Language: English

Marshallese TB Cultural Profile

© The Pacific Community (SPC), SPC.int, copyrighted image used with written permission.

Summary

The Marshall Islands have an extremely high incidence of tuberculosis (TB) disease, at least 100 times higher than in the U.S. as a whole.  Individuals who identify as Marshallese accounted for approximately 12% of all TB disease cases in Washington State in 2023. The prevalence of latent tuberculosis infection (LTBI) is estimated to be much higher (approximately 30% based on recent WHO testing). The history of nuclear testing by the U.S., lack of trust in the U.S. medical system, barriers to healthcare access, and stigma regarding TB can make individuals hesitant to undergo screening. There is confusion in the community regarding diagnosis of latent TB compared to active TB disease. There is also less awareness of blood testing (e.g. interferon gamma release assay, Quantiferon) as skin testing has been more prevalent in the Marshall Islands. Many recent immigrants will be familiar with the recent World Health Organization (WHO) TB campaign in the Marshall Islands which aimed for universal screening.


Recommendations

  • Recommend TB screening for all individuals from the Marshall Islands, consider screening for U.S. born members of the Marshallese Community.
  • Recommend screening with blood test (e.g. interferon gamma release assay, Quantiferon) rather than skin testing (e.g. tuberculin skin testing, Mantoux).
  • Recommend addressing other common health issues such as diabetes, obesity, and renal disease.
  • Recommend highlighting the impact of screening on community health, particularly that of children in the community.
  • Recommend explaining the difference between latent TB infection and TB disease.
  • Recommend starting short course LTBI treatment regimen as appropriate.
  • Recommend close follow-up in clinic once treatment has been initiated to ensure continued adherence  with regimen.

Methods

The following sections are based on transcripts from interviews with seven Marshallese community members who were identified by a Marshallese community navigator contracted with Public Health – Seattle & King County. Interviews were conducted either in English or Marshallese with a Marshallese community navigator providing interpretation. A supplemental literature review was also performed. 

Burden of Disease

Center for Disease Control (CDC) Rates for the Marshall Islands
Marshall Islands 2021 CDC Statistics
TB Disease Incidence (per 100,000 per year): 280.6
TB Disease Incidence (total number of cases reported): 118

United States 2021 CDC Statistics
TB Disease Incidence (per 100,000 per year): 2.4
TB Disease Incidence (total number of cases reported): 7882

Total population size of the Marshall Islands (2011) 53,158
Population proportion by island (2011): Majuro 52% / Ebeye 20% / Other islands 28%

Languages Spoken

Marshallese is the official language of the Marshall Islands. There are two major dialects. Nanimej means “sick” in Marshallese, but this can also refer to TB disease. Many names for specific diseases are borrowed from English, and “TB” is typically used to refer to the disease. 

Most Marshallese recognize the English term ‘TB” or “tuberculosis” for TB disease. 

Bacillus Calmette-Guérin (BCG) Vaccination

RATES AND UNDERSTANDING

BCG vaccination was introduced in 2004 to the Marshall Islands. A single dose is administered at birth. Most people receive the vaccine, with an estimated BCG coverage estimate of 89% in 2019 (www.bcgatlas.org). Respondents did not mention a belief that the BCG vaccine was protective amongst adults though recognize that it confers protection to children.

Diagnosis and clinical features

RECOGNIZED BY THE COMMUNITY

Some respondents understood that TB could be either symptomatic (TB disease) or could be asymptomatic (latent TB infection). Some respondents referred to latent TB infection as “sleeping TB”). However, some respondents were not aware of the distinction between latent TB infection and TB disease and felt that there is a general lack of awareness in the community of the distinction between the two.

Commonly identified symptoms of TB disease include chronic productive cough, weight loss, fevers, and poor appetite. Most respondents were not aware of extrapulmonary TB disease. 

There is consensus that TB disease is transmitted by cough/breathing. Participants noted that it is dangerous to be in the same area as others with TB disease, especially indoors. They noted that they would be reluctant to meet someone outdoors with TB disease unless they were a close family member. Several respondents highlighted the importance of social gatherings in Marshallese culture and that it would be difficult to decline invitations to participate in communal activities based on health concerns.

TB disease is considered to be a serious disease and it is known to have the potential of being fatal. 

Testing of TB disease and latent TB infection

PRACTICES IN THE MARSHALL ISLANDS

Testing in the Marshall Islands historically focused on diagnosis of TB disease in those who were symptomatic. The World Health Organization (WHO) supported mass screening of TB disease for the entire population of Ebeye Island (part of Kwajalein Atoll) in 2017. Screening for active and latent TB was started on Majuro Island in 2018 (http://open.who.int/2018-19/country/MHL). Ebeye Island and Majuro Atoll are two most populous islands of the archipelago and represent nearly 75% of the population of the country.  Nearly 80% of the population was reached during these two campaigns with the identification of 302 cases of TB disease (representing 1.6% of the population) and 4,700 cases of latent TB infection (about 29% of those tested). 

Regular TB testing and screening is done community-wide in the Marshall Islands as part of the WHO effort and is done in public settings such as schools, community gatherings, and churches. Most testing consists of tuberculin skin testing followed by chest radiograph and sputum testing if the patient is symptomatic. Overall, Marshallese are willing to be tested for TB in the Marshall Islands as testing has become accepted as a regular, communal event. However, treatment of latent TB infection is not mandatory so some people elect not to be treated. 

© Stefan Lins, Creative Commons License

TB Treatment in the Marshall Islands

In the Marshall Islands, only symptomatic individuals (those with TB disease) were treated until the start of a WHO initiative in 2018 to screen and treat cases of latent TB infection on Majuro Atoll. During the 2017 and 2018 WHO campaigns, supervised active TB treatment was offered through Community Health Outreach Workers. Latent TB infection was introduced for the first time and consisted of supervised isoniazid and rifapentine regimen. About 92% of those diagnosed with latent TB started treatment(http://open.who.int/2018-19/country/MHL). This has led to some confusion among our respondents about whether individuals were diagnosed with latent TB infection or TB disease since screening and treatment are carried out for both.

Practice of traditional medicine is less common among the Marshallese, particularly among the younger generation. However, there remain some community members who prefer to use traditional healing techniques and will be less likely to access care from Western medical providers.

Social factors and care delivery in the Marshall Islands

Marshallese society emphasizes collectivism with multigenerational households and frequent community events. Sharing of food is also an important part of social activities. There is a strong stigma in the community regarding TB. Respondents stated that they would avoid community members who were suspected of having TB. On the Marshall Islands, respondents noted that it was obvious and public when your neighbors and other community members were being screened for TB. When the health department followed up with a household and delivered medications for directly observed therapy (DOT), many community members assumed that this was due to a diagnosis of TB disease requiring treatment. However, the WHO began treatment of latent TB infection with DOT starting in 2018 in Majuro island. Therefore community members would be unable to distinguish whether their neighbors were being treated for latent TB infection or TB disease. Because of confusion regarding the clinical difference between TB disease and latent TB infection and the risks of transmission in both cases, stigma in the community extends to individuals diagnosed with latent TB infection.

There is recognition that treatment is available for TB and cure is possible. Respondents felt that the social stigma towards a community member would clear once treatment had been completed. However, they note that it would be difficult to ensure if treatment was completed, and there would likely be lingering concern that an individual would remain an infectious risk. Respondents noted that the closeness of the relationship with the person diagnosed with TB would determine how much distance one could keep from them. For intimate friends or close family members, maintaining distance would not necessarily be seen as being socially acceptable. This could lead to possible disease transmission in the case of TB disease.

