate with most refugees’ world views. Despite being at increased risk for some health problems, refugees frequently encounter barriers to health and mental health care in the United States. While some barriers are practical and more broadly shared, such as cost and location, others are more specific to refugees and other immigrants, and include language and subtle cultural differences stemming from very different conceptions of health, illness, and healing.
One very innovative and effective method for increasing access to health care for refugees is the development of strong partnerships between health centers and refugee communities. A newly published toolkit – a collaborative effort between the Office of Refugee Resettlement and their Federal partners in the Substance Abuse and Mental Health Administration/Refugee Mental Health Program, and the Office of Global Health Affairs – offers step-by-step guidance on how to develop such collaboration, and is highlighted later in this article. In this month’s Sidebar on “promising practices”, we feature a health center with a long history of collaboration with refugee communities and successful health promotion programs as a replicable model.
The Need for Health Promotion
Although refugees’ backgrounds may vary considerably (by country of origin, level of education, use of Western health care systems, exposure to infectious diseases, and experiences of physical and psychic trauma, etc),[2] they all share the same experience of being forced to flee their home countries, unable to return due to a well-founded fear of persecution.[3] Refugee health risks can be understood according to the different stages of this refugee experience: pre-migration, flight and time in refugee camps, and post-migration/resettlement.
Health Risks According to Stages of Forced Migration & Resettlement
Pre-migration: Prior to leaving their homes, refugees may be exposed to diseases, depending upon the region of the world in which they live, and may be targeted for violence, resulting in physical and psychic trauma.
During flight & refugee camps: As refugees flee their homes, and spend sometimes years in refugee camps, they may experience malnutrition, exposure to the elements, and continued trauma. Children who have been separated from their parents are more likely to experience physical and emotional trauma, and may be at higher risk of health problems. Refugee children, in particular, may arrive in the U.S. malnourished, in need of dental care, and with high blood lead levels.
Post-migration/Resettlement: Once in the U.S., refugees may confront racism and unemployment in addition to the stresses of adjustment to a different language and culture. Over time, refugees tend to develop a higher risk of chronic diseases, such as obesity, heart disease, and diabetes, and may have ongoing responses to trauma, including depressive, anxiety, and post-traumatic stress disorders. Families may also experience more conflict as some members, especially teenagers, adapt more quickly to the new culture than others. Compounding these risks may be a low health literacy and lack of access to, or low utilization of appropriate health and mental health services.
Holistic health promotion and the important role of ethnic-based organizations
Holistic health promotion programs follow a public health and community mental health model and aim towards disease prevention by building on refugee strengths – such as healthy and sustaining cultural values and traditions and strong family and community networks. In addition, refugees can learn more about their health, how to use the health care system, and how to communicate with their Primary Care Provider so that they get the quality care they deserve. Partnerships between health centers and ethnic-based organizations can build on the strengths of both. Health centers can provide the medical and scientific expertise, while ethnic-based organizations can provide the cultural expertise, interpretation, and access to refugee communities. Read about this health center for an example of this partnership in action.
The Office of Refugee Resettlement (ORR) Initiative: “Points of Wellness” – Partnering for Refugee Health and Well-Being
ORR has developed a ground-breaking health promotion and disease prevention initiative, Points of Wellness: Partnering for Refugee Health and Well-being* to help the refugee resettlement and refugee health fields develop and implement holistic health promotion and disease prevention within refugee communities. The “Points of Wellness” refer to the three points of physical, mental, and social well-being. The goals of this initiative are to:
- Improve the long-term health of refugees in the United States
- Reduce physical and emotional suffering and promote social and community productivity
- Contribute to improved refugee health care by increasing health literacy
- Help build the capacity of community-based organizations to promote health and prevent disease among refugees
- Develop partnerships among refugees, providers and community-based groups (Mutual Assistance Associations, employment, legal, language, health, mental health, etc) to ensure refugees are seen and accepted in a holistic manner
Points of Wellness Resource
- Refugee Health Listserv:* A refugee health listserv for sharing of information and as a national forum for dialogue with refugee health providers, researchers and policy makers.
- Refugee Health Promotion and Disease Prevention Toolkit & Annotated Bibliography on Refugee Mental Health: This refugee health promotion and disease prevention toolkit includes guidelines for selecting an appropriate menu of community health activities and the mechanisms of implementing various community health programs and activities. A new Refugee Mental Health Annotated Bibliography is also available.
For further information, please contact one of the Points of Wellness* representatives:
- Ms. Marta Brenden, Project Director, ORR. 202-205-3589 Mbrenden@acf.hhs.gov
- Captain John Tuskan, Director, Refugee Mental Health Program, SAMHSA. 240-276-1845 john.tuskan@samhsa.hhs.gov
- Dr. David B. Smith, Director, Humanitarian and Refugee Health Affairs, OGHA. 301-443-6279 Dbsmith@osophs.dhhs.gov
*In 2010, a new technical assistance provider on refugee health and mental health was announced. The Refugee Health Technical Assistance Center provides consultations, training, Webinars, a listserv, and more.
