Module 9: Health and Patient Barriers to Care for Resettled Refugees

Resettled refugees’ access to healthcare depends on their ability to navigate the healthcare systems in their new country. There are many barriers that refugees must overcome in order to receive effective healthcare, including language difficulties, cultural differences, inadequate translational services, and structural or logistical issues.

Language Barriers

Communication is a primary barrier encountered by refugees seeking to access healthcare. The ability to speak the language and communicate in the country of resettlement is very important because “language and communication affect all stages of healthcare access--from making an appointment to filling out a prescription.”(1) The ability to communicate is not only important for scheduling appointments and gaining access to the system, but it is also critical for medical compliance, understanding, and accurate diagnoses. Healthcare providers “mentioned the impact misinterpretation has on the quality of care they are able to provide, noting how difficult it was to properly diagnose patients when communication was broken and physician time is limited.”(2) In addition, the inability to communicate can negatively impact health in times of emergency. As a healthcare provider explained, “a Somali refugee delivered her baby on the doorstep of a hospital when there were open after-hour emergency services on the other side of the building.”(3) If the refugee had been able to read and understand English, the woman would have had a much better chance at receiving emergency obstetrical care.

Cultural Barriers

Cultural barriers were also cited as immediate and common barriers to care. In a study, which focused primarily on refugees in San Diego, cultural beliefs impacted the refugees’ use of the U.S. healthcare system. They were not familiar with preventative care, and they were only used to seeking care when they were sick. They also rarely sought out care for mental health diseases because of the stigma and lack of understanding about mental health conditions. A former refugee explained how “they think mental problems …should be reserved for… somebody with severe Down’s syndrome or something. They don’t think mental health can be things like depression or posttraumatic stress disorder.”(4) In addition to impacting mental healthcare, cultural barriers often significantly impact women’s utilization of western medical services. For example, pregnant Somali refugees living in the United States expressed frustration with the timing and fast pace of U.S. obstetrical interventions. 35% stated that they experienced great time pressures and rushed labor, while 75% of the participants expressed fear and an aversion to cesarean-section, which is often the preferred method used by U.S. obstetricians in cases of prolonged labor.(5)

Cultural barriers often negatively impact medical compliance. For example, Hmong patients generally are not used to delayed clinical response and initial side effects, so they prematurely stop taking their prescribed medications.(6) In addition, refugees often have different explanations for the causes of health and illness, which might also impact their utilization of western medical services. For example, “most Hmong believe that the body contains a finite amount of blood that it is unable to replenish, so repeated blood sampling, especially from small children, may be fatal.”(7) Therefore, for the Hmong “hospitals [are] regarded not as places of healing but as charnel houses” and because of this cultural disconnect many Hmong opt not to receive care in hospitals; rather, they prefer to consult with their traditional healers.(8)

Incorrect Interpretation/Translational Services

Though many cultural and linguistic barriers can be overcome through the use of interpreters, translators, and cultural brokers, it is important that these people receive proper training. Incorrect interpretations can make diagnoses and achieving medical compliance even more confusing and difficult and provoke unnecessary stress in refugees. For example, an immigrant father, upon learning that his baby was diagnosed with hepatitis B, was incorrectly interpreted as having said “should I throw the baby away?”(9) Though the father neither meant this nor said this, the healthcare service provider called Child Protective Services. This added a whole new level of stress and confusion for the baby’s family.

Additionally, children often serve as translators for their parents because they learn the language and adapt to the country of resettlement more quickly. However, as tempting and convenient as it is, it is extremely detrimental for children to serve as interpreters or translators. They do not have the advanced vocabulary and understanding and emotional maturity to serve as effective translators. The use of children as interpreters also puts them in a position of great responsibility, which places an unnecessary amount of stress on them and can lead to power battles within a family and the loss of authority of parental figures.(10) Adequately trained liaisons could improve the exchanges between refugees and their health care provider, especially if they have a cultural connection to the refugees themselves, establishing trust in an otherwise unfamiliar and daunting environment.

Structural Barriers

Structural barriers, including transportation, logistics, insurance and medical expenses are also widely cited by refugees as obstacles to receiving healthcare. For example, newcomers to Canada are required in most provinces to wait 3 months before they can enroll in their province’s health insurance program. Though most foreigners purchase private insurance to cover this interim period, refugees are usually financially unable to do so. Instead, they are eligible to apply to the Interim Federal Health Program for this period, which provides emergency and essential coverage. Unfortunately, in reality, many physicians do not recognize the Interim Federal Health program. Thus, refugees often have to resort to the emergency room in order to refill prescriptions or take care of other small health problems. This example shows the complexity of healthcare delivery. Even though refugee newcomers to Canada are covered by an insurance program during their first 3 months, they still experience substantial barriers to care.(11)

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(1) Morris, M., et. al., “Healthcare Barriers of Refugees Post-resettlement.” Journal of Community Health. 34.6 (2009): 529-538.

(2) Ibid.

(3) Ibid.

(4) Ibid.

(5) “ ‘They Get a C-Section . . . They Gonna Die’: Somali Women’s Fears of Obstetrical Interventions in the United States.” Journal of Transcultural Nursing. 21.3 (2010):220-227.

(6) Mendenhall, T., Kelleher, M., Baird, M., and Doherty, W. “Overcoming Depression in a Strange Land: A Hmong Woman’s Journey In the World of Western Medicine.” Collaborative Medicine Case Studies. 7 (2008): 327-340.

(7) Fadiman, A. “The Spirit Catches you and you Fall Down. A Hmong Child, Her American Doctors, and the Collision of Two Cultures.” (New York: Farrar, Straus and Giroux, 1998)

(8) Ibid.

(9) Morris, M., et. al., “Healthcare Barriers of Refugees Post-resettlement.” Journal of Community Health. 34.6 (2009): 529-538.

(10) “California Seeks to Stop the Use of Child Medical Interpreters.” The New York Times. October 30, 2005.

(11) Miedema, B., Hamilton, R., and Easley, J. “Climbing the walls. Structural barriers to accessing primary care for refugee newcomers in Canada.” Canadian Family Physician. 54 (2008): 335-336.