Experience with TB and barriers to care in the United States

Regarding provision of health care, there is a preference for translators who are the same gender as the patient. Several respondents have experience working as translators for Marshallese patients and noticed that patients would minimize symptoms and hold back information if they were with an unfamiliar provider or with a patient of different gender than the translator. Due to difficulties in accessing care and limitations in health insurance coverage, members of the Marshallese community are often establishing care for the first time when they receive a diagnosis of TB disease or latent TB infection. With the absence of a prior therapeutic relationship, communication regarding TB diagnosis and treatment can be more complicated. 

There is more privacy for Marshallese community members in the U.S. given the greater distance between households.  In addition, screening events are typically not done in public. Respondents noted that there was less social pressure to follow-up with medical providers given this increased level of privacy. However, news and rumors still travel quickly within the relatively small Marshallese community. 

In the U.S., Marshallese are less likely to be tested for TB due to financial and travel barriers to accessing healthcare. TB testing is also not a regular, community-wide event in the U.S. as it has been in the Marshall Islands. Among individuals who test positive for latent TB infection, it is simple to decline treatment and maintain anonymity within the community. In cases of TB disease, the local health department traces cases and provides treatment. Respondents felt that community members receiving treatment for TB disease in the U.S. had greater privacy and anonymity than they would have in the Marshall Islands.

Although there have been community screening events organized by the department of public health, many Marshallese community members have been reluctant to go since it was seen as optional and there was concern of being stigmatized by attendance. Respondents noted that members of the community would not share a diagnosis of TB disease or latent TB infection outside of their immediate family and closest friends. Although several interview participants noted that members of their community were hesitant to be screened for TB, they noted that most people are very sensitive and protective of their children. They knew of community members who were aware of the elevated infection risks of young children and were more motivated to be tested as a result. They recommended health care providers to highlight the community-wide benefits, particularly to young children, when recommending screening and treatment.

Additional barriers to screening include concerns that a positive TB test could jeopardize their employment, particularly as workers in the childcare or health care fields. The stigma of having a family member who tests positive for TB is also seen as possibly placing social relations between the community and the family at risk. Several respondents also noted that many Marshallese live in multigenerational households where a positive TB test could jeopardize their housing with limited affordable housing alternatives available.

Regarding treatment, respondents felt that medication regimens are poorly understood in the Marshallese community. Treatment for latent TB as part of the WHO initiative in the Marshall Islands used the combination of isoniazid and rifapentine taken weekly. Daily rifampin is another short course regimen which is used by many providers in King County and other parts of the U.S. Some respondents mentioned concerns about side effects from medication regimens, particularly gastrointestinal, renal, and hepatic complications.

Relevant Historical Factors

The Marshall Islands served as the site of 67 nuclear tests by the United States on various atolls from 1946 to 1958 as part of the Pacific Proving Grounds. Testing began in 1946 on Bikini Atoll following the forced relocation of inhabitants. The first hydrogen bombs were tested on the islands, including the Castle Bravo nuclear test in 1954 on Bikini Atoll. Significant nuclear fallout was detected on islands of the archipelago with continued dangerous levels of radiation on Bikini Atoll. A medical study, Project 4.1, was launched to study the effects of radiation on people exposed to fall-out in the wake of the Castle Bravo test. This research was conducted without the informed consent of Marshall Islanders and without translation of the information into the Marshallese language (Barker 2013).

© International Campaign to Abolish Nuclear Weapons, Creative Commons License

The classified nature of this study on members of the Marshallese population exposed to radiation has been a potential source of distrust with medical providers. Recent analyses of the study reveal a dose-dependent effect of radiation exposure to risk of cancer. Radiation exposure accounts for around half of all cancers in the most heavily exposed inhabitants of Rongerik Atoll, though radiation exposure was calculated to account for less than 2% of past and future cancer diagnoses among the exposed Marshall Island population as a whole. (Land et al. 2010)

Several trust funds were established for the Marshallese people, though payouts only amounted to a few hundred dollars per year. Citizens of the Republic of the Marshall Islands are not citizens or nationals of the United States. However, they are entitled to apply for admission to the United States as nonimmigrants without visas. They may reside, work, and study in the United States. They do not have the status of lawful permanent residents but can apply for permanent residence status once they come to the U.S.. Marshallese were entitled to Medicaid until the 1990s. Access was reinstated in 2020.
This history of nuclear testing has created lingering distrust amongst the Marshallese population towards the U.S. government and medical providers due to exposure to radioactive fallout, the initially classified Project 4.1 medical study, and the limited status provided to migrants who travel to the U.S. 

The ecological destruction, population displacement, and economic dependency which occurred as a result of this nuclear testing has led to high population densities on a number of islands and high rates of diabetes which has contributed to the spread of tuberculosis (Yamada 2001).

Co-morbidities / Other health concerns in the community

Several respondents mentioned nutrition, diabetes, and kidney disease as prominent concerns in the Marshallese Community. They noted the difficulty in accessing vegetables and fruits in the Marshall Islands because of the high cost. Although access to these fresh foods is better in the U.S., they noted that many members of the community have been habituated to a diet rich in carbohydrates, fats, and salt. Diabetes and kidney disease were raised as concerns since several respondents were familiar with community members who presented to the hospital with progressed forms of both diseases. 

A survey in the Marshall Islands of 3045 Marshallese between 15-64 years of age was conducted in 2002 (WHO 2007). Of these respondents, 23% were current smokers, 62.5% were obese or overweight, 10.5% were hypertensive, and 19.6% were diabetic. Diabetes rates have been estimated at 400% higher than the U.S. population as a whole (McElfish et al 2016). Health assessments in the United States revealed diabetes prevalence rates in Marshallese living in Hawaii and Arkansas at greater than 40% (McElfish et al 2015).

References

Barker HM. Bravo for the Marshallese: Regaining Control in a Post-Nuclear, Post-Colonial World. 2nd ed. Independence, KY: Cengage Learning; 2013

Fact Sheet – Status of Citizens of the Freely Associated States of the Federated States of Micronesia and the Republic of the Marshall Islands (uscis.gov)

Land CE, Bouville A, Apostoaei I, Simon SL. Projected lifetime cancer risks from exposure to regional radioactive fallout in the Marshall Islands. Health Phys. 2010 Aug;99(2):201-15. doi: 10.1097/HP.0b013e3181dc4e84. PMID: 20622551; PMCID: PMC3892964.

McElfish PA, Hallgren E, Henry LJ, Ritok M, Rubon-Chutaro J, Kohler P. Health Beliefs of Marshallese Regarding Type 2 Diabetes. Am J Health Behav. 2016 Mar;40(2):248-57. doi: 10.5993/AJHB.40.2.10. PMID: 26931757; PMCID: PMC5304418.

McElfish PA, Bridges MD, Hudson JS, et al. Family Model of Diabetes Education with a Pacific
Islander Community. The Diabetes Educator. 2015 Dec; 41(6):706–15.

The BCG World Atlas, 3rd Edition: BCG World Atlas (bcgatlas.org)

World Health Organization, Western Pacific Region and the Ministry of Health, Republic of the Marshall Islands, author. NCD Risk Factors STEPS Report: Ministry of Health, Republic of the Marshall Islands, 2002. Suva Fiji: World Health Organization; 2007

Yamada S, Palafox N. On the biopsychosocial model: the example of political economic causes of diabetes in the Marshall Islands. Fam Med. 2001;33(9):702–704.

Yanagawa M, Morishita F, Oh KH, Rahevar K, Islam TA, Yadav S. Epidemiology of tuberculosis in the Pacific island countries and areas, 2000-2020. Western Pac Surveill Response J. 2023 Feb 22;14(1):1-12. doi: 10.5365/wpsar.2023.14.1.996. PMID: 36923784; PMCID: PMC10008724.

