Refugees in Denver and their perceptions of their health and health care

Arab, Middle Eastern, and North African Health Disparities Research: A Scoping Review

BACKGROUND

Research in health disparities and how they affect underserved populations continues to grow and expand. However, the experiences of Arab/Middle Eastern and North African (MENA) Americans often go unnoticed, and yet, preliminary data suggests there are significant disparities between this population and other groups. The purpose of this scoping review is to examine and synthesize the extent of available literature on health disparities and outcomes for this group.

METHODS

A scoping review was conducted to investigate the current state of research on health disparities and outcomes among Arab/MENA individuals within the USA. The PRISMA protocol for scoping reviews was utilized.

RESULTS

Through the use of PubMed and PsychInfo databases, the search identified 43 articles that were eligible for inclusion in the final review. Five themes emerged: prevalence and health outcomes, factors impacting health, comparison studies, barriers, and health literacy and beliefs. Extant data was equivocal, suggesting the need for further research.

CONCLUSIONS

Research on Arab/MENA health disparities and outcomes is in the detection phase, indicating that more research is needed to elucidate the state of Arab/MENA health in the USA. These findings can help healthcare professionals and researchers understand the emerging literature on health disparities within the Arab/MENA community and inform further research and clinical practice within this population.

Kurdish Refugee Beliefs about Mental Health and Help-Seeking: A Community-Engaged Research Study in Tennessee

Refugee populations exhibit high rates of PTSD, anxiety, depression, and psychological distress, but are less likely to receive care than the general population. Perceptions among the Kurdish refugee community about causes and consequences of mental illness symptoms and perceived barriers to help-seeking are understudied. This community-engaged research study conducted in-depth interviews with Kurdish refugees from Iraq to explore their beliefs about drivers of mental illness and seeking help for mental health. Iterative thematic analysis of transcripts from ten participants indicated four key themes: (1) social network loss due to resettlement causes poor mental health; (2) socioeconomic status loss due to unrecognized professional qualifications puts strain on mental health; (3) social stigma about mental health and fears about disclosure of mental health issues within community and subsequent negative gossip prevent help-seeking; and (4) social interaction may alleviate mental illness symptoms. Overall, Kurdish refugees perceived social factors as major drivers of mental illness symptoms and barriers to help-seeking in their community. However, while participants believed that the general community attitude was against help-seeking, most participants personally expressed support of anyone in their community needing to see a mental health professional. Future research should assess the extent to which perceived community norms differ from aggregated personal help-seeking attitudes and behaviors among Kurdish refugees from Iraq in the United States.

Health disparities among Burmese diaspora: an integrative review

Tens of thousands of displaced Burmese ethnic minorities have endured various adversities for over six decades but are largely underserved. This study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. Using a holistic lens, we conducted an integrative review of 47 papers spanning the years 2004 to 2022 from diverse data sources. The results revealed widespread multimorbidity, triggered mainly by displacement. The diaspora's problematic health conditions were worse than their host country's general population. There was a strong indication that the diaspora's unfortunate health trajectory is determined early in life. Ongoing human rights violations and grossly inadequate health care interventions deepened pre-existing health conditions. Noteworthy emerging treatment initiatives, including integrative health care, were underutilized. The persisting health and intervention needs among the diaspora warrant advanced studies to facilitate much-needed resource mobilization and collaboration among stakeholders to promote health equity.

Funding

There was no financial support for this manuscript.

Health services access, utilization, and barriers for Arabic-speaking refugees resettled in Connecticut, USA

BACKGROUND

Arabic-speaking refugees are the largest group of refugees arriving in the United States since 2008, yet little is known about their rates of healthcare access, utilization, and satisfaction after the end of the Refugee Medical Assistance (RMA) period.

METHODS

This study was a cross-sectional observational study. From January to December 2019, a household survey was conducted of newly arrived Arabic-speaking refugees in Connecticut between 2016 and 2018. Households were interviewed in Arabic either in person or over the phone by one of five researchers. Descriptive statistics were generated for information collected on demographics, prevalence of chronic conditions, patterns of health seeking behavior, insurance status and patient satisfaction using the Patient Satisfaction Questionnaire (PSQ-18).

RESULTS

Sixty-five households responded to the survey representing 295 Arabic-speaking refugees - of which 141 (48%) were children. Forty-seven households (72%) reported 142 chronic medical conditions among 295 individuals, 62 persons (21%) needed daily medication, 285 (97%) persons were insured. Median patient satisfaction was > 4.0 out of 5 for 6 of 7 domains of the PSQ-18 but wide variation (scores from 1.0 - 5.0).

CONCLUSION

Arabic-speaking refugees in Connecticut participating in this study were young. The majority remained insured after their Refugee Medical Assistance lapsed. They expressed median high satisfaction with health services but with wide variation. Inaccessibility of health services in Arabic and difficulty obtaining medications remain areas in need of improvement.

Health literacy levels and correlates among refugees in Mount Lebanon

OBJECTIVES

The study aimed to assess the levels and correlates of health literacy among refugees.

STUDY DESIGN

This is a cross-sectional study design.