BRYCS’ CLEARINGHOUSE RESOURCES ON REFUGEE HEALTH CARE ACCESS:
Insurance:
Unfortunately, many refugee families do have access to private health insurance through their jobs, due to the fact that most entry-level positions do not provide medical benefits. Additionally, refugee families often cannot afford the high cost of medical insurance, especially soon after their arrival. The resources below explain eligibility and benefits for different types of coverage, particularly for children.
- Medicaid: Refugee families with dependent children are often eligible for Medicaid. For more information, see the Medicaid At-a-Glance brochure. You can also learn more from Medicaid’s Web site.
- Refugee Medical Assistance (RMA) is funded by ORR through the states for those refugees not eligible for Medicaid (generally single people and childless couples). Refugees may be eligible for RMA for up to 8 months following their arrival in the U.S., although specific policies vary by state. Since RMA services are based on each State’s Medicaid Plan, it is necessary to check with your state’s Medicaid office to find out which medical conditions are covered by RMA. The resettlement agency is generally responsible for ensuring refugees eligible for RMA are enrolled in the program.
- State Child Health Insurance Program (SCHIP): SCHIP, by definition, varies by state. You can search individual state plans through this website, and also find general eligibility requirements. SCHIP is used either in place of Medicaid, or as part of the Medicaid program in some states.
- Insure Kids Now is a government program that provides low-cost private insurance to families with children that do not qualify for Medicaid, but who may still be unable to afford the high cost of non subsidized medical insurance.
Interpretation and Translation Services:
The ability for an individual to be able to communicate with his/her medical provider is essential for good health care. Federal law requires that health and social service providers who receive Federal financial assistance ensure that Limited English Proficiency (LEP) persons receive language assistance so that they have meaningful access to benefits and services. See the links below for more information.
- Department of Health & Human Services/Office of Civil Rights’ Guidance concerning access to services for Limited English Proficient (LEP) persons. Additional information and translated materials concerning linguistic access rights are also available.
- Ensuring linguistic access in health care settings: Legal rights and responsibilities. This manual provides information on addressing language barriers, outlines language access responsibilities under federal and state law and in the private sector, and gives recommendations for addressing identified problems.
- National Council on Interpreting in Health Care
- Guidelines for Providing Health Care Services through an Interpreter
- Patients Who Don’t Speak English: Improving Language Minorities’ Health Care with Professional Interpreters. This OMH report presents results from a study of the effects of professional interpreter services on health utilization for a sample of limited English proficient (LEP) patients over a four-year period. .
Cultural Competence:
The Office of Minority Health (DHHS) defines cultural competence as “Quite simply, health care services that are respectful of and responsive to the cultural and linguistic needs of the patient.” Cultural competence on the part of the health care provider increases communication with the patient, which has been shown to improve health outcomes. (See the first resource listed below.) There are many Web sites devoted to cultural competence in health care:
- Office of Minority Health, The Center for Linguistic and Cultural Competence in Health Care
- National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report. These national standards (CLAS) were issued by the Department of Health and Human Services, Office of Minority Health.
- National Center for Cultural Competence
- Cross Cultural Health Care Program (CCHCP)
- EthnoMed.org
- DiversityRx.org
- Refugee Health ~ Immigrant Health
Health Care Provider Education:
- Physician Toolkit and Curriculum: Resources to Implement Cross-Cultural Curriculum Guidelines for Medicaid Practitioners
- Learning Module, Cultural and Spiritual Sensitivity: A Quick Guide to Cultures and Spiritual Traditions. Teaching Notes. Under the Professional Resources link, choose Reading Room.
Refugee Education:
- A broad range of health education materials in different languages can be found at a number of Web sites, including:
- The San Francisco Department of Health, Newcomers Health Program
- The Nutrition Education Project for New Americans
- The 24 languages project
- For information on immunizations required for children and educational materials in a variety of languages, go to Immunization Action Coalition.
- For a collection of programs that provide refugees with training in the health care professions, order Refugee Health Care Employment and Training Opportunities: Climbing the Ladder from the Institute for Social and Economic Development (ISED).
Promising Practices:
- Providing Healthcare to Limited English Proficiency (LEP) Patients: A Manual of Promising Practices.
- Reflections on CLAS Standards: Best Practices, Innovations, and Horizons
- CLAS in Health Care: Implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health Care at the Alameda Alliance for Health
- Immigrant Health: A Call to Action – Recommendations from the Minnesota Immigrant Health Task Force. This report provides eight action steps for improving immigrant health in Minnesota, and offers action steps for their implementation to policy makers, health care administrators, educators, providers, and immigrant advocates.