Other Resources

The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical Modelling | PLOS Medicine

Estimating the long-term effects of mass screening for latent and active tuberculosis in the Marshall Islands | International Journal of Epidemiology | Oxford Academic (oup.com)

Why Nuclear Justice for the Marshall Islands is the Biggest US-China Issue You’ve Never Heard Of – Union of Concerned Scientists (ucsusa.org)

Acknowledgments:

This project has been generously supported by the following funders:
TB Elimination Alliance (2023-2024 Mini-Grant Program)
Firland Foundation (2024-2025 Community Grant)


healthcare provider hands and patient hands, explaining primary care

Examining the Primary Care Experiences of Refugee Communities

Overview

Washington state and King County continue to be top resettlement destinations for refugees in the United States; however, newly arrived refugees experience many challenges and barriers when accessing health services after resettlement. EthnoMed’s mission is to provide culturally appropriate and relevant resources on refugee and immigrant health topics. One available resource is EthnoMed’s Primary Care Provider Toolkit. First developed in 2011, the original toolkit offers clinical recommendations and guidance for providers that serve refugee communities in King County. The goal of this project was to gather qualitative data from refugee community leaders to develop recommendations for EthnoMed’s updated Primary Care Provider Toolkit. Through this project, 15 key-informant interviews were conducted with leaders of Afghan, Ukrainian, and Iraqi refugee communities in King County. Community leaders were asked about the health needs and barriers to health care that new arrivals experience after resettlement. The qualitative findings from these semi-structured interviews were analyzed and synthesized into nine recommendations for the updated version of EthnoMed’s toolkit. By integrating community voices into this updated version, EthnoMed can develop a more culturally appropriate and patient-centered resource that will better inform primary care practices for providers that serve refugee communities.

healthcare provider hands and patient hands, explaining primary care
Health provider working with refugee newcomer

Background and Objectives

In 2011, the Primary Care Provider Toolkit resource was developed in response to the complex health needs of the growing refugee population in King County, Washington. This cross-sector community resource was developed by a team of health professionals, including social workers from Lutheran Community Services Northwest (LCSNW), graduate students from the University of Washington, and physicians from the International Medicine Clinic and Pediatric Clinic at Harborview Medical Center. The original resource includes information on health screenings, treatment recommendations, referrals, links, and resources. The primary audience for this toolkit is primary care providers that serve newly arrived refugees in King County.
The toolkit’s main objectives are:

  1. Explain overseas PRE-departure assessment and POST-departure screening needs
  2. Facilitate exchange of information between Public Health Refugee Screening and primary care providers
  3. Share links, referrals & other information, including contacts to interpretation services
  4. Advocate [for] and empower refugee patients

The original toolkit was developed over 10 years ago, with a subsequent update in 2015; however, sections of its information is now out of date, or is not relevant to the communities that are being predominantly resettled in King County. EthnoMed is seeking to update the resource to reflect the current landscape and needs of local refugee communities. The original toolkit lacked community input; therefore, the goal of this project was to effectively gather community feedback about the health needs and barriers to accessing health services that new arrivals experience in King County. This input will then be incorporated into EthnoMed’s updated version of its Primary Care Provider Toolkit resource so as to center community experiences at the heart of its guidance and information. In particular, this project considers the perspectives and experiences of three groups in King County: Afghan, Iraqi, and Ukrainian refugee communities.
This project focused on the following objectives:

  1. Conduct key-informant qualitative interviews with community leaders from Afghan, Iraqi, and Ukrainian refugee communities in King County, Washington.
  2. Develop recommendations for the updated version of EthnoMed’s Primary Care Provider Toolkit that reflect community experiences and perspectives.

Methods

This project involved 15 semi-structured interviews with leaders of the Afghan, Iraqi, and Ukrainian refugee communities in King County, Washington: 4 with Afghan community leaders, 6 with Ukrainian community leaders, and 5 with Iraqi community leaders. Interviewees were employees and volunteers of federally-qualified health centers (FQHCs), refugee resettlement agencies, Harborview’s Community House Calls Program, and local community-based organizations that serve refugees. All interviewees worked or volunteered in settings that maintain direct contact with refugees in King County. Almost all of these individuals identified with the refugee communities that they are now serving. All 15 interviews were conducted in English on Zoom, and lasted approximately 30 minutes to 1 hour. A single interview guide was used for all interviews, and consisted of 16 open-ended questions about the health needs and primary care experiences of refugee communities in the area.

To identify common themes among the three refugee communities included in this project, a thematic analysis was applied to all interview data. Dedoose software was used to code interview transcripts and to identify key excerpts that emphasize community needs and perspectives.

Findings

Below is a brief summary of major findings from analysis of interview transcripts. These larger themes describe common considerations and health issues that were discussed throughout the 15 interviews conducted for this project. Six common themes were identified across all three refugee communities, and additional themes were identified that were specific to either one or two communities, as opposed to be shared across all three groups.

Themes Across All Three Refugee Communities

THEME 1: Language access services are an important component of health care that must be considered when serving refugee communities.

Interviewees across all three groups discussed how interpreters increase accessibility of health services for refugees after resettlement, but communities emphasize that there are important considerations that providers should be aware of when using these services. These considerations include the genders of interpreters, and community leaders called for asking patients if they have a preference for the gender of the medical interpreter used during appointments. Additionally, community leaders caution providers against using patients’ family members as medical interpreters during appointments. Community leaders also called for more in-language, written materials available to patients with limited English proficiency. These resources may include pamphlets or brochures about health topics.

THEME 2: Mental health continues to be an important issue for refugee communities.

Mental health was among one of the most heavily discussed topics among all three refugee communities included in this project. Interviewees speculated that refugee communities may not have an in-depth understanding of what mental health is, how it physically manifests, and what support is available. Many of the mental health conditions discussed during interviews included anxiety, depression, and post- traumatic stress disorder (PTSD). Language barriers and stigma may be important barriers to accessing mental health services. Community leaders called for increased intervention around mental health, and emphasized the need for culturally appropriate education about mental health for patients.

THEME 3: Community leaders feel that providers should understand factors that can influence patient-provider interactions.

Community leaders described factors that can impact interactions between providers and patients. These factors included the gender of health care providers and trust. Community leaders feel that patients should be asked what gender of provider they prefer for appointments, and that this preference should be heavily prioritized. Refugee patients may not trust health care providers in the area, and this may be due to unfamiliarity with the American health care system, or unfamiliarity with the individual provider. Interviewees believe that trust can be built over time as patients continue to see the same provider and have more positive interactions with them. One suggestion for improving trust was for providers to learn more about the cultures of their patients; however, it must be emphasized that patients are individuals with their own sets of values, beliefs, and experiences; there will not be universal cultural characteristics across all refugee communities. Community leaders feel that providers should make space for patients to share their own individual identities and beliefs.

THEME 4: Community leaders feel that providers should be aware of the major differences between the American health care system and foreign health care systems.

Refugee communities in King County are arriving from countries with health systems that are vastly different than what is in the United States. Community leaders shared that many patients have different expectations when interacting with health services after resettlement based on their experiences in their countries of origin. A lack of understanding about how the US health care system works may contribute to frustration, and may discourage community members from accessing health services. Community leaders called for increased education for community members about how to navigate the US health care system.

THEME 5: Community leaders identified health conditions that require particular attention from health care providers that serve refugees.

During interviews, community leaders discussed health conditions that they felt require more attention from health care providers that are serving newly arrived refugee communities. This is not a comprehensive list of health conditions for providers, but describes conditions that providers should pay particular attention to when providing care to refugee patients. The first condition was tuberculosis (TB), and while the domestic health examination addresses TB, community leaders feel that patients may need additional support after resettlement. Other health conditions included diabetes and dental health care. A final health condition discussed was COVID-19. While community leaders did not necessarily indicate that there was a high prevalence of COVID-19 among refugee communities in King County, they did identify this condition as an opportunity for increased education about COVID-19 vaccinations.

THEME 6: Community leaders feel that providers should have a basic understanding of which community-based organizations are available to refugees in the area.