METHODS

Health literacy was assessed through face-to-face interviews in eight primary healthcare centers (PHCs) in Mount Lebanon. The questionnaire consisted of the Arabic Functional Health literacy scale, the short version of the European Health Literacy Survey (HLS-EU-Q16), socio-economic questions (sex, age, nationality, marital status, educational level, and ability to pay for medical fees at PHCs), and health-related questions (self-perceived health, long-term illness, recent visit to health care, and freedom to make health decisions). Statistical analyses were performed to evaluate the association between functional health literacy (FHL), comprehensive health literacy (CHL), and potential explanatory variables.

RESULTS

Of 263 participants (61.6% females), mean age 38.49 ± 12.80 years, 52.1% had inadequate FHL and 35.7% had inadequate CHL. The likelihood of having inadequate CHL was higher in refugees who were ever married (odds ratio [OR] = 2.794; 95% confidence interval [CI]: 1.187-6.576) or had average ability to pay for medical expenses at PHC (OR = 4.562; 95% CI: 1.554-13.393). The odds of having inadequate FHL was lower in refugees with some level of education (OR = 0.211; 95% CI: 0.077-0.580). Furthermore, their perceived lack of freedom to make personal health decisions was associated with inadequate levels of CHL (OR = 5.195; 95% CI: 2.693-10.022) and FHL (OR = 4.676; 95% CI: 2.610-8.376).

CONCLUSIONS

Health messages and delivery should be tailored to refugee health literacy levels. Initiatives should seek to improve refugee interaction with the health system, promote uptake of available health services and facilitate health-related decision-making in daily life.

Patterns of Primary Care Use Among Young Adult Refugees Resettled in Colorado

Little is known about the prevalence of young adult refugees' primary care use following resettlement in Colorado. Among a sample of Bhutanese and Burmese young adult refugees resettled in Colorado, proportions with a primary care provider (PCP), physical exam in the last 12 months, and knowledge to make an appointment were calculated across 4 years and compared within the refugee population by demographics using Pearson's Chi-Squared tests and compared to older refugees and to the general population using two-tailed tests of proportions. Greater than 70% of young adult refugees reported a physical exam in the last 12 months during the 4 years after arrival. Disparities were identified within young adult refugees by sex, marital status and country of origin. Young adult refugees were significantly different than both refugees over 55 and the general population in terms of their primary care use. Young adult refugees need support to identify PCPs earlier in resettlement and maintain primary care use years after resettlement.

[Access to Health Care After the Introduction of the Electronic Health Card: Views of Refugee Patients]

AIM OF THE STUDY

Access to healthcare for newly arrived refugees and asylum seekers is organised differently in the municipalities throughout Germany, both with regard to the organisation of support services and the choice of an access model (electronic health card/eHC or healthcare voucher/HcV). Some German states and municipalities have introduced the eHC model in the last years. Using the example of North-Rhine Westphalia (NRW), Germany's largest state, we analyse how access to healthcare is organised from the point of view of refugees and what role the healthcare model (eHC vs. HcV) plays for their access to healthcare.

METHODS

In 3 municipalities in NRW (2 with HcV and one with eHC), 31 interviews were conducted with refugees at 2 points in time (duration of stay in Germany ≤ 15 and > 15 months) in order to account for the different legal entitlements to healthcare. To include different perspectives and challenges, we ensured maximum variation of the interview partners with regard to age, gender, chronic diseases, pregnancy and parenthood. The interviews were conducted with the support of interpreters. The transcripts of the interviews were evaluated using computer-assisted content analysis (atlas.ti 8).

RESULTS

In municipalities with a HcV model, the approval process at the social welfare office leads to additional waiting time for (continued) treatment. The more direct access through the eHC model and the elimination of entitlement restrictions after 15 months of stay can facilitate access to care, especially for chronically ill refugees. Initial contact with the health system is usually facilitated by social workers, friends or family members.

CONCLUSIONS

The eHC model can facilitate access for refugees with higher healthcare needs. Further access barriers, such as the limited availability of interpreters, exist independently of the access model.

Psychology of Working Theory With Refugee Persons: Applications for Career Counseling

The world is facing the largest number of displaced persons in history, with many refugee persons seeking safety in the United States. Among many challenges, refugee persons may face difficulty when navigating the world of work in the United States. We conceptualize career-related barriers for refugee persons residing in the United States, including economic constraints, acculturation challenges, and health disparities. Given these challenges, we describe the relevance of psychology of working theory as a potential theoretical model from which to conceptualize career concerns in refugee persons. Finally, based on previous research, we provide implications for counselors working with refugee persons with vocational concerns, as well as suggested areas for future research.

Burmese and Bhutanese refugee utilization of healthcare services in Colorado

Purpose

The purpose of this paper is to identify factors, within a framework for integration, associated with healthcare utilization (primary care use, dental care, and insurance coverage) for Colorado refugees, by gender.