A final theme that was identified from conversations with community leaders is the importance of social networks and community-based organizations for recently resettled refugees in King County. Almost all of the individuals interviewed for this project are involved with community-based organizations that serve local refugees, and many of these groups have direct contact with newly arrived refugees. Community leaders shared the wide array of educational campaigns, events, and outlets that organizations use to disseminate information on health topics to community members. This information is usually delivered in the native languages of refugee communities, and are framed in culturally sensitive manners, which improves acceptance among community members. When asked if refugee community members trust other community members more than health care providers, almost all community leaders responded that patients would probably trust other community members more. This is largely due to shared language, culture, and experiences among the refugee community.

Themes Within The Afghan Community

THEME 1: Community leaders feel that providers should be aware of important cultural considerations when serving Muslim patients from Afghanistan.

Afghanistan is a predominantly Muslim country with many individuals who continue to practice their religion even after leaving their home country. For many Afghan refugees in King County, a large part of their identities is rooted in their Muslim values and traditions. Among Afghan nationals that have been resettled in the US, racism and Islamophobia are salient issues that they experience. This is especially true for individuals who wear traditional Muslim dress, such as hijabs. While individuals may have unique ways of practicing their religions, a lack of provider knowledge about key characteristics of the Muslim culture may be extremely detrimental to building trust with patients from Afghanistan.

THEME 2: Community leaders feel that providers must be considerate when discussing sensitive health topics and performing physical examinations with Afghan patients.

Other important considerations for providers to acknowledge is that Afghan nationals, especially women, may be extremely uncomfortable discussing sensitive health topics, such as sexual health, during appointments. While these health topics are important to discuss, providers must acknowledge that patients may be extremely hesitant or even unwilling to engage in conservations about certain health behaviors. It is crucial that providers give patients the opportunity to discuss these topics during health visits, but providers must be sensitive to patients’ level of comfort around these topics. It may be helpful for providers to frame these topics in culturally sensitive manners, or to indirectly ask patients about their health behaviors. Similar sentiments are felt by the Afghan refugee community during sensitive physical examinations, such as pelvic exams, mammograms, or pap smears. Providers serving these communities should be educated on the Muslim culture and values as they relate to physical examinations to tailor their approaches with patients. Patients may also benefit from increased education about these procedures, what they entail, and their importance in identifying health conditions. This education should be framed in a culturally sensitive manner that addresses the concerns of Muslim communities.

THEME 3: There is a need for providers to address elevated blood lead levels (EBLLs) and lead exposure in the Afghan refugee community.

A common health condition that providers should be aware of is elevated blood lead levels (EBLLs) within the Afghan refugee community. This was a topic that came up among all 4 Afghan interviewees. While exposure to lead also occurs in Afghanistan before resettlement, many new arrivals are still exposed to lead after resettlement through common cultural practices. Screenings for elevated blood lead levels are included in domestic health examinations for new arrivals in Washington state; however, providers should be aware of practices within the Afghan community that increase lead exposure after resettlement. Additionally, providers may wish to use this knowledge to tailor their education to Afghan patients about elevated blood lead levels and household lead exposures.

Themes Within The Ukrainian Refugee Community

THEME 1: There is a need for increased education for providers about religious and cultural considerations within the Ukrainian community.

The 6 interviews with Ukrainian community leaders all mentioned the role that religion plays in the health and culture of many Ukrainian refugees. While not all community members identify as religious or engage in religious practices, this topic came up frequently when discussing health and social topics. Providers may wish to educate themselves about how to explain the importance of vaccinations in the context of refugees’ religions. Interviewees shared that there may be anti-vaccination sentiments in the Ukrainian refugee community, which they felt are most common within religious groups. Another topic that providers should be aware of is the way that religion in the Ukrainian refugee community impacts support for members of the LGBTQ+ community. Because of beliefs attributed to their religion, individuals that identify as LGBTQ+ may not receive support from other community members, or may even be shunned or physically harmed by others. Another important consideration for providers to be aware of is the sensitive politics of the war in Ukraine, as well as recognizing Ukraine’s unique history as an independent nation. All 6 Ukrainian interviewees emphasized that providers should not make assumptions about the language that a Ukrainian patient prefers to speak during appointments. While some patients may prefer to speak Russian, it could be extremely traumatic and triggering for other Ukrainian patients to hear Russian spoken during appointments.

THEME 2: Community leaders feel that providers should be aware of how Ukrainian patients access medications after resettlement.

A second theme that was identified through analysis of interview transcripts was how Ukrainian refugees access medications after resettlement in the US. The majority of interviewees discussed how Ukrainian refugees are often purchasing over-the-counter medications in local Ukrainian or Russian stores, as opposed to purchasing them in pharmacies or other American retailers. These medications may be imported from foreign retailers and sold in local shops. This may be due to the fact that Ukrainian community members are more familiar with the names or brands of medications that they purchased in their home country, when compared to the medications available in the US. Some interviewees speculated that refugees may be overwhelmed by the amount of over-the-counter medications available in the US, which can make it difficult to know which medication they should buy. One example was the purchase of paracetamol, as it is called in Ukraine, in Ukrainian stores versus acetaminophen as it is known in the United States. While this is a milder example of differences between Ukrainian and American medications, multiple interviewees described how prescription medications including antibiotics may also be purchased in these stores.

THEME 3: Community leaders feel that providers should understand how the current immigration landscape can impact Ukrainian refugees’ decisions to access health care in the US.

A final theme identified within the Ukrainian refugee community pertains to immigration considerations. With the United States’ Uniting for Ukraine refugee pathway, Ukrainian refugees do not receive formal refugee status through US Citizenship and Immigration Services. Instead, Ukrainians that arrive through this pathway are granted humanitarian parole status and are permitted to stay in the US for a period of two years. After two years, it is unclear if Ukrainian refugees have a pathway to US citizenship. This uncertainty may impact the ways in which Ukrainians that recently arrived to the US access health services during their parole period. Community leaders speculated that some Ukrainian refugees who came through this pathway may have hopes of returning to Ukraine after the war and when it is safe again. Alternatively, there may be individuals who would like to stay in the US if immigration services allow this. These considerations may impact individuals’ decisions to access health services in the US.

Themes Within The Iraqi Community

THEME 1: Community leaders feel that providers should be aware of Muslim cultural considerations, and should understand how racism and Islamophobia impact the Iraqi refugee community.

Similar to Afghanistan, Iraq’s population predominantly identifies as Muslim. While individuals may choose to practice their religion based on their own values or beliefs, there are once again common considerations for Muslim patients that came up often during interviews with Iraqi community leaders. Community leaders suggested that providers should educate themselves about Iraqi and Muslim culture to better understand the values and experiences of Iraqi patients. One recommendation was to ask patients directly about their culture and to create space for them to share their perspectives and stories. Additionally, Iraqi patients may be extremely hesitant or unwilling to discuss sensitive health topics such as sexual health, which was similar to Afghan patients. It also may be stigmatized to openly discuss these topics with a provider. When seeing patients from refugee communities, providers should explain why they are asking questions about sensitive health topics, ask patients if they feel comfortable answering them, and respect patients’ decisions if they do not wish to proceed. Finally, another topic that came up often with the Iraqi refugee community was racism and Islamophobia. While Muslim groups from other refugee communities certainly experience racism and Islamophobia as well, this was a topic that came up among all 5 Iraqi community leaders. Many providers that serve refugee communities in King County are well-educated on respecting the diverse cultures and identities of patients; however, providers should be aware of the racism that Iraqi community members experience and how this racism impacts trust. The Iraqi refugee community is very close-knit in King County, and racist experiences may be shared with other community members which could further harm relationships with providers.

THEME 2: Community leaders identified preventive health screenings of certain conditions that should be prioritized with Iraqi refugee patients.

A second theme that was identified through interviews with Iraqi community leaders centered around the need for important health screenings. One need that came up frequently during conversations was addressing sexually transmitted infections (STIs) among Iraqi refugees. While STI screenings are generally included in the domestic medical examination for newly arrived refugees, it is important that providers continue screenings after resettlement. Patients’ behaviors, such as engaging in sexual activity, may have changed since they left their country of origin or after resettlement in the United States. A change in behaviors may increase patients’ risk of health conditions such as STIs, and providers should be aware of these risks. Iraqi refugees may also greatly benefit from increased education about common STIs, how STIs are spread, and how patients can decrease their risk of acquiring an STI. Iraqi community leaders also frequently brought up cancer screenings as a health need among resettled refugees. Interviewees that participated in this project frequently discussed the burden of cancer within the Iraqi refugee community, and called for increased cancer screenings during primary care visits.

THEME 3: The accent of medical interpreters may negatively impact Iraqi patients’ ability to communicate with providers.

A third theme that was brought up by all Iraqi interviewees was how the accent of medical interpreters impacts communication between providers and patients. Arabic is one of the most commonly spoken languages in the world, but there are numerous Arabic accents that vary by country or region. If Iraqi patients opt to use a medical interpreter during primary care visits with health care providers, they will most likely use an interpreter that speaks Arabic; however, community leaders pointed out throughout this project that medical interpreters may speak Arabic with an accent that can be difficult or even impossible for Iraqi patients to understand. Providers should be aware of how the accent of Arabic- speaking medical interpreters could impact communication with Iraqi patients. It may also be extremely beneficial to ask patients if they are able to understand the interpreter, or ask interpreters if they can understand the patient.

THEME 4: Iraqi patients may need additional support when navigating situations such as domestic violence or disabilities.

A fourth theme that was identified during interviews is the need for additional support regarding some health topics in the Iraqi community. One topic that came up was the issue of domestic violence in the Iraqi community. While domestic violence is not an issue experienced exclusively by Iraqi refugees, this was a topic that was discussed by the majority of Iraqi community leaders during this project. Domestic violence is an extremely sensitive topic for most individuals, but Iraqi refugees may face increased barriers to accessing support. There may be a lack of knowledge among community members about what domestic violence is, and what protections people living in the United States are entitled to.
Another opportunity for providers to offer additional support to Iraqi refugees is around children who are diagnosed with autism-spectrum conditions or learning disabilities. The conditions discussed included autism, attention-deficit disorder (ADD), and attention-deficit hyperactivity disorder (ADHD). While these experiences are not unique to the Iraqi refugee community, they were commonly discussed with Iraqi community leaders during interviews. According to community leaders, Iraqi parents may be unfamiliar with these diagnoses, the symptoms of these conditions, and how they can best provide for children diagnosed with a disability. The Iraqi refugee community may have misconceptions about these disabilities in children, and may be unaware of what support is available for children living with disabilities. Stigma around disabilities may also impact parents’ willingness to accept diagnoses in children.

Recommendations For EthnoMed’s Primary Care Provider Toolkit

The following nine recommendations were developed based on themes identified from conversations with refugee community leaders. These are recommendations for EthnoMed’s updated Primary Care Provider Toolkit to better address the needs and gaps in health care that refugee communities experience in King County:

  1. Feature an in-depth explanation of what cultural humility is and how providers can practice cultural humility when serving refugee patients.
  2. Include a section on medical interpretation and important considerations for providers when using medical interpreters.
  3. Recommend important health screenings for refugee patients, including screenings for hypertension, cancer, sexually transmitted infections, elevated blood lead levels, diabetes, and tuberculosis.
  4. Outline for providers how immigration status can impact patients’ health decision-making.
  5. Emphasize that providers offer more explanations and education to patients about health services, health conditions, and medications.
  6. Include a more robust section on mental health as it relates to refugee cultures and experiences.
  7. Offer descriptions about health care systems in other countries and how providers can educate patients about the American health care system.
  8. Include sections on domestic violence, disabilities, and LGBTQ+ communities as they relate to refugee health and cultures.
  9. Feature a list of local community-based organizations to connect patients with for further support and education.

Conclusion

The purpose of this project was to develop recommendations for EthnoMed’s updated Primary Care Provider Toolkit for health care providers that serve newly arrived refugees in King County, Washington. Through this project, 15 key-informant interviews were conducted with leaders of the Afghan, Ukrainian, and Iraqi refugee communities. These leaders were able to share community experiences through their roles at organizations or clinics where they directly interact with newly arrived refugees. Nine recommendations for EthnoMed’s Primary Care Provider Toolkit were developed based on the common themes identified from conversations with refugee community leaders in the area. These recommendations attempt to address the needs, barriers, and experiences of refugee communities as they access health services after resettlement.

Winter – Cold Weather and Power Outage Safety

Winter brings cold temperatures, snow, freezing rain, and high winds. When rain freezes, ice weighs down trees and power lines, this can lead to power outages (see below for multi-language fact sheets).

Photo by Brett Sayles (cc license)

During a winter storm

Washington Department of Health tips:

  • Wear several layers of loose-fitting, lightweight, warm clothing rather than one layer of heavy clothing. Wear mittens rather than gloves. Wear a warm, woolen cap.
  • Do not drive unnecessarily.
  • Reduce the temperature in your home to conserve fuel.
  • Heat only the areas of your home you are using. Close doors and curtains or cover windows and doors with blankets.
  • Use alternative heat methods safely. Never use a gas or charcoal grill, hibachi or portable propane heater to cook indoors or heat your home.
  • Never use a generator indoors or in a garage or carport.
  • Be careful when shoveling snow. Do not overexert yourself.
  • Be sure to eat regularly. Food provides calories that maintain body heat.
  • Watch for signs of frostbite and hypothermia — slurred speech, disorientation, uncontrollable shivering, stumbling, drowsiness and body temperature of 95 degrees Fahrenheit or less.
  • If you become trapped outside, get out of the wind and stay dry. Build a lean-to or snow cave if nothing else is available. Do not eat snow; it will make you too cold.

If in your vehicle

  • Make sure someone knows where you are going. Stay on the main roads.
  • If you must stop, remain inside the vehicle. Use a bright distress flag or your hazard lights to draw attention to your vehicle.
  • If trapped in a blizzard, clear your tail pipe and run your engine and heater for 10 minutes every hour. Open your window slightly.
  • During night hours, keep the dome light on in the car so rescue crews can see your vehicle.
  • Keep an emergency kit in your vehicle. Include a three-day supply of water and non-perishable food that can be eaten without being cooked. Include a blanket or sleeping bag for each passenger, a flashlight, cell phone, shovel, sack of sand or kitty litter, booster cables, flare, coffee can with lid, and toilet paper.

PDF tip sheets in other languages: Spanish, Chinese, Korean, Russian, Somali, Ukrainian, Vietnamese

What should I do if I see damaged or downed power lines?

Department of Health Seattle & King County:

  • Don’t get near any fallen or sagging power line!
  • Call the utility company about the line
    (Seattle area residents: 206-684-7400, other King County residents: 1-888-225-5773).

If you have a power outage, safe ways to stay warm

  • Find places where you can go to get warm, such as the home of friends and family whose homes have power.
  • Wear several layers of light weight, warm clothing rather than one layer of heavy clothing. Wear hats, mittens, and blankets indoors.
  • Close curtains and cover windows and doors with blankets. Everyone should try to stay together in one room, with the door closed, to keep in body heat.

Prevent poisoning from carbon monoxide

  • If you don’t have electricity, only use a generator outdoors and far from open windows and vents.
  • NEVER use a generator indoors, in garages or carports
  • NEVER cook or heat indoors with a charcoal or gas grill 

Help Others

Q&A RSV, flu and COVID in King County: What should I know?