Design/methodology/approach

The Refugee Integration Survey and Evaluation project was a four-year longitudinal study of refugees that resettled in Colorado beginning in 2011. Refugees from Burma and Bhutan were used in this secondary data analysis. Various integration domains were explored as predictors, across gender groups, of the healthcare utilization outcome variables (physical exam in the past 12 months, dental exam in the past 12 months, and current healthcare coverage) using bivariate and multivariate logistic regression analyses.

Findings

In 2015, 73.1 percent of the sample reported accessing primary health care in the past year, and only 13.2 percent used dental care services. Nearly three-quarters reported having health insurance at the time of survey. In the adjusted models, there was a strong positive association between the outcome variable “physical exam” and the predictor variables “employment and economic self-sufficiency” (OR=0.70, p<0.001), “social bonding” (OR=3.73, p<0.001), and “safety and stability” (OR=2.23, p<0.001). Additionally, education and training predicted dental visit (OR=2.06, p<0.01). None of the integration domains were statistically significant predictors of dental visits in the adjusted models.

Originality/value

This study offers insights about facilitators and barriers to healthcare utilization uptake after resettling in a major US city. These findings can be used by agencies and governmental organizations to best tailor healthcare services and promotion of those services for this vulnerable population.

Challenges of Refugee Health Care: Perspectives of Medical Interpreters, Case Managers, and Pharmacists

Purpose

Our objective was to identify perceived challenges in the provision of health care for refugees from the perspective of medical interpreters, case managers, and pharmacists working with refugee patients in Milwaukee, Wisconsin.

Methods

Two 60-minute focus groups were performed exploring challenges in refugee health care using a literature-based semi-structured protocol. Focus groups were transcribed and de-identified prior to independent analysis by two of the investigators. Using a memoing-process qualitative approach, major concepts, cross-cutting themes, and subthemes were established and ultimately developed a narrative. The project protocol was approved as not human subject research by the local institutional review board.

Results

Four overarching themes regarding health care for refugee patients were identified: 1) difficulty balancing the dynamic of autonomy versus support for refugees; 2) educational needs of refugee families outpacing available resources; 3) challenges for refugees developing trust; and 4) diversity of cultures, education levels, and experiences among refugee families. Language barriers in accessing health care services and insufficient time to meet educational needs of refugees were major challenges outside of the clinic visit setting. Poor health literacy and difficulties communicating health needs and building trust within the interactive triad of refugee, physician, and interpreter impacted clinic visits.

Conclusions

Refugee patients and other participants in refugee care work to navigate a complicated path to equitable health care for a vulnerable population. Continued pursuit of strategies that increase time allocation, education, and support for all parties are needed as we seek to improve health outcomes for newly arrived refugee families.

Forced migrants involved in setting the agenda and designing research to reduce impacts of complex emergencies: combining Swarm with patient and public involvement

PLAIN ENGLISH SUMMARY

The UK's National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response was asked to undertake research on how to reduce the impact of complex national/international emergencies on public health. How to focus the research and decide on priority topics was challenging, given the nature of complex events. Using a type of structured brain-storming, the researchers identified the ongoing UK, European and international migration crisis as both complex and worthy of deeper research. To further focus the research, two representatives of forced migrant communities were invited to join the project team as patient and public (PPI) representatives. They attended regular project meetings, insightfully contributed to and advised on practical aspects of potential research areas. The representatives identified cultural obstacles and community needs and helped choose the final research study design, which was to interview forced migrants about their strategies to build emotional resilience and prevent mental illness. The representatives also helped design recruitment documents, and undertake recruitment and interviewer training.

BACKGROUND

Many events with wide-ranging negative health impacts are notable for complexity: lack of predictability, non-linear feedback mechanisms and unexpected consequences. A multi-disciplinary research team was tasked with reducing the public health impacts from complex events, but without a pre-specified topic area or research design. This report describes using patient and public involvement within an adaptable but structured development process to set research objectives and aspects of implementation.

METHODS

An agile adaptive development approach, sometimes described as swarm, was used to identify possible research areas. Swarm is meant to quickly identify strengths and weaknesses of any candidate project, to accelerate early failure before resources are invested. When aspects of the European migration crisis were identified as a potential priority topic area, two representatives of forced migrant communities were recruited to explore possible research ideas. These representatives helped set the specific research objectives and advised on aspects of implementation, still within the swarm framework for project development.

RESULTS

Over ten months, many research ideas were considered by the collaborative working group in a series of six group meetings, supplemented by email contact in between. Up to four possible research ideas were scrutinised at any one meeting, with a focus on identifying practical or desirable aspects of each proposed project. Interest settled on a study to solicit original data about successful strategies that forced migrants use to adapt to life in the UK, with an emphasis on successfully promoting resilience and minimizing emotional distress. "Success in resettlement" was identified to be a more novel theme than "barriers to adaption" research. A success approach encourages participation when individuals may find discussion of mental illness stigmatising. The patient representatives helped with design of patient-facing and interview training materials, interviewer training (mock interviews), and aspects of the recruitment.

CONCLUSION

Using patient and public involvement (PPI) within an early failure development approach that itself arises from theory on complex adaptive systems, we successfully implemented a dynamic development process to determine research topic and study design. The PPI representatives were closely involved in setting research objectives and aspects of implementation.