In the Fall and Winter months there is often a rise in respiratory viruses. This Fall (2022) there have been many RSV and flu cases requiring emergency room visits – especially for young children. Health clinics might also see more COVID cases and hospitalizations in the winter as people gather indoors and new COVID variants spread. These diseases can make young children, older adults, and other vulnerable people very sick, and overload hospitals and clinics.

RSV is a common respiratory virus that spreads every winter. Anyone can get RSV, but in 2022 we’re seeing a lot of cases in young children. For healthy adults and older children RSV can feel like a cold, with symptoms like runny nose, less appetite, coughing, and fever. But it can be a very serious illness for babies, older adults, and others.

The Seattle and King County Department of Public Health has put together an informative slide deck in eighteen languages. The deck Includes information about RSV, flu and COVID in King County, what to look for and how to prevent illness.

These slides can be shared in waiting rooms, at community centers, and in other places where people gather. Slides are available in the following languages:
• አማርኛ (Amharic)
• العربية (Arabic)
• 简体字 (Chinese – Simplified)
• 繁體字 (Chinese – Traditional)
• دری (Dari)
• English
• Français (French)
• 日本語 (Japanese)
• ភាសាខ្មែរ (Khmer)
• 한국어 (Korean)
• KajinM̧ajeļ (Marshallese)
• ਪੰਜਾਬੀ (Punjabi)
• Русский (Russian)
• Af Soomaali (Somali)
• Español (Spanish)
• Wikang Tagalog/Filipino (Tagalog/Filipino)
• ትግርኛ (Tigrinya)
• Українська (Ukrainian)
• Tiếng Việt (Vietnamese)

How Does the American Health System Work

The American Health System is complicated. This fact sheet was produced to guide patients to where they can see a doctor. It describes the differences between a Primary Care Clinic, a Specialty Clinic, the Emergency Room, and In-Patient Care and when it is appropriate to use each service. The goal of this resource is to help improve health literacy for English, Spanish, Chinese, and Vietnamese speaking patients.

photo by Online Marketing (cc license)

Infant Formula Shortage Resources

Washington State Department of Health Resources

Photo by: Jaye Haych (cc license)

The Washington State Department of Health (DOH) has compiled the following resources to assist families and caregivers trying to find nutritionally appropriate food for their babies. The below information comes from the American Academy of Pediatrics (AAP), the U.S. Department of Health and Human Services, the Washington WIC program, the Centers for Disease Control and Prevention, and the U.S. Food and Drug Administration. For the full news release, please see here.

  • Baby Formula Shortage Partner Toolkit – in English and Spanish, download here.
  • Resources for Families Impacted by the Infant Formula Shortage  in English, Spanish and 14 different languages (FAQs)
  • If you still have concerns about your child’s health, contact your child’s primary care provider’s office and ask to speak with a nurse, medical assistant, or health educator on your child’s care team.
  • For people needing a connection to health care providers, call the Help Me Grow WA hotline at 1-800-322-2588 for referrals and to apply for food and health resources in Washington. Additional support and resources are also available to participants in federal and state nutrition programs.
  • For WIC participants and families, contact your local WIC clinic to get infant formula benefits replaced or change baby formulas. WIC has expanded the types of formula they provide to offer more choices for families participating in the program. They can often tell you which stores have formula in stock. If you can’t reach your local clinic, call the state WIC office at 1-800-841-1410 Monday to Friday, 8:00 am – 5:00 pm. Check the Washington WIC web page for more information on approved replacement infant formulas.
  • For participants in Basic Food (SNAP), visit the Parenthelp123 web page or call 1-800-322-2588.

Some additional tips to help with your infant formula search:

  • Check smaller stores and drug stores or buy online from reputable distributors and pharmacies.
  • Gerber’s MyGerber Baby Expert: reach a certified nutrition or lactation consultant by phone, text, Facebook Messenger, web chat, or video call, who can help you identify a similar formula that may be more readily available
  • Abbott’s Consumer Hotline: call 1-800-986-8540; Abbott’s urgent product request line: ask your OBGYN or your infant’s pediatrician to submit an urgent product request by downloading and completing the form – PDF 
  • Mead Johnson/Reckitt’s Customer Service line: call 1-800 BABY-123 (222-9123)

Community Resources

  • Locate your nearest Community Action Agency (CAA). Your neighborhood CAA may be able to provide you with formula or connect you with local agencies that have formula in stock.
  • United Way’s 2-1-1: dial 2–1-1 to be connected to a community resource specialist affiliated with United Way who may be able to help you identify food pantries and other charitable sources of local infant formula and baby food.
  • Feeding America: call your local food bank to ask whether they have infant formula and other supplies in stock.
  • Human Milk Banking Association of North America (HMBANA): certain HMBANA-accredited milk banks are distributing donated breast milk to mothers in need; please note that some may require a prescription from a medical professional. Find an HMBANA-accredited milk bank.
  • Relactation or induced lactation is also possible and can be an alternative to using formula. La Leche League International has resources on how to stimulate milk supply.
Vaccine bottle and syringes

COVID-19 Vaccine Videos

Covid-19 Booster Shots

King County Public Health: Informative videos about Covid-19 booster and pediatric vaccine in 12 languages; All language playlist

Vaccine Videos

You Should Get a COVID-19 Vaccine … Here’s Why
21 one-minute plain language videos in multiple languages explaining why it is important to get a COVID-19 vaccine. Created by Georgia State University (Prevention Research Center, School of Public Health, College of Education and Human Development, Adult Research Literacy Center).

Spanish language videos counter misinformation about vaccines for children. The Kaiser Family Foundation’s La Conversación series, which features health care providers answering questions about COVID-19 vaccines, is out with a new  5-minute video and multiple new FAQ videos in Spanish. 

Interpreter COVID-19 Vaccine PSA Videos
Harborview Medical Center interpreters share their experiences with his second vaccine dose and talks about community concerns and common side effects.

Preguntas frecuentes sobre la vacuna contra el COVID-19
UW Medicine interviews Dr. Santigo Neme in Spanish about COVID-19 vaccine safety. 

UW Medicine Community Conversations: Straight Talk about COVID 19 Vaccines. This YouTube playlist includes UW Medicine’s vaccine Town Hall videos in English, Spanish, Oromo, Tagalog, Somali, Tigrigna, Mandarin and Amharic.

COVID-19 Video Updates from the Somali Health Board. Every week they post videos with COVID-19 updates and answer community member questions. They also are working to actively counter mis-information around the new vaccines.

The National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) has a video page with a number of COVID-19 vaccine information videos translated into different languages. They also have two vaccine campaigns, Get the Facts and Get Vaccinated, that are translated into Spanish, and will soon be translated into more than 30 languages.

Iraqi/Arab Health Board Community Conversation videos discussing COVID vaccines can be viewed on the IAHB website.

The Iraqi/Arab Health Board held a live Facebook event with community members on February 14, 2021, answering frequently asked questions about the COVID-19 vaccine. 

Videos documenting a COVID-19 vaccination event at the Ethiopian Community of Seattle. Includes an Amharic interview with community members, and an interview with the Seattle Fire Department.

Are COVID-19 Vaccines Halal? Imam Mohamed Magid talked with then-U.S. Surgeon General about the COVID-19 vaccines to get answers on questions that matter most to Muslims families and communities.

Get your Covid-19 vaccine, do not hesitate! This video from the Iraqi Arab Health Board is in Arabic and encourages viewers to get their COVID-19 vaccination.

The New American Neighbors video outreach project has created a set of nine videos concerning COVID-19 vaccination hesitancy. The videos are in Amharic, Arabic, Dari, French, Nepali, Pashtu, Somali, Spanish, and Tigrinya. Videos in Burmese and Karen will be added soon.

COVID-19 Vaccine and Immigrant & Refugee Communities (Pashto Translation). This video was created by the Afghan Health Initiative and HealthPoint.

The Conversation
Black and Latinx health care workers answer questions about the COVID-19 vaccines in this series on the Greater than COVID website. These FAQ videos are also available in Spanish.

From MN Department of Health

The Minnesota Department of health has created a COVID-19 Vaccine Communication Toolkit that includes videos about vaccine safety, translated into multiple languages (including Amharic, Chinese, Hmong, Karen, Oromo, Somali, Spanish and Vietnamese). Scroll down to the “Vaccine Safety” section and click on the drop down menus under: 

  • Translated versions: How COVID-19 Vaccines Are Made
  • Other languages and transcripts: FAQs About the COVID-19 Vaccine

From WA Department of Health

COVID-19 Vaccine Resource Guide to Support Community-led Vaccination Efforts
English | Spanish

How COVID Vaccines Are Made
English | Spanish

How Would COVID Vaccines Work in Your Body
English | Spanish

Making Sense of Vaccines During COVID-19
English | Spanish

How to Spot Fact vs. Fiction Online
English | Spanish

Resources for New Arrivals from Afghanistan

Community Resources

Afghan Health Initiative

Located in King County, WA, the mission of Afghan Health Initiative is to serve the immigrant and refugee population in Washington State by promoting community-based public health interventions which target social determinants of health thereby increasing equal access to health, education, and economic independence.

Resources made available for newly arrived refugee community members:

  • Emergency Funds
  • Essential Items for Infants, Children, Expecting Mothers
  • Household Items and Furniture
  • Groceries and halal meat
  • Connection to Community
  • Systems Navigation and Interpretation
  • Job Search

Health and wellness programs include Lead and Toxics Prevention (Lead Poisoning in Children PSA videos in Dari, Pashtu, English, Spanish)

Hazara Community of Washington 

Address: PO BOX 6234 Kent WA, 98064

Contact information: Info@hcofwa.org

Website: https://hcofwa.org/

HCWA is a non-profit non-religious, nonpolitical community-based institution established to help refugee/immigrant communities from Afghanistan to resettle smoothly in Washington, also help them receive the necessary support from the stakeholders.  HCWA aims to provide community support, initiate cultural programs and festivals, raising awareness and organizing integration initiative to local U.S culture, including job market awareness, creating self-help groups, connecting the communities with the voluntary participation in community affairs, and preserving community practices and values. 

Muslim Association of Puget Sound

Founded to serve the Muslims of Puget Sound and the wider community, MAPS is the largest Islamic Center in Washington, with a diverse community of over 5,000 families from more than 50 countries and many services and programs. MAPS AMEN (American Muslim Empowerment Network) program has organized to help address the crisis in Afghanistan and welcome incoming Afghan families to Washington state. They have collated and coordinated a number of different efforts/resources, focusing on Washington state, including providing opportunities of specific ways to help. See: Sep. 14 Message on Crisis in Afghanistan: How You Can Help

Viets for Afghans

Viets for Afghans are Vietnamese Americans mobilizing community members to help Afghan refugees.

WA Department of Health

Resources for New Arrivals from Afghanistan

Since 1975, Washington has welcomed nearly 150,000 refugees from 70 different countries to our state, including almost 5000 individuals from Afghanistan.  Washington is actively engaged with the federal government to help resettle Afghan individuals and families. Through Operation Allies Refuge, Washington anticipates resettling more individuals and families from Afghanistan in coming weeks and months.

DSHS Office of Refugee and Immigrant Assistance’s Welcoming Afghans to Washington State website provides regularly updated information from the federal government regarding Afghan resettlement.

WA DOH Afghan Health Profile and Screening guidance for adults and children ( WA and MD ), plus WA DOH Refugee Health Program’s Afghan Health Resources shares fact sheets, webinars, videos and other resources to support new arrivals from Afghanistan.

Learn about:

  • Local Community Resources
  • Afghan Culture and Health
  • Behavioral Health
  • State and Federal Assistance and Benefits Eligibility
  • Local Health Screening Examination
  • Health Outcomes
  • Health Promotion and Education Resources in Dari and Pashto (Covid-19, Handwashing, Masking, Lead, Measles Tuberculosis, Vaccine Information Statements, Varicella (Chickenpox) and more)

Hazardous Waste Management Program in King County

Helping families reduce exposure to lead

Some aluminum cookware brought from Afghanistan by resettled families as well as cookpots available for purchase in the United States represent a previously unrecognized source of lead exposure. The Hazardous Waste Management Program in King County, in collaboration with the Department of Environmental and Occupational Health Sciences at the University of Washington, conducted a study that revealed that several aluminum cookpots released enough lead under simulated cooking and storage conditions to present a significant risk for lead poisoning. While lead poisoning is a serious concern, researchers identified several solutions. Study findings are published in the Journal of Exposure Science and Environmental Epidemiology. See also, additional resources about lead and ways to reduce exposure: WA DOH Refugee Health Program’s Afghan Health Resources, Afghan Health Initiative’s Lead Prevention Program

Centers of Excellence for Newcomer Health

CDC

CDC’s Response to Afghan Evacuees: The CDC provides health education information translated into Dari, Pashto and Farsi for Afghan new arrivals, in hopes of helping to prevent the spread of infectious diseases during the resettlement process.

Minnesota

The Minnesota Center of Excellence in Newcomer Health has created a collection of Afghan Evacuees Health Resources to support and share best and promising practices meeting the needs of newly arrived Afghan people. Resources range from infectious disease FAQs, to suggestions on promoting health in households who will host newcomers.  They include medical forms/documents for initial intake/encounter (prior to a formal Domestic Medical Examination), on-demand educational material on “getting to know your Afghan patient”, and cultural and historical information to help better serve these individuals and families as they are resettling.

The Minnesota Center of Excellence in Newcomer Health’s Afghan Clinical Workgroup has issued a brief overview for clinicians caring for Afghan new arrivals.
• A series of recorded webinars and PDF slides

Protect Afghan Families from Lead Poisoning
Resources to prevent and address lead exposure and poisoning among Afghan newcomers, including translated print materials, social media assets, text message templates, and audio and video PSAs.. Fact sheets in English | Dari | Pashto

Colorado

The Colorado Center of Excellence in Newcomer Health, in partnership with the CDC and other partners, have released a set of infographics available for print and web usage, and each set contains an infographic on arrivals from Afghanistan from 2009-2019. The web versions are smaller in size, making them easy to share online. The print versions are larger in size, making them printable for hanging on walls or sharing as handouts.

The Colorado Center of Excellence in Newcomer health has also created a health education resource repository for Afghan Newcomers which contains health education materials in English, Dari, Farsi, Pashto, and Urdu, when available. The majority of resources have been gathered from the CDC and the NRC-RIM.

Cultural Orientation Resource Exchange (CORE)

CORE provides an Afghan Backgrounder and a Cultural Orientation for Afghan Arrivals webinar, which includes written answers to questions about the Afghan Placement and Assistance Program (APA). Login to CORE’s Learning Platform is required to access webinar and files.

Learn how to use CORE’s Settle In Facebook page with Afghan arrivals to ensure clients access vital, correct information about early resettlement services.

CORE has a full array of Dari fact sheets, videos, and podcasts on Cultural Orientation and the resettlement process available on the CORE Resettlement Navigator website, as well as a playlist of Dari videos.

Additional Resources

Afghan Health Initiative: Legal/Immigration resources for families in Afghanistan

The U.S. Department of Health and Human Services’ Office of Refugee Resettlement (ORR): Resettlement services continue after 90 days, English, Dari, Pashto

DHHS, Centers for Medicare & Medicaid Services: Health Coverage Options for Afghan Evacuees

National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM): COVID-19 Resources for Afghan New Arrivals

Federal Office of Refugee Resettlement:  Afghan Assistance Resources

Catholic Legal Immigration Network: Guide to Client Documentation and Benefits for Afghan Parolees

Catholic Legal Immigration Network: Assistance for Afghans Toolkit

Department of State: Afghans Granted Humanitarian Parole

Office of Refugee Resettlement: Benefits for Afghan Humanitarian Parolees

Switchboard: Resources for Afghan Arrivals

USCIS: Information for Afghan Nationals on Requests to USCIS for Humanitarian Parole

Vermont Language Justice Project : PDF Guide with Translated Afghan Resources

Sscreenshot from FIT Instructional Video

FIT Instructional Videos

Colon cancer is a leading cause of cancer-related deaths, but it is preventable with screening. The fecal immunochemical test (FIT) is the most used stool test for colon cancer screening. These videos demonstrate how to properly use a FIT kit to collect a stool sample for colon cancer screening. They are available in Arabic, Cantonese, English, Khmer (Cambodian), Russian, Somali, Spanish and Vietnamese.
* It is recommended that adults begin screening for colon cancer age 45 (previously age 50).

A PDF document containing QR Codes that link directly to each video is provided in the sidebar.

Demonstration: Dr. Rachel Issaka
Videography: Dr. Carey Jackson
Arabic Interpreter: Joseph Tawadros
Cantonese & Vietnamese Interpreter: Lien T. La
Khmer Interpreter: Jeniffer Huong
Russian Interpreter: Oleg Gouts
Somali Interpreter: Mohamed Hashi
Spanish Interpreter: Araceli Gonzalez-Medel


Screenshot from video

Live Better with Kidney Disease & Learn About Dialysis

Background

Increasingly, dialysis, a treatment for severe kidney disease, is of concern among Cambodian patients with diabetes. This tool was developed to help educate Cambodian patients and community members about dialysis, also known as renal replacement therapy. It is tailored to reflect common concerns and questions some Cambodians may have when learning about and considering dialysis.

There are two videos (see below and in sidebar), one in Khmer and one in English.

Methods/ Acknowledgements

The project was initiated by Cambodian Caseworker/Cultural Mediator Jeniffer Huong and Renal & Transplant Clinical Nurse Specialist, Nancy Colobong Smith, MN, ARNP, CNN. They aimed to create a product that is both culturally sensitive and clinically applicable. The project was facilitated by EthnoMed Program Coordinator, Rekha Ravindran, MPH. Advanced practice nursing student Megan Jane Melvin, DNP, ARNP, was recruited to lead the development of this tool, in collaboration with the project team. A literature review was conducted about barriers and knowledge gaps about dialysis among Cambodian patients with diabetes, and interviews and focus groups were conducted with a Cambodian patient, Cambodian community advocates and medical providers who work in refugee health. Information was synthesized to determine key educational messages for the script and images. EthnoMed Program Supervisor Christine Wilson Owens and Community House Calls Program Nurse Manager Lea Ann Miyagawa, MN, RN participated in project meetings. Special thanks to Tessavan Ros who played the role of the patient in the photos and narration. Original photos were taken by UW Medicine Photographer Clare McLean. Northwest Kidney Centers gave permission to use several photos by C. B. Bell, III, Scott Areman and Ben Jenkins. Illustrations are credited to University of Washington and UWMC Health Online. EthnoMed Program Coordinator Anna Cowan, MPH, produced the final media product. Special thanks to all others who supported and contributed to this work: Dr. Bernadette Thompson, Dr. Carey Jackson, Physician Assistant Phalla Kith, Taing Bun Nam, James Heng, Keo Soth, Sorphon Sim, Channdara Sos, Sothea Thong, Jenny Ap, Phon Som, Sophearom Lim, Sokha San, Thy Savu, Sambath Soung and Kimnay Siev. UWMC generously shared their clinic for photography.

Funding

This project was funded in part through an American Nephrology Nurses Association (ANNA) and Gloria Scharf Beedie Memorial Grant.

Steering Wheel of Self-Management

In my role as a cultural mediator and diabetes navigator over the last five years, I have recognized the need for simple messaging of abstract concepts for patients from all socio-economic backgrounds in order to be meaningful. There are Western concepts that, as a system, we may take for granted. These include “chronic disease”, “prevention”, and “primary care”. In addition, we have a non-trivial number of illiterate and/or indigenous language speakers that also have low numeracy and a completely different concept of time and scheduled appointments.

The idea behind the “Steering Wheel of Self-Management” is to have a visual tool to be used by providers and patients alike. Providers/ educators can teach patients, patients can teach other patients.

Concept of Self

Perhaps the most basic concept I share with patients is the notion of SELF within the patient-centered care model in a clinical setting. Many of our patients come from countries or health systems that discourage patient participation, questions, or self-empowerment. They come to clinic for a “cure” or “fix” from an educated expert. Once they learn there is no “cure” for a chronic condition like diabetes, they may quickly lose interest or feel that it is not within their rights to express misgivings to a doctor. Hence, I developed the idea of the steering wheel as a central metaphor for illustrating control over one’s chronic disease, instead of being a passive recipient of it.

Prevention: Know how to avoid complications by managing YOUR own personal steering wheel according to YOUR life situations.

Concepts of Journey and Time

For many immigrants and refugees, the concept of a long journey or travel is a familiar one. This implies both distance and time in a way that our patients can more easily connect with.

  • Conceptual Message: TIME, something managed over time
  • Implicit message: Drive your diabetes so it doesn’t drive you

Chronic = continuous: Recognize that your highway and terrain will change over time. Learn to navigate the curves keeping both hands on the your steering wheel.

Steering Wheel Metaphor

Through trial and error during clinical visits and discussions in the lobby, I developed a series of images relating to the one central metaphor that seemed to easily illustrate chronic disease as a tangible concept. Originally I used a stock clip art wheel (later, we developed this original illustration, below) with three spokes to signify the three basic impacts on blood glucose: medication, food and exercise. The two hands on the steering wheel indicating patient empowerment.


  • Steering Wheel of Self-Management, the tool to keep a handle on things (your health).
  • Steering wheel has 3 spokes or points: Exercise, Food, Medicines, all three used in combination,
  • to keep on the road and not drive over the edge or off a cliff.
  • Emphasizing it is not just one thing.

Highway Metaphor

Then over time I began to deepen the metaphor to include the “highway of life” and its curves and roadblocks encountered that can affect diabetes management.

Highway is your diabetes or your health in general, there are many curves and stops on the highway.

Practical Uses

Practical uses of the steering wheel include a version with text and a pictorial-only version for patients with illiteracy or low literacy. The wheel can be printed out and notes written for patients identifying short term goals in the areas of exercise, nutrition and medication management, and for visualizing a care plan. The wheel image can be sent in mailer reminders, as motivator, to patients.

Steering Wheel with Words

Steering Wheel with Spanish words for Exercise, Food, Medicines, and “Driving (Managing) the Course of Your Diabetes”

Steering Wheel – Pictures only

Steering Wheel with images (no words) for Exercise, Food, Medicines

Patient Feedback

Patient feedback has been very positive both in clinic and in community health worker settings. Through the teach-back method, patients have demonstrated a strong grasp of the concept of chronic disease, despite education level. Patients have been able to individualize care plans and select small tangible goals to work on for behavior change.

Copyright

The Steering Wheel of Self-Management operates under the Creative Commons License Attribution-Noncommercial-No Derivative Works 3.0 United States. You are free to copy, distribute, display this work under the following conditions:

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The Brain

Brain Death: What It Means

This handout offers information for families and loved ones of patients. It explains how doctors determine that a person is dead based on their brain function.

Handout PDFs are available at UW Medicine Health Online in English, Arabic, Tigrinya, Russian, Chinese, Vietnamese, Amharic and Spanish languages.

For information for providers, see Determination of Brain Death/Death by Neurologic Criteria – The World Brain Death Project (article accessible with JAMA subscription).

The Brain
Photo by Francisco Bengoa (cc license).